Pelvic Mass

Benign ovarian tumors unilateral, 99% cystic, mobile,

smooth
Malignant ovarian tumors bilateral, cystic & solid, fixed,
irregular, 50% have ascites, cul-de-sac nodules, rapid growth
rate
!" & endometriosis fixed li#e malignant ovarian tumors
$%, !", & liver d& can present w' ascites
( )0% of abd masses in #ids * + years are renal in origin
Pelvic kidney occurs in ( ,5% of girls w'o vagina or uterus
-drenal-renal tumors are partially cystic, partially solid
do ultrasound first, .$ scan second
elvic mass in pre-pubertal female /0 age +1
21% ovarian/tubes
o 100% neoplastic
20% benign3 )0% malignant
o 95% are germ cell tumors
!% bladder/renal
o 95% adrenal-renal tumors
MC presentation = palpable mass (85%), abd pain
& discomfort (55%)
All ovarian masses in pre-pubertal females
require surgery
elvic mass in young reproductive age female /,5-+0yo1
0% ovarian/tubes
o "0% p#ysiologic
o ,5% neoplastic
$!% benign
95% of neoplasms are germ cell
tumors
2$% uterus
o ,00% pregnancy related
elvic mass in pre-menopause female
!!% ovarian/tubes
o +5% physiologic
o 55% neoplastic
!% benign3 +5% malignant
40% of neoplasms are epithelial
tumors
45% of those are lo%
malignant potential
o 5% endometriosis
o 4% !"
o 5% 6ctopic precnancy
&0% uterus
o 45% pregnancy related
o ,5% leiomyomata
&% bo%el
,
elvic mass in post-menopause female
&"% ovarian/tubes
o 100% neoplastic
20% benign3 )0% malignant
o 90% are epit#elial tumors
99% of those are invasive ca
&0% uterus
o !!% cancer of uterus
o +5% cancer of cervix
o +0% leiomyomata
10% bo%el
o )0% infection3 &0% cancer
Most require surgery
Always investigate tmor mar!ers
o '() * colon cancer
o ')12! * ovarian cancer
o )+P * germ cell cancer
alpable ovary
o .ystic, * 5 cm, and normal .-,+5 0-
,% chance of malignancy
o 7ulticystic w' echoes, * 5 cm, normal
.-,+5 -10% chance of malignancy
o .ystic, 0 5 cm, and normal .-,+5 -
10% chance of malignancy
o 7ulticystic w' echoes, 0 5 cm, normal
.-,+5 2!-,0% chance of malignancy
Mullerian epithelium tumors of ovary M' in
reproductive age - post-menopausal females derived
from coelomic epithelium /peritoneum is too1 cause lower
abd pain and abd enlargement3 can cause massive ascites3
may have elevated Osteopontin
.erous cystadenocarcinomas 8 M' tumor of
ovary3 45% benign3 us9 bilateral & unilocular
o $issue resembles fallopian tube
epithelium
o Psammoma bodies
o Papillary pro/ections
o ')-12!
Mucinous cystadenomas 8 +
nd
7. ovarian
neoplasm3 50% benign3 5% bilateral3 us9
multilocular3 tissue resembles cervical epithelium
o :ining of tall columnar epithelial cells w'
apical mucin and absence of cilia
o 7iddle adult life
o Pseudomyxoma peritonei 8 extensive
mucinous ascites, cystic epithelial
implants on peritoneum
(ndometrioid carcinomas 8 ;
rd
7. ovarian
neoplasm3 )0% bilateral3 tissue resembles
endometrial epithelium
o ,5% assoc9 w' endometriosis
o ')-12!
