Benign Pelvic and Perineal masses

Prof (M) Dr Mohd Hashim OmarJabatan Obstetrik & Ginekologi

Fakulti Perubatan, UKM

Introduction

Recognition of a pelvic or perineal mass requires a complete familiarity with con stitutes normal female pelvic anatomy

Definition of “Normal” differs depending on pubertal status, phase of menstrual cycle, occurrence of menopause, previous surgery and known intercurrent disease.

Gynaecologic and Obstetrical Pelvic Masses

Uterine Pregnancy Leiomyomata Adenomyosis Congenital anomalies Carcinoma Sarcoma Pyometra

Tubal Inflammatory(Hydro-S) Pregnancy(ectopic) Benign tumours (adenomatoid,

myoma) Carcinoma

Ovarian Benign tumours (solid and

cystic) Malignant tumours (mainly

solid) Pregnancy

Ligamentary Endometroid Benign tumours

(Leiomyoma, haematoma) Malignancy (mainly

metastatic)

Pelvic Anatomical Consideration

Ovaries Prepubertal &

Menopause Measure less than 2 cm

in its longest Diameter AND not not clinically palpable

Fallopian Tube Delicate and not

palpable

Uterus Multiparous uterus

remain symetrically larger 2-3cm larger than nulliparous

Smaller (atrophic) in prepubertal & menopausal

Pelvic Mass

Size Preferably the mass is describe as anterior or

posterior, midline, left or right to a given reference point ( usually Uterus)

Most often, uterine size is compared and describe as the size of pregnant uterus at a given gestation period

Measurement in cm is preferred

Pelvic Mass

Mobility or Fixation The ovaries, fallopian tube, and uterus are

suspended by pliable, distensible ligaments Highly mobile

usually the uterus move with the mass if the mass arising from the uterus.

Inflammatory lesions, malignancy, endometriosis, previous radiotherapy and previous surgery diminishes mobility

Pelvic Mass

Consistency To differentiate the mass is solid, cystic or

both component. Benign, simple ovarian cyst are smooth and

soft (cystic) Ovarian malignancy, fibroid are solid

Pelvic Mass

Tenderness Tender uterus is typically adenomyosis or

endometritis Salpingitis or tubal pregnancy will result in

tenderness to palpation or cervical motion Torsion and infarction of mass can also lead

to tenderness

Pelvic Mass

Shape and Symmetry Uterus is a symmetric structure

Enlargement of any of its components can lead to an irregular enlargement

Symmetrical enlargement suggest pregnancy or adenomyosis

Diagnosis and management of pelvic masses

Premenarchal Female No Physiologic ovarian lesion or pregnancy-related

masses Mainly related to congenital anomalies involving

Complete or partial duplication of Mullerian system Benign or malignant ovarian cyst (germ cell) Congenital cyst of mesonephric system Pelvic kidney

A careful history and examination including EUA, IVP and serum tumour markers (AFP and Beta HCG) as well as karyotyping should always be done.

Cont.

The sexual abuse also should be role out Pelvic inflammatory disease and pelvic abscess Chronic haematomas secondary to forced sex

Diagnosis and management of pelvic masses

Menstruating Female Intrauterine and ectopic pregnancy are always a

diagnostic consideration Careful menstrual history, sexual activity and

pregnancy symptoms Pattern of menstrual cycle, amounts and any pain

should be asked Association factors eg. Fever, pain, dyspareunia

and progression Constitutional symptoms

Diagnosis and management of pelvic masses

Postmenopausal Female Pelvic mass is consider omnious Consider malignant Functional cyst do not enter into the

differential diagnosis Fibroid and endometriosis get smaller or

better during menopause Silent PID lead to pelvic abscess should be

considered

Benign Uterine lesions

Leiomyomas of Uterus The most common tumour of uterus 20-40% in women over 35 years old Frequently cause no symptoms It is the commonest indication for

hysterectomy Growth of fibroid is faster and incidence of

fibroid in black women

Cont (fibroid)

Pathology Is discrete and may be single or more Cut surface has a glistening, white colour with a

characteristic whole-like trabeculation Pseudocapsul comprised of compressed cell on the

outer layer Occur in several location, cervix, uterus, broad

ligaments. Symptoms may related to the size and site of the

fibroid

Cont (fibroid)

Pathogenesis Aetiology is not established Hormonal influence on the growth of

leiomyomas is obvious Growth rapidly during pregnancy , OCP,

PCOS, granulosa cell tumour Rarely before menarrche and regress after

menopause

Cont (fibroid)

Secondary Changes of Fibroid Because of sparce in blood supply, fibroid are

subjected to severe degenerative changes Hyaline degeneration is the most common and not clinically

significant and lead to Calcification Cystic degeneration is an extreme form of hyaline

degeneration Red degeneration occur in pregnancy and menopause

The main symptom is pain due to congestion and swelling Sarcomatous degeneration is rare.

