Gynecologic Pathology as it Relates to General Surgery
Lily Shamsnia, MDDepartment of Obstetrics and Gynecology
Tulane University School of Medicine
GYN vs. General Surgery
• Many Gynecologic disorders mimic those of General Surgery, especially regarding etiology of acute and chronic pelvic pain, as well as the diagnosis/treatment of an acute abdomen.
• Abdominal pain may be infectious, inflammatory, anatomic or neoplastic
Acute right lower abdominal pain in women of reproductive age: Clinical clues Hatipoglu, et. al
Patient (n=290), n (%) Age (yr)
Acute appendicitis 224 (77.2) 21 (12-24)
Perforated appendicitis 29 (10) 22 (14-42)
Ovarian cyst rupture 21 (7.2) 24 (15-38)
Corpus hemorrhagic cyst rupture 12 (4.2) 21 (13-55)
Adnexal Torsion 4 (1.4) 24 (19-30)
290 female patients presenting to ED with acute abdominal pain
Alvarado ScoreAlvarado Score Point Value
Abdominal pain migrating to RLQ 1
Anorexia or urine ketone 1
Nausea or vomiting 1
Tenderness in RLQ 2
Rebound tenderness 1
Fever 1
Leukocytosis 2
Neutrophilia 1
Scoring: 0-4: unlikely appendicitis 5-6: consistent with dx of appendicitis 7-8: probable appendicitis 9-10: very probable appendicitis
Symptoms/signs of appendicitis similar to many GYN disorders
Approach to Acute Abdominal/Pelvic pain in a Female
• History and physical exam• Bimanual and speculum exam• UPT/ serum bHCG• Cervical cultures • Radiologic studies
DDx pelvic pain of GYN origin
• Pelvic Inflammatory Disease (PID)• Tubo-ovarian Abscess (TOA)• Endometriosis• Ruptured or Hemorrhagic Ovarian Cyst• Adnexal Torsion• Uterine Fibroids• Ectopic Pregnancy
Pelvic Inflammatory Disease (PID)
• Inflammation and infection of the upper female genital tract, including the cervix, fallopian tubes, and uterus.
• Peritonitis also may be present. • Early diagnosis and treatment to prevent long-
term morbidity is key. • An episode of PID can cause recurrent/chronic
PID, chronic pelvic pain, ectopic pregnancy, infertility.
PID
• Ascending infection from the lower genital tract. – Neisseria gonorrhoeae, – Chlamydia trachomatics, – Diptheroids, – Gardenella vaginalis, – Mycoplasma genitalium, – Bacteroides, – Anaerobes, – Streptococci
• > 50% cases have more than one organism isolated
PID
• Symptoms/signs mimic that of appendicitis due peritoneal irritation and can often be vague/ misleading
• Diagnosis missed in up to 35% of patients. • Mucopurulant cervical/vaginal discharge is
present with PID
PID- CDC Diagnostic Criteria• Minimal Dx Criteria-
– Pelvic or lower abdominal pain AND – CMT OR uterine tenderness OR adnexal tenderness
• Additional criteria:– oral temperature >101 F– Cervical/vaginal mucopurulent discharge– WBC on microscopy of vaginal secretions– Elevated ESR– Elevated CSR– Documented gonorrhea/chlamydia cervical infection
• Most specific– Endometrial biopsy showing endometritis – Radiographic imaging showing thickened fluid filled tubes indicative of
infection– Laparoscopic abnormalities consistent with PID
PID
• Ultrasound– Transvaginal preferable – Uterine enlargement/thickened endometrium – Ovarian enlargement (reactive inflammation)– Edematous distended fallopian tubes with
hypervascularity on Doppler US• CT scan– Pelvic inflammation and fat stranding, indistinct
tissue planes.
PID- Ultrasound
Ovary
Dilated fallopian tube
PID- CT scan
Right side , normalLeft side, thickened/inflamed tubal wall
PID- treatment
• Outpatient: Ceftriaxone 250 mg IM PLUS Doxycycline 100 mg PO BID x 14 days +/- Metronidazole 500 mg PO BID x 14 days
• Inpatient: – A: Cefoxitin 2 g IV q 6 hours PLUS Doxycycline 100 mg PO/IV
q 12 hours– B: Ampicillin/Sulbactam 3 g IV q 6 hours PLUS Doxycycline
100 mg PO/IV q 12 hours • Diagnostic laparoscopy vs exploratory laparotomy- If
diagnosis is unclear ( i.e. PID vs appendicitis vs TOA), or no improvement with antibiotics
PID on laparoscopy
Fitz High Curtis
• Occurs with pelvic inflammation of PID spreads to right upper quadrant via right paracolic gutter and involves peritoneal surface of liver.