'lear cell adenocarcinoma occurs w'
endometriosis or endometrioid carcinoma of ovary
'ystadenofibroma proliferation of fibrous
stroma
0renner tumors adenofibromas w' nests of
transitional cells glandular spaces lined by
columnar mucin secreting cells
Germ cell tumors of ovary M' in pre-puberty and
young reproductive age females
1eratomas M' germ cell tumors
o Mature 2benign3 teratomas 2dermoid
cysts3 hair, cheesy sebaceous material,
thyroid tissue cystic & solid
1x * laparoscopy %/ unilateral
salpino-oop#orectomy
o Monodermal teratomas
Struma ovarii 7. type,
composed entirely of thyroid
tissue, causes #ypert#yroidism
<varian .arcinoid type
/'arcinoid syndrome1
o 4mmature 2malignant3 teratomas hair,
cartilage, bone, calcifications3 fetal tissue
solid tumors
5ysgerminomas ovarian counterpart of
seminoma of testis M' malignant germ cell
tumor
o -ll are malignant3 no endocrine function
o !nfiltration w' mature lymphocytes,
occasional granulomas
(ndodermal sinus 2yolk sac3 t umors 2
nd
M'
malignant germ cell tumor fatal w'in + yrs pts
present w' rapidly developing pelvic mass w' abd
pain
o -fetoprotein 2)+P3
o 1-antitrypsin
o .c#iller-5uval bodies characteristic
glomerulus structure w' central blood
vessel enveloped by germ cells lined by
germ cells
6varian c#oriocarcinoma #ig# #'7
o =nresponsive to therapy fatal
o .ompare to trophoblastic choriocarcinoma
Sex cord stromal tumors of ovary
7ranulosa-1#eca cell tumors extremely rare
elaborate lots of (2 endometrial hyperplasia,
endometrial ca, cystic d& of breast3 us9 solid3 us9
unilateral3 acidophilic 'all-(xner bodies3 all
potentially malignant3 high levels of inhibin
o Can case complete psedoisose"al
precocity
+ibroma-1#ecomas us9 unilateral3 elaborate lots
of (2
o Meigs syndrome 8 nonspecific pain and
pelvic mass w' or w'o ascites and right-
sided hydrothorax3 benign condition
.ertoli-8eydig cell tumors 2adrioblastomas3 us9
unilateral3 masculini9ation3 pea# incidence in +
nd
-
;
rd
decades3 tumors may bloc# normal female sex
development /breast atrophy, amenorrhea, sterility1
+
:ilus cell tumors 2mature 8eydig cell tumors3
unilateral3 large lipid laden cells3 ;einke
crystalloids3 high 1-ketosteroid excretion
7onadoblastoma mixed tumors /germ cells and
stromal cells13 occurs w' hermaphroditism
Metastatic tumors of ovary
7. mets are from contralateral ovary, derived from
mullerian system neoplasms
7. extramullerian primaries 8 breast and >! tract
o <rukenberg tumor >! mets to ovaries3
mucin production3 signet-ring cells
5-,0% of women in =? will have surgery for suspected
ovarian neoplasm during lifetime
,5-+0% of these will have malignant ovarian
neoplasm
Most adnexal masses are benign
4nfant female /age * + years1 7. pelvic mass due to
transient elevation in circulating gonadotropins after birth
/p#ysiological ovarian cyst1
P#ysiologic 2functional3 ovarian cysts in reproductive age
female /age ,5-+01 repeat ultrasound in 2 wee#s b'c 5%
chance of neoplasm
Paratubal fallopian tube cysts 8 M' primary lesions of
fallopian tubes /tiny, translucent cysts filled w' clear serous
fluid13 develop from cranial portion of mesonephric duct
!ydatids of Morgagni 8 larger paratubal cysts near
fimbriated end
"eiomyomas #fibroids$ 45% of reproductive age females
M' tumor in humans %#orled bundles of smooth muscle
cells red degeneration
#enign metastasi$ing %eiomyoma extremely rare
7. to lung
&isseminated peritoneal leiomyomatosis multiple
small nodules on peritoneum
ris# for spontaneous abortion /esp9 if
submucosal1
7ost are -?x
"eiomyosarcoma us9 arise de novo /not from leiomyomas1
invade uterine wall <@ proAect into uterine lumen lots of
atypia pea# incidence )
th
-2
th
decades 50% mets to lungs,
bone, brain via bloodstream
Bibroid 6C:-@>!C> in a post-menopausal female
us9 indicates malignancy
erimenopausal female passing large clots, very irregular,
very heavy bleeding, enlarged uterus cancer of t#e
endometrium
%aginal carcinoma always @'< cervical carcinoma
( 95% are ?.. assoc9 w' :P=
>reatest ris# factor 8 previous carcinoma of cervix
or vulva
7. along upper posterior %all of vagina
;
&ervical carcinoma ( "0% are .'' assoc9 w' high-ris#
DE /esp9 type 1>1
7. variant 8 fungating /exophytic1
?tage , confined to cervix3 ?tage + extends beyond
cervix but not onto pelvic wall3 ?tage ; extends
onto pelvic wall3 ?tage ) extends beyond true
pelvis or involves bladder'rectum
o .an obstruct and cause hydronephrosis,
dilated ureter
?ymptomatic early on post-coital bleeding foul
smelling disc#arge
&ervical carcinoma ? 20% are adenocarcinomas
/endocervical gland origin3 assoc9 w' :P= type 1"1 <@
adenosFuamous carcinomas /mixed3 less favorable
prognosis1 <@ poorly differentiated /oat cell carcinomas3
poor prognosis due to early lymphatic spread1 <@ clear cell
adenocarcinomas /5(. exposure1
'!ip lesions
)cute Pelvic Pain
:-P @uick and to t#e point
Pregnancy-related
6ctopic pregnancy
-bortion
Gynecologic
-cute !"
