Chapter 41

PELVIC MASSES

Ellen C. Wells

The discovery of a pelvic mas s in a reproductive-age woman

may be precipitated by symptoms of pain, pressure, fullness,
increasing abdominal girth. Assocated symptoms such as
urinary frequency or constipation provide clues to location
bu! do not elearly delineate the tissue of origin, as they may
generated secondary to external pressure on these organ
.systems. Deterrnining the exact organ from which the mass
originates is the most direct way of formulating an appro
priate differential diagnosis and proceeding with a timely
conclusion and plan.
The presence of a pelvic mass identified on a routine exam
or noted as an incidental finding during an evaluation for an
complaint deserves appropriate but not necessarily emer
gen! evaluation. Similarly, many complaints associated witb
pelvic masses are gradually progressive over a number of
.months and represent the effeet of growtb on surrounding
pelvic functions. The timing of presentation is dependent on
when enough symptoms are generated tbat the woman recog
lIJ.es a change. An outpatient evaluation is again appropriate.
Masses tbat present witb pain may necessitate admission,
depending on tbe severity of pain, tbe presence of an acute ab
domen, tbe potential need for immediate surgical attention, or
for infections witb abscess requiring intravenous antibiotics.
Ectopic pregnancy must be considered and a pregnancy test
be performed in any reproductive-age woman witb pain
a masS. An intrauterine pregnancy witb pain also requires
evaluation and may neeessitate hospitalization.

DIFFEREI\JTIAL DIAGNOSES

UTERINE MASSES

of uterine origin will be palpable contiguous witb tbe

on bimanual exam and, depending on size, be detectable

in the abdomen aboye the leve} of tbe pubic symphysis. Preg

nancy should be considered in any reproductive-age woman
with an enlarged uterus on exam. Particular attention should
be directed to her last menstrual period and her contmceptive
method. A 6-week gestaton may be palpable as a mildly en
largd., boggy uterus. The diagnosis can be confmned witb a
positve pregnancy test or an ultrasound showing an intrauter
ine gestational saco A 12-week gestaton will produce uterine
enlargement tbat fills tbe pelvis and rises to tbe level of tbe
pubic symphysis. At this gestaton, fetal heart tones can fre
quently be heard witb Doppler. A uterus tbat is enlarged to tbe
level of tbe umbilicus would be consistent witb a 20-week ges
taton. By tbis time fetal movements have frequently been per
ceived by tbe woman and fetal heart tones can be heard witb
a fetoscope. An unsuspected, but somewhat advanced preg
nancy may be encountered in adolescence, in obese women,
and in women with oligomenorrhea.
Uterine leiomyomas are a common cause of uterine en
largement. Leiomyomas, or myomas, are benign tumors of
muscle cell origin and are the most frequent pelvic tumors
in women. They occur in one of four white women and one
of two black women and are commonly multiple. Locatons
within the uterus inelude subserosal, intramural, submu
cosal, and cervical. Myomas are also occasionally found
within tbe pelvis witbout a direct attachment to the uterus.
The etiology of uterine leiomyomas is incompletely under
stood. Each tumor results from proliferaton of a single mus
ele cell. The cell of origin may be from a small embryonic
rest or from tbe smooth muscle of blood vessels. The stim
ulus for growth is also unelear. The role of estro gen as a
stimulus has been explored. Estrogen receptors are found in
higher concentration in myomas than in the surrounding my
ometrium. Most myomas decrease in size during hypoe
strogenic states such as menopause or during therapy witb
gonadotropin-releasing hormone (GnRH) agonists (e.g., le
uprolide or naferilin). Myomas often enlarge during early
pregnancy, with stabilization in size occurring n later preg

