Department Of Obstetric & Gynecology

PELVIC MASS

Supervised by Dr Isam Lataifeh

Esra Sami Mohamed Fayez

JORDAN UNIVERSITY OF SCIENCE AND TECHNOLOGY

Introduction

Differential Diagnosis

Gynecological causes:

1) uterine masses

pregnancy fibroids endometrial carcinoma adenomyosis

Differential Diagnosis

2) Tubal masses inflammatory origin ectopic pregnancy carcinoma

3) Ovarian masses functional cysts endometriomas Ovarian neoplasms

Differential Diagnosis

Non - gynecological causes

bowel gas or faeces in sigmoid or caecum appendicitis diverticular diseases

miscellaneous distended bladder, pelvic kidney abdominal wall hematoma retroperitoneal neoplasm

History

age pain (onset and type,site ), menstrual status,

menstrual disturbances, interference with sexual activity , look for GIT symp (abd.bloating or fullness ,constipation or change in stool caliber)

parity, gravidity (obs hx), previous personal (past surgical & medical) and

family history family history breast( BRCA family Risk ), ovarian , GI

tumors + ( Fibroids have a familial pr) weight loss

Physical Exams

General exam (VS ,weight, hydration, anemia) Lymphadenopathy (supraclavicular) chest + breast exam abdominal exam : masses and tenderness etc bimanual exam

(size,shape,irregularity ,mobility , consistency)

( sensitivity and specificity of pelvic exam R both only 50 %)

rectovaginal exam (post.uterine surface, uterosacral ligament , POD, rectum )

FIBROIDS

tumors or lumps made of muscle cells and other tissue that grow within the wall of the uterus.

may grow as a single tumor or in clusters

Where do uterine fibroids grow?

Where do uterine fibroids grow?

Submucosal fibroids grow just underneath the uterine lining.

Intramural fibroids grow in between the muscles of the uterus.

Subserosal fibroids grow on the outside of the uterus.

Pedunculated fibroids grow out from the surface of the uterus, or into the cavity of the uterus

Symptoms (patient’s history)

GYNECOLOGICAL PROBLEMS

1) Abnormal vaginal bleeding- intermenstrual- menorrhagia- irregular bleeding

2) Pain -acute (degeneration & torsion)-chronic pelvic pain-deep dysparunia pain-throughout menstruation

Symptoms cont’

3) Pressure symptoms

- bladder pressure

- bowel compression

- nerve compression

4) Infertility

-tube obstruction

-interfere with implantation

Associative Risk Factors

Hereditary? Null parity Black women, low in asian Age : 35-50 (reproductive age) – estrogen &

progesterone’s role- Fibroids grow rapidly during pregnancy when

hormone levels are elevated.- Fibroids shrink after menopause when hormone

levels are decreased. Obesity is associated with the presence of uterine

fibroids. *genetic, hormonal, environmental

Investigation & Diagnosis

complete blood count (CBC) - anaemia blood tests (bleeding disorder & hormonal

level) Most often confirmed by transabdominal

ultrasound Transvaginal ultrasound endometrial biopsy – rule out carcinoma

Investigation & Diagnosis

Pelvic exams

Hysterosalpingography - uses a dye to highlight the uterine cavity and fallopian tubes on X-ray images.

Hysteroscopy - small, lighted telescope

MRI, CT Scan

Management and Treatment

Treated only if :

-symptomatic regardless of the size

-if the size > 12 W fetal gestational age even if

it’s asymptomatic Medical Rx

- Uterine Artery Embolization

- GRHA & Androgens Analogues Surgical Rx

-myomectomy

-hysterectomy

Surgical Rx

Myomectomy (laparoscopy, hysteroscopy, open laparatomy)

-removes only the fibroids and leaves the healthy areas of the uterus in place

-preserving ability to have children

Surgical Rx

Hysterectomy

-removal of the whole uterus

-done if fibroids are large + abnormal bleeding + nearly menopause + not wanting children

Types of hysterectomy

Abdominal hysterectomy is a procedure that involves a cut into the abdomen to remove the uterus.

Vaginal hysterectomy is less invasive because the doctor reaches the uterus through the vagina, instead of making a cut into the abdomen

Medical Rx

Uterine Artery Embolization (radiology intervention) - cuts off the blood supply to the fibroids, making them shrink

-access to femoral artery

-tiny tube into the vessel

-guided to the uterus (fluoroscopy)

-inject tiny plastic particles into artery supplying the fibroid

-fibroid shrinks

Uterine Artery Embolization

Uterine Artery Embolization

Advantages

- Relief of symptoms in 85 %

- non-surgical, safe

- no significant blood loss

- one-night stay

- resume daily activities in short time Disadvantages

-moderate to severe cramps

-injury to uterus

-infection

Focused ultrasound surgery

inside of a specially crafted MRI scanner visualize fibroid’s anatomical location, and

then locate and destroy (ablate) them focused high-frequency, high-energy sound

waves are used to target and destroy the fibroids

single treatment session is done in an on- and off-again fashion, sometimes spanning several hours

Focused ultrasound surgery

Medical Rx

Gonadotropin Releasing Hormone Agonists

-Estrogen and progesterone levels fall, menstruation stops, fibroids shrink and anemia often improves

Androgens

-Danazol, a synthetic drug similar to testosterone, has been shown to shrink fibroid tumors, reduce uterine size, stop menstruation

Obstetric Complications

Abortions (submucous) Abnormal fundal height, lie and presentation Failure of implantations Abnormal labor Preterm labour and prematurity Atonic postpartum haemorrage

~ sarcomatous change?