<varian cyst /torsion, hemorrhage, rupture1
6ndometriosis
'ongynecologic
-cute appendicitis
=$! cystitis, pyelonephritis
"iverticulitis
(ctopic pregnancy
7. implantation is in fallopian tubes 2$!%3
7. predisposing condition is P45
7. cause of #ematosalpinx
7. cause of 1
st
trimester maternal mortality
o .auses 2% of all maternal deaths
(riad of symptoms = amenorr)ea, vaginal
bleeding, lower abd pain
Possible (ctopic pregnancy 8 7. clinical
presentation3 ultrasound shows no !=3 -h.>
level below discriminatory &one
Probable (ctopic pregnancy 8 lower pelvic pain,
spotting'bleeding, adnexal'cervical motion
tenderness, absence of != on ultrasound, -#'7
level 1!00-2000 25iscriminatory Aone3
)uptured (ctopic pregnancy * surgical
emergency3 severe abd pain, di&&iness, unstable
vital signs
"iagnostic tests 8 #'7 should double every )5
hours /if not, thin# 6ctopic or abortion13
transvaginal ultrasound should show gestational
sac by wee# 5 of amenorrhea
$reatment of 6ctopic pregnancy
o !f pt has no evidence of acute abd &
pregnancy is * ;95 cm w' no fetal heart
activity 90% cure w' met#otrexate
o 7ethotrexate is a chemotherapeutic agent
embryo dies & is resorbed
o !f pt is in -.=$6 pain, is spotting, has
lower left Fuadrant tenderness
laparoscopy
;isk factors for (ctopic pregnancy * previous (ctopic
pregnancy 2B13, Dx of !", cigarette smo#ers, Dx of tubal
ligation, Dx of tubal reconstructive surgery, use of assisted
reproductive technology
Cormal #'7 levels
5 wee#s gestational sac on sono h.> level ,500
!=':
2 wee#s fetal pole on sono h.> 5+00
4 wee#s fetal cardiac motion on sono h.>
,4,500
+hreatened abortion no $x, bed rest
?'? 8 GpainlessH bleeding before +0
th
wee# /can
have cramping1
,nevitable abortion empty gestational sac past 5-4 wee#s
%leeding, cramping, cervical dilation
$x 8 5-'
,ncomplete abortion passage of tissue3 some retained
Missed abortion dead fetus, retained
Co bleeding, cramping, or passage of tissue
ris# of coagulopat#y
$x 8 5-( /dilation and evacuation1
&omplete abortion all products of conception passed
severe bleeding w' large clots, severe lower abdominal
cramping, cervix dilated
( ;0% of pregnant women will bleed in ,
st
trimester
half will abort 2? 1!%3
half will continue w' normal pregnancy
)uptured ovarian cyst
=ltrasound free fluid in pelvis
?urgical intervention if orthostatic & anemic
<bservation and C?-!"s if not orthostatic and
anemic
Ovarian +orsion 8 twisting of vascular ovarian pedicle or
fallopian tube3 bigger cysts are more li#ely to twist
<ccludes lymphatic & venous drainage of adnexa
)bsence of blood flo% on "oppler
=ltrasound presence of adnexal mass
)
7ust be treated surgically
Digh index of suspicion in female w' repeat
episodes of abd pain and Dx of "E$Is w' oral
contraceptive use
Pelvic ,nflammatory -isease #P,-$ upper reproductive
tract infection, us9 ascending
7. bilateral
7. etiologic agents 8 gonococcus, c#lamydia
S.S * fever/ pelvic mass/ tenderness/ acute abd/
high 0B&/ mucopurulent cervicitis
.an cause pyosalpinx, hydrosalpinx,
infertility
.omplications
2J ris# for 6ctopic pregnancy
,)J ris# for infertility
2-,0J ris# for pelvic pain
+it9-:ug#-'urtis syndrome =@K pain
due to infection of liver capsule
"x by laparoscopy
"iagnose and treat empirically in sexually
active female w' ris# factors &