Cont (fibroid)

Sign and Symptoms Compression symptoms eg. Discomfort, urinary

retention, constipation Menstrual problems: Submucosa and intramural

fibroid. Hydronephrosis and hydroureter Polycytemia in Right broad ligament fibroid Pain in red and sarcomatous degeneration

Cont (fibroid)

Treatment Conservative

Asymptomatic Pregnancy

Surgical Symptomatic Completed family : Hysterectomy Not completed family: Conservative surgery/

Myomectomy

Benign Uterine lesions

Adenomyosis Benign uterine disease caractersed by endometrial

glands and stroma found within the uterine musculature

There is hypertrophy and hyperplasia of the myometrium

Resulting a diffuse enlarged uterus There is ectopic growth of endometrial tissue The incidence is difficult to determine 50% asymptomatic

Adenomyosis (cont)

Pathology Uterus is diffusely enlarged There may be small, dark, bloody cystic area throughout

the of the uetrus within myometrium Microscopically : islands of endometrial tissue includibg

glands and stromal scattered in the myometrium 50% of patient with adenomyosis have a uterine fibroid When endometrial carcinoma is present, adenomyosis is

frequently associated Implying a common aetiology factors such as hyperestrogenism

Adenomyosis (cont)

Clinical Characteristics and diagnosis Patient is in between 40 to 50 Parous, and has symptoms of menorrhagia Menorrhagia is resistant to hormonal treatment Dysmenorrhoea in 25% of patient Diagnosis is made clinically by the symptoms and

examination of symmetrically enlarged uterus Diagnosis is only confirmed by HPE

Adenomyosis (cont)

Treatment Medical treatment

Pseudopregnancy drugs: OCP/progesterone Pseudomenopause drugs: Danazol/GnRH

Surgical treatment Hysterectomy

Benign Ovarian Mass

Functional Cyst Most commonly found during reproductive age Rarely cause symptoms or require treatment Follicular cyst

Normally only one follicle will goes to full development and ovulation

Others degenerated and the follicular fluid is absorbed Replaced by fibrous and hyaline If fluid not absorbed: Follicular cyst. Rarely beyond 7 cm diameter Decrease in size and disappear within 6-8 weeks

Functional Cyst (cont)

Corpus luteum cysts During pregnancy, CL may become cystic and

enlarged No clinical significant; however if ruptured may

confused with ectopic Rarely get twisted

Functional Cyst (cont)

Theca-lutein cysts May occur in molar pregnancy Large cyst derived from theca cells or luteinized

granulosa cells Not require treatment unless it undergone torsion,

rupture or haemorrhage Cause by excessive HCG stimulation The cyst will disappear with the disease treatment

Benign Ovarian Mass

Luteoma of pregnancy Uncommon Occur in pregnancy and is the result of excessive

response of ovarian stroma to high level of HCG Tumour disappear once pregnancy terminated Occasionally they secrete androgen and cause hirsutism

of mother,and musculinization of female fetus Tubo-ovarian inflammatory mass Para-ovarian Cyst

Cysts arise from the mesonephric remnants and located in the mesovarium

Benign Ovarian Mass

Benign neoplastic cysts Epithelial tumour

Serous Mucinous Endometrial Clear cell or mesonephroid Adenofibromas Brenner

Sex Cord Stromal Tumour Thecoma, fibroma and Sertoli-Leydig cell

Germ Cell Tumours Mature teratoma

Benign Perineal masses

Benign solid tumour Condylomata Seborrheic Keratosis Acrochordons

(fibroepithelial polyps) Fibromas Neurofibromatosis Hidradenoma Accesory breast Sebaceous adenoma

Cystic tumor Epithelial inclusion

cyst Bartolin’duct (abscess

or cyst Mucous cyst Hydrocoele, hernia

and/or cyst of the canal of nuck

Benign Perineal masses

Cystic Masses Epidermal Inclusion Cyst

Sebaceous cyst Extremely common on the vulva and usually

appear as multiple small, firm subcutaneous nodule

Ocassionally are recurrently infected with associated irritation, demanding incision and drainage

Cystic Masses (cont)

Bartholin’s duct abscess/cyst Bartholin’s gland entering the interoitus just above

the fourchette at the vaginal outlet May be dilated as the result of chronic infection

and/or cyst formation

Thank