• Violin-string adhesions, typically encountered during laparoscopy, typically laparoscopic cholecystectomy
Fitz High Curtis
Tubo-Ovarian Abscess (TOA)
• 35% of women with PID, 20-40 years old, small percentage postmenopausal.
• 2/3 are unilateral- may lead to misdiagnosis of appendicitis if on right side.
• Initial insult to the female genital tract- inoculation and destruction of fallopian tube epithelium a purulent exudate with low oxygen environment favorable for anaerobic organisms.
• Inflammatory response induces edema, ischemia, and necrosis of fallopian tube.
TOA
• Surrounding structures may become involved in the expanding inflammation and walled off abscess, including ovary, round ligament, broad ligament, contralateral fallopian tube and ovary, appendix, bowel, and bladder.
• With expansion, rupture of TOA can occur. • TOAs can be the result of non- gynecologic
disease, including diverticulitis, appendicitis, inflammatory bowel disease, and surgery.
TOA• Polymicrobial:
– E. coli, – Bacteroides– Peptostreptococcus– Enterococcus– Klebsiella– Staphylococcus– Streptococcus– H. influenza.
• N. gonorrhoeae and C. trachomatis are rarely cultured from TOAs.• Anaerobic bacteria are present in 60-100% of TOA cultures.
TOA
• Lower abdominal pain (acute vs chronic), nausea/vomiting
• +/- fevers/chills- up to 50% of patients are afebrile • If bowel is involved- anorexia/diarrhea • Leukocytosis- present but not reliable indicator • Palpable abdominal/pelvic mass, rebound
tenderness/guarding• CMT, mucopurulent discharge, vaginal
discharge/abnormal bleeding
TOA- Imaging
• Ultrasound- sensitivity > 90% for diagnosis. – Transabdominal- larger field of view for identifying adnexal
masses.– Transvaginal- detailed view of pelvic anatomy and
vasculatyure. • Appear complex, multilocular, cystic with thickened
walls and internal echoes/debris. • Tubal and ovarian architecture disordered with
destruction of planes between the ovary and developing abscess.
• Cogwheel sign- thickening of endosalpingeal folds.
TOA- Imaging
• CT scanning if diagnosis is unclear- septated tubular structure with thickened walls.
• Hydronephrosis/hydroureter may be seen when surrounding tissue is involved with the inflammation.
• Gas bubbles within the fluid collection- highly specific for TOA
• TOA vs. appendicitis- TOA was highly associated with appearance of abnormal ovary, peri-ovarian fat stranding, small bowel and recto-sigmoid thickening, and free fluid in the pelvis.
TOA on US
TOA on CT
Appendicitis on US
Appendicitis- CT Imaging
TOA- Treatment
• Treat infection and preserve fertility• Mainstay of therapy is antibiotics +/-
additional drainage procedures ( image guided transabdominal or transvaginal approach)
• Parenteral antibiotics until 48 hours afebrile; continuation of oral antibiotics for 14 days
TOA- Surgical Treatment
• 1) Concern for alternative surgical emergency i.e. appendicitis, cholecystitis, bowel obstruction/perforation
• 2) Failure of clinical response after 48-72 hours of medical therapy
• 3) Intra-abdominal rupture of TOA- emergent surgery warranted due to hemodynamic instability, sepsis, multi-system organ failure
TOA on laparoscopy
Endometriosis
• Defined as presence of endometrial glands and stroma outside uterine cavity.
• Most accepted theory- development is retrograde menstruation. Other theories include coelemic metaplasia of endometrial tissue with lymphatic spread, and transformation of embryonic rests.
Endometriosis
• Prevalence - 7-10% in general population; up to 50% in infertile women
• 60% of women with dysmenorrhea, 87% of women with CPP
• Symptoms- dysmenorrhea, dyspareunia, CPP, pain with ovulation, micturition, defection
• Risks- early menarche, short menstrual cycles, reduced parity, heavy bleeding
• Increased risk- tall /thin women, excess alcohol and caffeine
Endometriosis
• Most common location of endometrial implants is the ovaries, followed by deep/central pelvis and vesico-uterine pouch
• 60% of Stage IV disease involves intestinal tract (rectum, sigmoid, colon, appendix, small bowel)
• With Stage IV disease- pain mediated by deep infiltrating endometrial lesions in muscular propria of surrounding organs
Endometriosis Treatment
• 1st line- NSAIDs and hormonal therapy • If pain is refractory, surgical intervention is
warranted, with laparoscopic ablation or removal (preferred) of endometrial implants
• With significant bowel/bladder involvement, laparotomy may be required
Endometriosis
• MRI- superior for detection of endometriomas- hyperintense signal of T1 weighted imaging or hypodense signal of T2 imaging
• CT- endometrioma appears as cystic mass with hyderdense clot within
• US- used to assess endometrioma involving ovary- hypoechoic cystic structure
Endometrioma on MRI
Endometrioma on US
Endometriosis on laparoscopy
Catamenial pneumothorax
• Recurrent pneumothorax occurring within 72 hours of onset of menses.