514

Par! IV

EMERGENCY GYNECOLOGIC DISORDERS IN THE REPRODUCTIVE AGE

nancy. Myomas may enlarge with the use of oral contra

ceptive pills. However, it is also noted that many women
with small myomas show no growth under the influence of
even high circulating estro gen levels.
Pelvic pain and abnormal uterine vaginal bleeding are the
commonest symptoms associated with myomas. One of three
women with myomas experiences pelvic pain. Secondary dys
menorrhea is the most frequent complaint. Symptoms of pelvic
heaviness or dull aching are common. Myomas with rapid
growth (e.g., during pregnancy) may present with severe pain
and even localized peritoneal irritation from acute degenera
tion. This occurs secondary to central necrosis as the tumor
outgrows its blood supply. An anterior myoma pressing on the
bladder may produce symptoms of urinary frequency and ur
gency. Abnormal bleeding, usually presenting as hypermenor
rhea is reported by 30 percent of women with myomas.
The incidence of leiomyosarcomas in women felt to have
leiomyomas is low. Leibsohn 1 reported a series of 1429 hys
terectomies with a preoperative diagnosis of leiomyomas in
which leiomyosarcomas were found histologically in 0.49
percent. Rapid growth of leiomyomas at any age or growth
of myomas after menopause should raise the suspicion of
malignancy. Rapid growth in the reproductive-age woman
should al so alert the physician to the possibility of a preg
nancy within a myomatous uterus.
A pelvic mass associated with pain in an adolescent
around the time of menarche may be the first presentation
of a congenital uterine anomaly. A transverse vaginal sep
tum or an imperforate hymen may present with cyc1ic
monthly pain without menstruation and may progress to a
significant pelvic mass consisting of a hematocolpos and
hematometra with marked pelvic and rectal pressure. Cyc1ic
pain with menses and a pelvic mas s in adolescence may rep
resent a bicomuate uterus with one noncommunicating uter
ine hom (Fig. 41-1).

Figure 41-1
Noncommunicating uterine horn (top left, long arrow) with
hematometra and (/ower midline, short arrow) hematocolpos.

OVARIAN NEOPLASM
A palpable but otherwise asymptomatic adnexal mass should
raise suspicion of an ovarian neoplasm. Benign cystic ter
atomas, or dermoid cysts, are among the most common ovar
ian neoplasms. Histologically, these slow-growing tumors
are found to contain elements from all three germ celllay
ers. They occur in all age groups, and are common in
teenagers and young adults. They are bilateral in 10 to 15
percent.
Benign teratomas frequentIy contain a thick sebaceous
fluid as well as hair, musc1e fibers, cartilage, bone, and teeth.
Although they are frequentIy discovered incidentally, they
may produce acute symptoms with rupture, which causes a
severe chemical granulomatous peritonitis, or with torsion,
which occurs secondary to their size and increased weight.
Approximately 1 to 2 percent of dermoid cysts undergo ma
lignant transformation, usually in women over age 40. The
malignant component is generally a squamous carcinoma.
Rarely, ovarian teratomas will contain functioning thyroid
tissue (struma ovarii) , causing hyperthyroidism. Other be
nign ovarian tumor s encountered in reproductive-age women
inc1ude serous cystadenomas, fibromas, and Brenner tumors.
Malignant ovarian neoplasms may al so occur in reproduc
tive-age women, but most occur in menopausal women. In
early stages, these adnexal masses may be mobile witb no
evidence of ascites, but at advanced stages they will
monly be fixed with accompanying ascites.

OVARIAN CYST
Ovaran cysts are a common cause of adnexal eIlliilgt;lIm
associated with pain. The term.functional cyst is often
in this setting, and although dysfunction might be a
description, the term is simply used to convey the
tion of this cystic enlargement with the components of
mal cyc1ic ovaran function. Normal ovarian follic1es
a size of about 2.0 to 2.5 cm prior to ovulation.
the termfollicular cyst should be used to refer to cystic
tures within the ovary that are greater than 2.5 to 3 cm
diameter. Follicular cysts may reach 8 to 10 cm in size
generally regress spontaneously in i to 3 months.
stretching of the ovarian capsule due to the sze of the
is the general source of discomfort. Cysts may rupture
ing examination or with intercourse. Rupture is generally
sociated with an immediate sharp pain that which may
solve rapidly or gradually improve over several
Peritoneal signs may be present due to irritation from
fluid or blood.
Corpus luteum cysts are less common than follicular
A normal corpus luteum may be up to 3 cm in
Therefore, corpus luteum cysts are described as
. greater than 3 cm in diameter originating from the
luteum. In the normal development of a corpus luteum,
illaries invade the granulosa cells and produce a spontaneo