uterine'adnexal'cervical motion tenderness
$x 8 antibiotics
4npatient if pregnant, failed oral $x,
unreliable pt, severe illness, tubo-ovarian
abscess
.an be caused by Actinomycosis assocD %/ 4E5
us9 unilateral in this case
(ndometriosis 8 presence of endometrial glands outside of
uterus
.lassic triad 8 dysmenorr#ea, dyspareunia,
dysc#e9ia
o "ysmenorrhea ,-+ days prior to menses
early in clinical course
o "yspareunia deep thrust penetration
?'? 8 tenderness, echogenic ovarian mass, fixation
of uterus w' nodularity of uterosacral ligaments,
chocolate cysts
7. in pre-menopause female
7. cause of secondary dysmenorr#ea
7. cause of cul-de-sac nodularity
"6B!C!$!E6 "!->C<?!? 8 biopsy at time of
laparoscopy
"6B!C!$!E6 $x 8 surgical /total abdominal
hysterectomy w' bilateral salpingo-oophorectomy3
laparoscopy w' ablation and excision of implants1
7edical $x 8 oral contraceptives, C?-!"s, >n@D
agonists /bserelin, leprolide acetate3 temporary
$x for ( , year1, "ana&ol
Appendicitis * 7. intestinal source of acute pain in women
?'? 8 abd pain, anorexia, vomiting, normal %,
normal pulse, temp ,00-,0,95
)cute abdomen pain starts periumbilical, shifts
to @:K w'in hours
L%. ,+,000-,5,000 /normal ;,000-,0,0001
!f L%. 0 +0,000, thin# about rupture
$x 8 surgical
Acute abdomen 8 rebound & guarding
"ue to blood, pus, or chemicals irritating
peritoneum
%owel problems that can present as pelvic mass 8
inflammatory or neoplastic bo1el d2/ ulcerative colitis/
regional ileitis/ diverticulitis
Bluctuant adnexal mass could be inflamed bowel in
pelvis
?tool guaiac positive for occult blood
$x 8 corticosteroids
5ysmenorr#ea
:-P more broad and in dept#
Primary dysmenorrhea 8 pain w' menses3 no defined
pathology3 us9 starts w'in 2-,+ mos9 of menarche
elvic cramping, pain radiating to bac# or thighs,
diarrhea, headache, nausea, vomiting
Secondary dysmenorrhea 8 pain w' menses due to defined
pathology /7. due to endometriosis1
<ther causes 8 adenomyosis, fibroids, ovarian
cysts, pelvic congestion syndrome, congenital
malformations
,
st
line $x for dysmenorrhea 8 C?-!"s M oral contraceptives
C.)45s bloc# prostaglandin release
o Caprosyn, -leve, .elebrex, 7otrin, -dvil
6ral contraceptives suppress endometrial growth
o -novulation prostaglandin levels
!f ,
st
line $x fails laparoscopy and ultrasound to loo# for
secondary cause of dysmenorrhea
'#ronic Pelvic Pain
:-P very meticulous
&hronic pelvic pain 8 non-specific pain 0 2 mos9 duration
unrelieved by C?-!"s3 pain affects Fuality of life
,'; have no apparent pathology on laparoscopy
,'; have endometriosis
N-,'; have adhesions Ofrom prior surgeryP or
remnants of chronic !"
>ynecologic causes 8 endometriosis, adenomyosis,
adhesions, chronic !", leiomyomata, pelvic congestion,
ovarian remnant syndrome
Pelvic congestion syndrome 8 dilated veins in pelvis3 assoc9
w' post-coital aching
5
Ovarian )emnant Syndrome 8 previous hysterectomy but
some ovarian cortex left behind
>astrointestinal causes of chronic pelvic pain 8 !%?,
inflammatory bowel d&, hernia
=rologic causes of chronic pelvic pain 8 interstitial cystitis
/common1, urethral syndrome
%ladder 8 most neurally sensitive organ in the body
7usculos#eletal causes of chronic pelvic pain 8 abd wall
defects, incisional neuroma, pelvic diaphragm ?'"