• SOB, CP, cough; usually RIGHT sided • Manifestation of thoracic endometriosis, likely
via transdiaphragmatic lymphatic/vascular transplantation of endometrial tissue
• Confirmed by presence of endometrial glands and stroma within pleura or diaphragm
Ruptured/Hemorrhagic Ovarian Cysts
• Most common- functional cysts, including corpus luteal cysts/ follicular cysts, which are more prone to rupture due to increased vascularity as part of the menstrual cycle
• Rupture typically occurs between 20-26 days of menstrual cycle (i.e. luteal phase, after ovulation has occurred)
Ruptured/Hemorrhagic Ovarian Cysts
• Mittelschmerz- sensation of pain and release of peritoneal fluid associated with physiologic rupture of corpus luteum, cyst during ovulation
• Ruptured cyst- most commonly right sided• Usual symptoms- acute pain, vaginal bleeding,
nausea/vomiting, shoulder tenderness• If associated with massive hemorrhage- signs of
circulatory collapse
Ruptured/Hemorrhagic Ovarian Cysts
• Ultrasound- thin wall, anechoic; with hemorrhage and clotting of blood- internal echoes appear with fluid and debris
• With massive hemorrhage- free intraperitoneal fluid present, while cyst itself is collapsed
Hemorrhagic Ovarian Cysts
Ruptured/Hemorrhagic Ovarian Cysts
• Hemodynamically stable- conservative management, analgesia, observation
• Unstable- emergent surgical intervention, even if diagnosis is uncertain
• If active/uncontrollable bleeding present- oophorectomy recommended; otherwise, conservative management with preservation of ovary is preferred
Ovarian Torsion
• Partial/complete twisting of adnexa around its vascular pedicle ( infundibulopelvic ligament and tubo-ovarian ligament)
• Vascular and lymphatic obstruction results, leading arterial occlusion and ovarian necrosis
• Right adnexa most commonly involved, possibly due to longer utero-ovarian ligament on the right vs. decreased mobility of left adnexa due to presence of sigmoid colon
Ovarian Torsion
• Commonly associated with ovarian mass (cyst, neoplasm, etc) as a fixed point around which adnexa may twist
• Previous pelvic surgery also increases risk, likely due to post surgical adhesions around which adnexa can twist
• Patients with ovarian hyperstimulation syndrome (due to assisted reproductive technology) also at increased risk
Ovarian Torsion
• Acute pelvic/abdominal pain; prolonged pain associated with high risk of necrosis
• Nausea, vomiting, dysuria, urinary retention, frequency, urgency
• Low grade leukocytosis/fever less common • Peritoneal signs
Ovarian Torsion
• Ultrasound- gold standard • Enlarged ovary (>5 cm) with edema• Absent arterial/venous flow is highly specific
for torsion • Pelvic free fluid present with
infarction/hemorrhage
Ovarian Torsion
No Doppler Flow
Ovarian Torsion
“Whirlpool sign”
Ovarian Torsion
• Preferred surgical treatment- laparoscopic detorsion with salvage of adnexa
• Oophorectomy warranted if ovary appears necrotic, ovarian mass present, or there is evidence of peritonitis
• If ovary is salvageable, consider ovarian suspension to decrease likelihood of recurrence.