Chapter 41

bu! limited bleeding that fills the central cavity. This blood
is subsequcntly absorbed, forming a small cystic space. If
hemorrhage is excessive, the cystic space enlarges, stretch
ing the ovarian capsule and causing pain. An unruptured fol
licular or hemorrhagic cyst may continue to produce symp
toms of pain throughout the remainder of the cycle. It will
commonly regress after the cycle s complete and hemor
rhagic contents will gradually be resorbed. If a hemorrhagic
cyst ruptures, a sharp. pain as well as peritoneal irritation
from the blood will be noted. Bleeding after rupture is usu
ally self-limited. Rarely, women with anemia, marked or per
sistent pain, hypovolemia, or marked cul-de-sac fluid will
require admission for observation, seral hematocrits, or op
erative intervention.

Torsion of the ovary or.of the ovary and fallopian tube is a

twist or turu of the ovarian attachments through the
uteroovarian ligament to the uterus and through the in
fundibulopelvic ligament to the pelvic side wall, which com
ovaran blood supply. A woman with adnexal tor
sion will present with acute, severe, unilateral lower
abdl)mlnal and pelvic pain. She may relate the onset of pain
an abrupt change in position. A palpable adnexal mass is
in over 90 percent of patients. Progressive en
larg,ement may occur as arterial blood flow continues, but
flow is compromised. At the point of arterial com
infarction occurS. Associated symptoms include
nausea and vomiting, with acute appendicitis or small bowel
OOSIruC;UOill in the differential diagnosis. With infarction, an
white blood cell count and low-grade fever may be

uvllllVl"'UU."U

Torsion may occur within a normal adnexa, though any

process resulting in ovaran enlargement increases the risk
of torsion. Approximately 50 to 60 percent of women with
adnexal torsion will be found to have ovaran tumors, with
demlOids being the most frequently encountered? Ovaran
I'lll<ll/5<;,llICJlll from other ovaran cysts, ovulation nduction,
and paraovarian cysts is also seen in patients with ovaran
mlsion. Torsion of a malignant ovarian tumor is rare, as the
ovaran mass is usually fixed in the pelvis.

,Endometrlosls is a disease process in which endometrial

and stroma develop outside the endometrial cavity.
of glands and stroma initially produce cyclic pain
a8S0Clalted with menses, which may progre ss to pelvic ad
disease resulting in pain throughout the cycle. En
aometfllOS:lS within the ovaran capsule produces cystic struc
called endometriomas, which may range from a few
m.II1w\",I",.~ up to 5 to 10 cm in diameter. These are often
chocolate cysts due to the thick brown hemosiderin
fluid within the cyst. A pelvic exam may reveal ten

PELVIC MASSES

515

der, enlarged ovaries that are commonly adherent to sur

rounding structures.

TUBOOVARIAN ABSCESSES
Pelvic inflammatory dsease refers to nflammaton caused
by an infection in the upper genital tracts. This includes en
dometriosis, salpingitis, oophoritis, myometritis, parametri
tis, and peritonitis. A tuboovarian complex (see Chapo 44)
is defined as a collection of infected fluid within an anatomic
space created by adherence of adjacent organs, ncluding the
fallopian tubes, ovares, and sometmes the intestines. Acute
pelvic inflammatory discase is usually a polymicrobial in
fection caused by organisms ascending from the vagina and
cervix. Bacterial organisms include Neisseria gonorrhoeae,
Chlamydia trachomatis, endogenous aerobic and anaerobic
bacteria, and perhaps genital mycoplasmal species. Women
with pelvic inflammatory disease will cornmonly have fever,
an elevated erythrocyte sedimentation rate, cervical motion
tenderness, and bilateral adnexal tenderness with or without
masses. 3 Indications for hospitalization in patients with
pelvic inflammatory disease include presence of a tu
boovarian complex or abscess, pregnancy, uncertain diag
nosis, gastrointestinal symptoms, and peritonitis in the up
per quadrants. Positive human immunodeficiency virus
(HIV) status, recent operative or diagnostic procedures, and
inadequate response to outpatient therapy are also reasons
for hospital admission.
Women with a history of pelvic inflammatory disease may
have sequelae of pelvic adhesive dsease presenting as
chronic or recurrent pelvc pain with the involved adnexus
palpable as a pelvic mass. Approximately 20 percent of
women with acute pelvic infections subsequently develop
chronic pelvic pain. Recurrent acute pelvic inflammatory
disease is experienced by approximately 25 percent of
women.

