8:30 - 9:25 WS #99: Masses in the Pelvis

9:35 - 10:30 WS #111: Masses in the Pelvis (Repeated)

Mr Doug BarclayGynaecologist

Ascot Central Women’s Clinic

Auckland

Mr Simon EdmondsGynaecologist

Middlemore Hospital

Auckland

Douglas Barclay

&

Simon Edmonds

Masses in the Female Pelvis

Middlemore Hospital and Ascot Central Women’s Clinic

Today’s Talk

• Pelvic Masses

– Location, investigation and management

• Red Flag referral guidelines

– Risk of Malignancy Index

• Case Histories

Pelvic Masses

A Pelvic Mass Pathway

Pregnancy Mass - Quiz

Anatomical location

Functional Ovarian Cyst

Hydrosalpinx

Paratubal Cyst

Age

• Infants

– Rarely adnexal cysts from in utero hormones

• Puberty

– Haematocolpos (vaginal mass)

• Reproductive age

– Pregnancy

– Fibroids

– Functional ovarian cysts

– Adnexal masses eg TOA or hydrosalpinx

– Endometriomas

• Postmenopausal

• - ?Cancer

History

Gynae Hx

Acute Pain

– Ovarian torsion

– Ovarian cyst accident

– PID

– Fibroid degeneration

Dysmenorrhoea

Examination

• Distinguishing uterine from adnexal masses

Investigations

• Urine pregnancy test

• TVUS

• Ca125

Ovarian masses

Ovarian Cysts – Dermoid Cyst

Ovarian Torsion

US benign ovarian mass

Simple Cysts

Ultrasound of a Malignant Ovarian Mass

Malignant Ovarian Mass

IOTA Group US characteristics

Risk of Malignancy Index

Management of Ovarian Cysts

BEAT Ovarian Cancer / Symptoms

GP Red Flags

• Histology / Cytology Positive

• V, V, Cx – abnormal lesion

• Gynae Sx AND abnormal examination

• PMB

• Pelvic Mass

• Genetic risk and Sx

Gynae Onc Referral

Faster Cancer Pathway

• 62 day pathway. Referral receipt to first cancer treatment

• 31 day pathway. Decision to treat to first cancer treatment.

FCT

Summary

• Large variety of pelvic masses

– framework for diagnosing and treating

• Pelvic mass - referrals

Case History 1 – 13 yo Acute Admission

• 5/7 Hx of lower back pain & constipation

• ?bilateral ovarian masses on US

History

• Never sexually active – BHCG negative

• No menarche

• No cyclical pain or urinary retention

• Normal secondary sexual characteristics

Bilateral pelvic cystic adnexal masses

Uterine appearance on US

Catia Correia et al. BMJ Case Reports 2015;2015:bcr-2015-209303

Imperforate hymen / Haematocolpos

• Most common cause of genital outflow obstruction

• Common Sx – abdominal/back pain, primary amenorrhoeaand urinary retention

Case History 2 – 43 yo Cervical Smear

• No specific complaints

• K = 5 / 28-30; regular

• Periods heavier recently

• Bimanual – enlarged 8 wk mobile uterus

TVUS

Fibroids

• Most common benign uterine tumour.

• Most are asymptomatic; however, can present with excessive uterine bleeding, symptoms secondary to pressure on bladder and rectum, and, less often, distortion of the uterine cavity, leading to miscarriage or infertility.

• An enlarged irregular uterus may be found on examination and the woman may be anaemic because of menorrhagia.

• Pelvic ultrasound usually shows well-circumscribed uterine tumours.

• No treatment required if asymptomatic, but follow-up should be scheduled annually.

• If symptomatic, definitive treatment is surgical, including hysterectomy when fertility is not desired, and myomectomy to preserve fertility.

• Non-surgical treatments include uterine artery embolisation, gonadotropin-releasing hormone agonists, or symptomatic management with non-steroidal anti-inflammatory drugs (NSAIDs).

Case History 3 – 32 yo Menstrual Pain

• Dysmenorrhoea

• Dyspareunia

• Dyschezia

• Pelvic Mass: R/V fixed, tender uterus with bilateral adnexal masses

Endometriosis

Case History 4 – 57 yo Maori Woman

• Admitted to ITU with chest pain, SOB, severe hypotension

• Urgent echo: right ventricular emboli

• CTPA: multiple PE

• Rx: Streptokinase and significant respiratory support

• Abdominal examination: NAD

• Discharged 3 weeks later on anticoagulation

Readmitted 6 mths later – inflamed umbilicus

Beware Abdominal Pain with increased BMI

Thankyou