<nly +-4% of all afferents passing thru each dorsal
root ganglion are visceral & 9;-95% are somatic
cross-tal# viscerosomatic pain referral
o @eason for referred pain to pelvic floor
sychiatric causes of chronic pelvic pain 8 depression,
somati&ation, hypochondriasis
6 incl9 chec# abd wall, F-tip test for vestibulitis /indicates
referred pain1, abd wall trigger points, ovarian point
tenderness /suggests pelvic congestion syndrome1, pelvic
floor myalgias /transvaginal single digit exam1, piriformis
screen, traditional bimanual exam /last portion of pelvic
exam1
Pelvic 6rgan Prolapse
Cormal, standing female bladder, upper +'; of vagina, and
rectum are #ori9ontal urethra, lower ,'; of vagina, and
anal canal are vertical
Primary support of pelvic organs 8 pelvic diaphragm
muscles
+ailure of primary support 7. due to term
labor and delivery3 also caused by intra-
abdominal pressure /chronic cough, heavy lifting,
constipation, etc1 and iatrogenic factors /surgery1
7uscles of pelvic diaphragm incl9 levator ani
/pubococcygeus & iliococcygeus1,
ischiococcygeus, pubovaginalis, puborectalis,
piriformis, obturator internis
Secondary support of pelvic organs 8 endopelvic fascia
,1 .ardinal-uterosacral ligament complexes
/suspensory3 apical axis1
a9 Dold bladder and vagina up
+1 aravaginal supports /hori&ontal axis3 paravaginal1
a9 ubocervical fascia holds uterus up
b9 @ectovaginal fascia holds rectum down
;1 Eertical orientation of urethra, vaginal outlet, anal
canal
+ailure of cardinal-uterosacral ligaments apical
vaginal prolapse /vagina drops out1
+ailure of pubocervical fascia anterior vaginal prolapse
cystocele 8 bladder bulges thru ant9 wall of vagina
+ailure of rectovaginal fascia posterior vaginal prolapse
rectocele 8 rectum bulges thru post9 wall of vagina
enterocele 8 loop of bowel bulges thru post9 wall of
vagina
Splinting 8 placement of finger in vagina to have bowel
movement3 7. if pt has rectocele
"x of prolapse 8 speculum exam, rectal exam
Consurgical $x 8 Qegel exercises, pessaries
?urgical $x 8 lots3 can only repair brea#s in continuity of
endopelvic networ# /fixes secondary failures, not primary1
4ncontinence
Genuine stress incontinence #GS,$ /50-40% of cases1 lea#
w' coughing, laughing, snee&ing3 no detrusor contraction
!ypermobility of bladder nec3 due to wea#
pelvic diaphragm muscles and connective tissue
/pubocervical fascia1 7. after c#ildbirt#
o Bire hose in muddy ground
,ntrinsic sphincter deficiency #,S-$ severe form
of >?!3 Gstove pipeH uret#ra
+x = estrogens, Qegel exercises, pessaries, surgery
/suburethral sling1
-etrusor ,nstability #-,$ /,0-;0% of cases1 urgency,
freFuency /voiding 0 5 times per day3 nocturia 0 + times per
night1, overactive bladder
Enin#ibited detrusor contraction assoc9 w' strong
urge to void
=n#nown etiology
.ommonly assoc9 w' triggers /i9e9 running water,
etc91
+x 8 timed voiding, oxybutynin /"itropan1,
tolterodine /"etrol1, tri-cyclic antidepressants
Mixed ,ncontinence /,0-;0% of cases1 8 >?! M "!