PELVIC MASSES OF RECTAL OR LOWER

GASTROINTESTINAL ORIGIN
Pelvic masses presenting in patients with weight loss, ane
mia, or specific GI symptoms may have a lower GI or rec
tal origino Diverticulitis may present with fever and pain 10
calized to the left lower quadrant. A tender, sausage-like,
fixed mass may be palpable in the left adnexus on exam.
The pathologic change in diverticulitis i8 a focal area of in
flarnmation in the wall of a diveliiculum, usually at its apex,
which develops in response to the irritating presence of in
spissated fecal material. Appendicitis should be considered
in women who present with right-lower-quadrant pain.
Anorexia is common, and nausea and vomiting may occur.
The pain of appendicitis is initially periumbilical in location
but moves to the right lower quadrant. A low-grade fever is
typicaL The white blood cell count is usually mildly ele
vated. Examination will reveal tenderuess in the right lower

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Part IV

EMERGENCY GYNECOLOGIC DISORDERS IN THE REPRODUCTIVE AGE

quadrant with peritoneal signs present. A mass or fullness

may be palpable, depending on the degree of inflammation
and adherence ofthe appendix to surrounding structures. Of
ten no mass is palpable.
Colorectal cancer is a concern in patients, particularly
those over 50 years of age, who present with a fixed pelvic
mass, history of change in bowel habits, amI/or blood in the
stool. Carcinomas of the large bowel are predominantIy ade
nocarcinomas and begin as intramucosal epithelial lesions
usually arising in adenomatous polyps or glands. Further
growth penetrates the musculars mucosa, invading lym
phatic and vascular channels to involve regional lymph
nodes and adjacent structures. These cancers may have long
periods of silent growth before producing bowel symptoms.
Symptoms are typically nonspecific but may present as a
change in bowel habit, melena, or rectal bleeding. Abdom
inal pain, bloating, constipation and diarrhea are more in
dicative of partial bowel obstruction present in a quite ad
vanced colon carcinoma.

RETROPERITONEAL OR EXTRAPERITONEAL MASSES

Sorne types of lymphoma, particularly subtypes of diffuse

non-Hodgkin's lymphoma, may come to medical attention
because of an abdominal mass, splenomegaly, or a gas
trointestinal mass with symptoms associated with space-oc
cupying growth. These symptoms inc1ude chronic pain, ab
dominal fullness, early satiety, obstruction, or even
gastrointestinal hemorrhage. A mas s that is fixed and ap
pears to arise from the pelvic side wall or retroperitoneal
space also suggests the diagnosis of lymphoma. However,
lymphomas are an unusual cause of pelvic mass.

EVALUATION
HISTORY
The initial history in any reproductive-age woman with ab
dominal or pelvic complaints should inc1ude her age, gra
vidity, party, last menstrual period, status of sexual activ
ity, and type of contraception. Symptoms that correlate with
the size of the mas s may inc1ude pressure, fullness, early
satiety, or increasing abdominal girth. Conditions producing
uterine enlargement may be associated with urinary fre
quency, urgency, and even stress urinary incontinence.
Masses at the level of the cervix or the lower uterine seg
ment or masses exerting pressure at the pelvic brim may pre
sent with ureteral obstruction or hydronephrosis and flank
discomfort. Masses in the cul-de-sac from the uterus, ad
nexa, or lower gastrointestinal tract may present as rectal
pressure, deep dyspareunia, or fullness and constipation. It
is somewhat disturbing to realize that a number of etiolo