Ovarian Torsion
Ovarian Torsion
Ovarian Torsion in Pregnancy
• Adnexal torsion is the most common complication of an adnexal mass occurring during pregnancy, typically in 1st and 2nd trimesters
• If ovarian mass without torsion is noted, surgery is performed in 2nd trimester
• If torsion is present, surgery is warranted regardless of gestational age
Uterine Fibroids
• Most common pelvic tumor in women; consist of hormonally responsive smooth muscle cells, which can lead to progression during pregnancy or with hormonal contraceptive use, and typically regress after menopause
• Most common symptoms- abnormal vaginal bleeding, pelvic pain and pressure
• Hydronephrosis can occur with chronic impingement of ureter
Uterine Fibroids
Degenerating fibroids that have outgrown/lost blood supply can present as acute abdominal pain
Ultrasound- anechoic, irregular cystic spaces within the fibroid, indicating necrosis
Ectopic PregnancyDefined as any pregnancy outside uterine cavity, most commonly in the fallopian tube (ampulla> isthmus> fimbria), abdominal cavity, ovary, cervix, or uterine cornua
Typically occur between 6-10 weeks gestation, and is the leading cause of death during the 1st and 2nd trimesters of pregnancy
Ectopic Pregnancy
• Risk factors- previous ectopic pregnancy, history of PID, previous pelvic surgery, smoking, infertility, intrauterine device use
• Symptoms- pelvic pain, vaginal bleeding • Quantitative bHCG- initial test– if >1500 mIU/mL, pregnancy can be seen on
transvaginal US– If > 5000 mIU/mL, pregnancy can be seen on
abdominal US
Ectopic Pregnancy
• US evaluation- 1st evaluate if pregnancy is intrauterine; at 5 weeks gestation (corresponding to bHCG between 1000-2000 mIU/mL) a gestational sac should be visible
Ectopic Pregnancy
• With ectopic pregnancy- gestational sac/fetal pole +/- cardiac activity seen outside the uterine cavity
• Adnexal mass separate from ovary with empty uterus, free fluid in pelvis, tubal “donut” sign and “ring of fire” on Doppler ultrasound
Ectopic Pregnancy on US
Ectopic Pregnancy- “Ring of Fire”
Ectopic Pregnancy
• If unruptured and hemodynamically stable- can consider conservative management with medical therapy i.e. Methotrexate with follow up of serial bHCG levels at day 4 and day 7 after injection, and then weekly until negative
• If bHCG fails to decrease by 15% from day 4 to day 7 after MTX injection, consider additional MTX injection vs. surgery
Ectopic Pregnancy
• If ruptured, emergent surgery is indicated, especially if hemodynamically unstable
• Depending on degree of patient stability, surgical approach via laparoscopy (preferred) versus laparotomy, with salpingostomy versus salpingectomy
• Salpingectomy indicated with uncontrolled bleeding, severely damaged fallopian tube, large gestational sac (> 5 cm)
Ectopic Pregnancy
Appendicitis in Pregnancy• 1/800 - 1/1500 pregnancies, incidence slightly
higher in the second trimester • Appendiceal rupture occurs more frequently
in pregnant women, especially in the third trimester -possibly due to inconclusive symptoms/reluctance to operate on pregnant women delaying diagnosis and treatment; associated with higher risk of fetal loss (36% vs. 1.5%)
Appendicitis in Pregnancy
• Less likely classic presentation, especially in late pregnancy– More GI complaints– Leukocytosis is common with pregnancy
• Pain typically originates at McBurney's point regardless of the stage of pregnancy; however, location of the appendix migrates a few centimeters cephalad with the enlarging uterus
• In the third trimester, pain may localize to the mid or even the upper right side of the abdomen
Appendicitis in Pregnancy
• US- wide variation in the diagnostic performance during pregnancy; gravid uterus can interfere with visualizing the appendix and performing graded compression (particularly in the third trimester)
• CT imaging- when clinical findings and ultrasound examination are inconclusive and MRI is not available
Appendectomy in Pregnancy
• Open preferred if late gestation• Laparoscopic – slight left lateral positioning if 2nd trimester and
beyond– avoid cervical instrumentation– open entry techniques/ trocar placement under
direct visualization– limit intra-abdominal pressure to less than 12
mmHg
Cholelithiasis in Pregnancy
• Gallstones are more common during pregnancy- decreased gallbladder motility/increased cholesterol saturation of bile– Estrogen increases cholesterol secretion– Progesterone reduces bile acid secretion and slows
gallbladder emptying, promoting the formation of stones via biliary stasis
• In pregnant women with biliary colic, supportive care will lead to resolution of symptoms in most cases, but the symptoms frequently recur later in pregnancy
Cholelithiasis in Pregnancy
• 1st episode - supportive care vs. cholecystectomy (laparoscopic if in 1st/2nd trimesters)– low risk of fetal mortality and high risk of disease
relapse/need for urgent surgery later in pregnancy. • Acute cholecystitis cholecystectomy – If near term- conservative management is
preferable as surgery is technically difficult, with plan for cholecystectomy 6 weeks postpartum
The End!Questions?