revalence increases w' age
$reat urge ,
st

Other #overflo1/ neurogeneic$ incontinence /,0% of cases1
result from detrusor areflexia or hypotonic bladder
7. in pts w' prolapse
:7C d&, spinal cord inAuries, autonomic
neuropathy /"71
7anagement 8 intermittent self-catheteri&ation
'limacteric
2
Climacteric 8 phase in female reproductive life when
gradual decline in ovarian function results in sex steroid
production and assoc9 seFuelae
-verage onset ( 5, years old
<varies lose ability to respond to >n@D
estrogen production
<vulation ceases
Menopase 8 last menstrual period3 made in retrospect, us9
after ( ,yr w'o menses
7ost women ovulate ( )00 times btwn menarche &
menopause the rest of the eggs are lost
%orn w' ( ,95 million primary ovarian follicles
@each menarche w' ( )00,000
(arly effects of estrogen deficiency * Perimenopausal
symptoms 8 heavy menses, endometrial hyperplasia,
mood and emotional changes, hot flashes, night sweats,
shortened cycle length, irregular menses, breast tenderness
7ay last ;-5 yrs before complete loss of menses
-vg9 age of onset of perimenopausal ?'? 8 )495
years
freFuency of anovulation
Premature ovarian failure #premature menopause$ 8
menopause before the age of )0
:ormone c#anges
(2 2estradiol3 declines but (1 2estrone3 may be
higher
androgen production but lost opposition by
estrogen causes sensitivity to androgens
e"cessive facial )air growt), breast si$e
o $estosterone ( +0%
o -ndrostenedione may ( 50%
)ndrostenedione from ovary and adrenals is
converted to estrone in peripheral fat tissues
capable of maintaining vagina, s#in, and bone in
reasonable cellular tone and reducing incidence of
flashes
o 6, may be responsible for
incidence of endometrial or breast
cancer among obese women /unopposed
estrogen1
progesterone levels too low to induce
en&ymes that convert 6+ to 6,, too low to induce
secretory activity in endometrium irreglar
vaginal bleeding, endometrial )yperplasia, celllar
atypia, incidence of endometrial cancer
+.: - 8: due to more >n@D released by
arcuate nucleus and paraventricular nucleus in
hypothalamus due to low circulating estrogen
levels
Cormal vagina very sensitive to estrogen produces thic#
moist epithelium w' acidic secretion /pD ( )901
4ntermediate effects of estrogen deficiency 2age !!->!3
Atrophic vaginitis loss of estrogen results in thin,
dry epithelium w' al#aline secretion /pD 0 4901
o ?'? 8 dysuria, dyspareunia, vaginal
pruritis
o elastic capacity of bladder
freFuency, urgency, nocturia
"yspareumia
=rge incontinence
?tress incontinence
?#in atrophy
4
8ate effects of estrogen deficiency 2age >!I3
-therosclerosis
-l&heimerIs d&
.ancer
Osteoporosis
o 6strogen loss osteoclast activity far
exceeds osteoblasts activity osteopenia
osteoporosis
o .linical sign 8 loss of 0 ,95H height due to
vertebral compression fracture
o 7ost .a
+M
lost from trabecular bone
M' fractures are spinal column and
femoral neck
o ?creening 8 dual-energy x-ray
absorptiometry /5(J)1 measurements of
total hip and spine
o @educe ris# of fracture w' ,+00-,500mg
calcium and )00-200= vit" daily,
wal#ing, weight-bearing exercise
o $x 8 estrogen, selective estrogen receptor
modulators /?6@7s, li#e raloxifene1,
biphosphonates /alendronate1, calcitonin,
$D
(strogen replacement therapy
ris# of coronary artery d&, stro#e, thrombosis,
breast cancer
ris# of -l&heimers, colon cancer, osteoporosis
4ndicated primarily for relief of significant
menopausal symptoms 2fre@uent #ot flas#es,
genitourinary discomfort, ot#er @uality-of-life
issues3
.ontinuous estrogen 0 )0% incidence of
endometrial hyperplasia
>ive cyclic estrogen M progesterone reduced ris#
of endometrial hyperplasia
o 7onitor endometrium annually w'
ultrasound3 thic#ness should be * 5mm
.ontraindications 8 pregnancy, breast cancer,
estrogen-dependent neoplasia, undiagnosed -%C
vaginal bleeding, thrombophlebitis
-lternatives 8 progesterone, clonidine D.l,
methyldopa, phenobarbital, paroxetine D.l /axil1,