gies for pelvic masses may progress to advanced stages with

relatively few symptoms until size alone brings them to the
attention of the patient or physician.
In women who present with pain the quality, quantity, lo
cation, and duration are all important. The activity associ
ated with the onset of pain should be elicited. An adnexus
may twist with a sudden change in position. A common pre
sentation of pain for a woman with a ruptured ovaran cyst
is during sexual intercourse. Sorne 75 percent of women with
symptoms of pelvic inflammatory disease develop this dis
order within a few days after menses. A ruptured cyst may
present as an acute unilateral pain which subsides gradually'
over time. Torsion and appendicitis can present as acute, un
remitting unilateral pain often associated with nausea and
vomiting. Bowel obstruction may present in a manner very
similar to torsion. A differentiating factor may be that fue
pain in the bowel obstruction is more colicky or crampy,
with waves of pain followed by intervals of relief. Women
with any of these sources of pain commonly maintain a fe
tal position during the interview. Associated gastrointestinal
symptoms may inc1ude loss of appetite, nausea ancl/or vom
iting, and diarrhea. Any recent fever or chills should be
elicited. The presence of flank pain, dysura, urgency, orfre
quency should be identified, as urinary tract infection is ex
tremely common.
In addition to the last menstrual perod, contraceptive
method, and sexual activity, the normal menstrual
should be established. If the patient has had any similar pain
before, it should be determined whether this was related
quentially to any particular. time in her menstrual cyc1e.
should be noted whether she has a new sexual partner.
vious abdominal or pelvic surgeries, particularly histories
tuballigation, previous ectopic pregnancy, tubal reconstruv'
tive surgery, or gastrointestinal surgery should be
Past gynecologic or gastrointestinal disorders should
noted, such as history of infertility, previous pelvic .
matory disease, diverticulosis, or polyps. Pertinent
history would inc1ude site-specific ovaran cancer, breast
ovaran cancer c1usters (BrCa 1) or Lynch syndrome II
family members having colorectal cancer in association
ovaran amI/or endometrial cancers.

PHYSICAL EXAMINATION
The physical examination begins with an initial
of vital signs. Blood pressure and pulse with
changes may demonstrate evidence of hypovolemia
acute hemorrhage. An elevated temperature may
diagnosis of infection. An acute abdomen with fever
alert one to the possibility of a ruptured tuboovarian
or a ruptured appendix, which could progress rapidly to
SISo

The abdomen should be inspected for evidence of

tion. Ascites may be determined by shifting dullness
fluid wave. The presence or absence of bowe1 sounds

be
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Chapter 41

be documented. The upper and lower abdomen should be as

sessed for masses. Mobility of any mas ses should also be as
sessed. Enlarged ovares, particularly if mobile, may present
in the upper abdomen on occasion. These mght be mssed
jf the physician relied solely on a pelvic exam. The degree
and location of tendemess should be elicited as well as signs
of rebound and voluntary or involuntary guarding. The in
guinal area should be assessed for lymph nodes.
A pelvic exam is best performed when the bladder is
empty, since a distended bladder may be misdiagnosed as a
pelvic mass. Even when bladder fullness is recognized, its
presence may distort or mask an underlying pelvic mass. A
full bladder may lift the \).terus and ovares further away from
!he vaginal hand, limiting the bimanual examnation. A
'V"',U.lU.Ul exam should be performed to evaluate the cervix
anyevidence of irritation, ulceration, bleeding, or mass.
mucopurulent discharge from the cervix may be exam
under the mcroscope to determine the presence of
lITanl-llt~2:a1[1ve intracellular diplococci (N. gonorrhoeae) or
evaluate the number of white 'blood cells per high-power
(possible C. trachomatis). Cultures should be obtained
this time for N. gonorrhoeae and C. trachomatis in any
for whom pelvic inflammatory disease is in the dif
diagnosis. Bimanual exam allows palpaton of the
for size and shape as well as any evidence of para
extension of induration or fullness. The uterine size,
and mobility may also be determined. A "fixed
with a firm mass effect that extends from side wall
side wall with limted or no moblity suggests extensive
adhesive disease, severe endometriosis, or cancer. A
nodular mass may be consistent with uterine leiomy
but could also contain an underlying ovaran enlarge
This differentiation often cannot be determined sim
by bimanual examnation. Similarly, a pedunculated

A large myoma, arising fmm the

, lower uterine segment, extended
, into the right adnexa.

PELVIC MASSES

517

myoma may be confused with an adnexal mass (Fig. 41-2).

Direct and rebound tendemess should be as ses sed in both
the right and left adnexa. The presence of cervical motion
tendemess is suspicious for adnexal disease (e.g., acute sal
pingitis), as movement of the cervix causes stretching across
this tissue. In women with marked tendemess, the bmanual
examination may be limted and inadequate to determine the
presence of a mass. Cul-de-sac fluid or a cul-de-sac mass
can best be determined by rectovaginal examinaton. Sirni
larly, the size and shape of a retroverted uterus can best be
determned with a rectal finge!. Dissection of an abscess may
alBO occur into the rectovagnal septum. Careful perianal and
rectal examnation is also necessary to identify perianal or
rectal abscesses. The stool should be tested for occult blood.
Diverticular abscesses and colon cancer are more likely to
be found in the left lower quadrantor cul-de-sac areas; 70
percent of colon cancers are within reach of the examining
finger.
An enlarged but soft and boggy uterus may be palpable in
early pregnancy. First-trimester pregnancy presenting with
mdline cramping and vaginal bleeding should be assessed for
the possibility of spontaneous abortion. If the cervical os is
closed and the bleeding is not profuse, the woman may be
followed expectantIy for threatened abortion. Follow-up stud
ies including transvaginal sonography and serial quantitative
human chorionic gonadotrophin (f3CG) values will aid in de
tennining the viability of the pregnancy. EarIy pregnancy with
adnexal pain with or without a mass and associated with light
bleeding should be evaluated for the potential of an ectopic
pregnancy. These women may give a history of previous
pelvic inflammatory disease, previous tubal reconstructive
surgery, or previous tuballigation. A corpus luteum cyst may
also present simiIarly in early pregnancy. Early pregnancy
complications are covered in detail inChaps. 3 and 4.

518

Part IV

EMERGENCY GYNECOLOGIC DISORDERS IN THE REPRODUCTIVE AGE

In adolescence, a pelvic mas s and pain should be evalu

ated for uterine anomalies. A noncommunicating uterine
hom may present as cyclic pelvic pain and a pelvic mass. A
transverse vaginal septum will be notable on exam as a
bulging membrane within the vagina with no cervix visible.
Similarly, an imperforate hymen wi11 demonstrate a bulge at
the introitus without a vaginal opening. The cervix or uterus
can be palpated on rectal exam.