venlafaxine D.l /6ffexor1
;adiology of Pelvis
Eltrasound is usually the initial imaging exam of the
female pelvis, transabdominal then transvaginal
-dvantages
>ood tissue differentiation
:ow cost, portable, easily available
7ultiple imaging planes
.tudy of c#oice
"isadvantages
?mall field doesnIt give global view
<perator-dependent
'1 excellent for detection of calcification or fat within
pelvic masses9 .an be used for staging ovarian cancer but
not very useful for endometrial or cervical cancer9
-dvantages
6xcellent tissue differentiation
7ultiple imaging planes
8arge field of vie%
"isadvantages
Digh cost and less available
M;4 can be used for staging uterine cancers and ovarian
cancers9 -lso used for further characteri&ation of benign
uterine or ovarian masses9
-dvantages
7lobal vie%
6xcellent anatomic resolution
"isadvantages
@adiation
7ainly used to eval metastatic malignancy
and abscesses
!ndications for imaging referrals
=aginal 0leeding
Pelvic Mass
Pelvic Pain
*nitial e"am is ltrasond+ %ocali$es a mass as
terine, ovarian or tbal, identifies potential
sorce of pelvic pain, sefl in determining t)e
case of vaginal bleeding+ A patient wit) a !nown
)istory of cancer will be imaged by C( or M-*+
=ltrasound !mages
Cormal uterus
4-5cm length in nulliparous menstruating
female
Cormal ovary
-verage 2-,0cc volume in normal
menstruating female
Eolume determined by l J w J h J 095+;
7@! !mages
6ndometrium
remenopause, variable
ost 7 5 mm
Runctional &one /dar# rim around endometrium1
+-5 mm
<uter myometrium
.ervixS mucosa, stroma
.auses of vaginal bleeding
(ndometrial
(ndometrial atrophy 7.
(ndometrial hyperplasia or polyp
6ndometrial thic#ening
o K ! mm /post
menopausal13
#ypoec#oic
5
o "iffuse T cystic change
6ndometrial polyps typically
demonstrate cystic change
(ndometrial carcinoma
!rregular border after giving
contrast shows infiltration into
myometrium
All e"cept atrop)y re.ire biopsy to
differentiate
Eterine 8eiomyoma 2especially submucosal3
%ocations for leiomyoma = intramral,
sbmcosal, sbserosal (can be
pednclated) and cervical
'ervical 'ancer
=ltrasoundS Cot very useful
7@!S Study of choice to evaluate local
mass
.$S (valuate adenopathy and distant
metastasis
)dnexal Pat#ology
!nitial evaluation 8 =:$@-?<=C"
7@! 8 problem solving modality
<varian vs adnexal
?olid vs cystic
Ceoplastic vs non neoplastic
Simple Ovarian &yst
=:$@-?<=C"
Bollicular cyst or corpus luteum 7.
.U?$ 8 larger t#an 2 cm
Co internal echoes, nodules, or septations
-lmost always benign
B'= in 2 wee#s
/5% resolve spontaneosly
%right on 7@!
!emorrhagic &yst
:ypoec#oic on ultrasound due to blood
"ar# on 7@! due to blood
(ndometriosis
G?tring of pearlsH on 7@!
Ovarian 'eoplasms
0(C47C dermoid 2teratoma3 M'
.omposed of varying amounts of
endoderm, mesoderm, &
ectoderm
<ccasionally unilocular /lined w'
ectoderm1 filled w' desF9 #eratin '
sebum
1orsion * M' complication
+% malignant transformation
M)847C)C1 8 .omplex cystic masses
w' internal echoes, septations, and nodules
4ltrasound for initial eval
B'= with M), or &+
6varian 1umor 1ypes
.urface (pit#elium 2>!-!%3L mucinous and
serous cystadenoma'adenocarcinoma
rimary criteria for malignancy
0 ) cm
?olid mass /bilateral1
Lall & septations thic# /0 ; mm1
Eegetations and nodules
0enign 'ystadenoma * M' surface
epit#elial tumor
%enign features 8 simple cyst or
few thin septations, little or no
free fluid, unilateral or bilateral
7erm 'ell 21! M 20%3L cystic teratomas,
germinomas
.ex 'ord 2!-10%3L granulosa cell, thecoma,
fibroma, androblastoma
Metastatic 2!-10%3L breast, colon or gastric
carcinoma /Qru#enberg tumor1, lymphoma
Pelvic 4nflammatory 59
Bever, elvic pain, vaginal discharge
=ltrasound 8 initial evaluation
.linical evaluation critical
.$ useful if larger field of view needed to evaluate
abscess
?evere adnexal tenderness
1ubo-6varian abscess 8 7. reason to evaluate
pts w' !"
(ctopic Pregnancy
=ltrasound w' clinical correlation reFuired
.$ and 7@! have little value
9