LABORATORY TESTS ANO OIAGNOSTIC STUOIES

A hemoglobin, hematocrit, pregnancy test, and white blood

cell count should be performed in the initial evaluation. Cul
tures for gonorrhea and chlamydial infection may be ob
tained at the time of speculum examination. For suspected
ovarian neoplasms, the tumor-associated antigen CA-125,
carcinoembryonic antigen (CEA), human chorionic go
nadotrophin (hCG), and alpha-fetoprotein (AFP) are useful
markers. The CA-125 may be mildly elevated in a number
of disease processes that irritate the peritoneal cavity, most
notably n endometrosis. It is generally markedly elevated
in women with ovaran adenocarcinoma. The CEA is com
monly elevated in colon cancer and may be elevated in sorne
ovarian neoplasms. Both hCG and AFP may be elevated in
younger patients with malignant teratomas or other germ
cell tumors.
Transvaginal sonography can be extremely helpful in the
evaluation of a pelvic mas s and is particularly use1'ul n dif
1'erentiatng enlargement 01' the uterus from that 01' the
ovaries. In the evaluation 01' female pelvic organs, sonogra
phy is usually better and less expensive than computed to
mography (CT) or MRI studies. In cases 01' early pregnancy,
a gestational sac may be seen as early as 5 weeks and a fe
tal pole with cardiac activity at 6 weeks. Ectopic pregnan
cies may also be visualized within the adnexa, sometimes
as an echogenic ring surrounding a small fluid saco A J3-hCG
value combined with ultrasound is also helpful in diagnos
an ectopic pregnancy. An intrauterine gestational sac is
usuaUy visualized by vaginal sonography when J3-hCG val
ues reach 1000. Therefore, the suspicion for ectopic preg
nancy increases with J3-hCG values at or aboye this level
without visualizing an intrauterine gestation.
Uterine leiomyomas have a distinctive ultrasound pattern
within or arising from the uterus (Fig. 41-3). Characteristics
of adnexal masses are extremely help1'ul in differentiating
masses of ovarian and fallopan tube origino A simple cys
tic structure is consistent with a 1'ollicular or corpus luteum
cyst (Fig. 41-4A). Recent hemorrhage into an ovaran cyst
has a characteristic cobweb pattem (Fig. 41-4B). Benign cys
tic teratomas contain echogenic material that 1'orms layers
consistent with ts mucnous secretions as well as areas of
calcification from teeth and bone, which may also be seen
with conventional radiography. Endometriomas ofien have
a homogeneous ground-glass appearance (Fig. 41-4C). A
cystic, tubular, or sausage-shaped structure may represent a

Figure 41-3
Transvaginal sonography reveals a circular pattern within the my
ometrium consistent with a myoma (arrow).

hydrosalpinx. Complex adnexal masses with cystic and

components with obvious distortion of the normal
ture may be seen with a number of diagnoses,
pelvic adhesive disease, tuboovarian
endometriosS
ectopic pregnancy, or ovaran cancer.
Identification of the organ system with which the mass
associated s important in determining not only the
sis but also whieh specia1ty services may be required
consultation. In cases where cervical, uterine, or ovaran
cer is suspected, a CT sean is helpful in demonstrating
presenee or absence of lymph node involvement,
obstruction, ascites, liver metastasis, or associated
masses. In potential gastrointestinal sources, a CT sean
be beneficial, but may also requre barium enema or
ble sigmoidoscopy or colonoscopy.

TREATMENT
In a woman who presents with acute, relentless
pain and a mass, immediate gynecologic or surgieal
sultation is imperative. It is particularly important to rule
ectopic pregnaney, as a del ay in this diagnosis may
significant morbidity or mortality. Hospitalzation is
ally required in tbis setting due to the potential of
ate surgical management or, in cases of an uncertain
nosis, close observation. Peritoneal lavage or
may give a rapid diagnosis of hemoperitoneum. ~.
laparoscopy can be help1'ul in evaluating the presenee
moperitoneum as well as inspecting the pelvis, the
dix, and the gallbladder.

Chapter 41

PELVIC MASSES

519

Figure 41-4
Transvaginal sonography reveals a follicular cyst (outlined by crosses)
(A), a hemorrhagic cyst (arrow) (B), and an endometrioma (outlined by
crosses) (e).

If a mass is detected but the patient is otherwise stable,

follow-up with a gynecologist is recommended for contin
ued evaluation on an outpatient basis. These women may
later be surgical candidates once their evaluaton is complete
aud these results as weIl as options of management have
been thoroughly discussed with the patient and her family.

ICATIONS OF PREGNANCY (see also Chaps. 3

women who present with a pelvic m~ss and are found to

pregnant, the management depends on any symptoms pre
If there are no symptoms of vaginal bleeding or pain,
woman should be referred to an obstetrician to begin or
her antepartum careo If she has any risk factors for
pregnancy, she should be seen for her initial obstet
evaluation within the next week. Often, follow up is
in 48 hours to follow serial f3-hCG levels. In
who present with a diagnosis of pregnancy and a

mass associated with pain or bleeding, immediate consulta

ton should be obtained to begin the assessment for preg
nancy viability and rule out ectopic pregnancy. If an intact
intrauterine pregnancy is identified by ultrasound and the
cervical os is closed on examination, a threatened abortion
is diagnosed and expected management recommended.
Women are often placed on "pelvic rest," meaning tempo
rary abstinence from sexual activity and no strenuous phys
ical activity. There is no evidence, however, that these lim
itations change the natural course of the pregnancy.
In women with a gestational sac by ultrasound but with
an open os or those with tissue protruding through an open
os, a diagnosis of inevitable or incomplete abortion would
be appropriate. These women may need dlatation and curet
tage to complete this process in a timely manner, particu
lady if their bleeding has been prolonged or profuse. A quan
titative f3-hCG will be an important value to obtain in any
woman in whom the viability of pregnancy is uncertain. In a
normal early pregnancy, the f3-hCG value doubles in 48 hours,
with the lower limit of normal demonstrating a rise of at

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Part IV

EMERGENCY GYNECOLOGIC DISORDERS IN THE REPRODUCTIVE AGE

least 60 percent over 48 hours. Values that do not rise ap

propriately or decline are indicative of a failed intrauterine
pregnancy or potential ectopic pregnancy. The l3-hCG val
ues may also be correlated with ultrasound findings in pa
tients in whom serial values are not available, as previously
discussed. Women who are pregnant and present with ad
nexal pain and bleeding for whom an intrauterine pregnancy
is not visualized should be followed with l3-hCG values and
gynecologic consultation. Diagnostic laparoscopy is partic
ularly useful in suspected ectopic pregnancy. Marked fluid
in the cul-de-sac on ultrasound or a positive peritoneallavage
or culdocentesis warrant immediate surgical intervention.

UTERIt\IE LEIOMYOMAS
Treatment of uterine leiomyomas depends on both their size
and the severity of the symptoms they produce. Small my
omas in an intramural or subserosal location may produce
minimal or no symptoms and may be followed expectantly
for any evidence of growth. Myomas that create uterine en
largement consistent with or greater than a 12-week gesta
tion, particularly those associated with symptoms or exces
sive bleeding, should be considered for remova1. In addition,
their size limits the ability of an examiner to adequately eval
uate the ovares on routine examination. Depending on their
shape and location, they may also cause obstruction of the
ureters at the level of the pelvic brim or ccrvix. Uterine
leiomyomas may also produce severe dysmenorrhea as well
as irregular bleeding and menorrhagia. Nonsteroidal anti
inflarnmatory drugs decrease prostaglandin release, reduc
ing menstrual pain and decreasing menstrual blood 10ss.
Medroxyprogesterone acetate or depo-medroxyprogesterone
acetate may control symptoms by regulating menses or pro
ducing amenorrhea. Gonadotropin-releasing hormone ago
nist therapy decreases the size of uterine leiomyomas by as
much as 60 percent. 4 Women also experience amenorrhea
on this therapy, with a subsequent rise in their hematocrit.
Limitations of GnRH agonist therapy include hot flashe8 and
other menopausal symptoms. Its use is generally limited to
6 months, as use beyond this point is associated with bone
los8. The reduction in size of uterine leiomyomas does not
persist after discontinuation of therapy and virtualIy all
leiomyomas retum to their pretreatment size. Surgical op
tions include myomectomy, which involves removing the in
dividual leiomyomas without complete remo val of the
uterus, versus hysterectomy. The blood loss at the time of
surgery is generally higher with myomectomy than wth hys
terectomy. Among women followed after myomectomy, ap
proximately 25 to 30 percent subsequentIy undergo a sec
ond surgical procedure for recurrent myomas and symptoms.
Women who have not completed childbearing may choose
myomectomy over hysterectomy despite the increased in
traoperative blood 1088 and potential recurrent symptoms.
Women who are followed expectantly should have ultra
sound evaluation of the ovaries on a regular basis if the ad

nexa are not easily palpable on examination. Hysteroscopic

resection of submucosal or intracavitary leiomyomas may
be used for therapeutic relief in appropriate patients. Women
who present with acute pain due to degenerating leiomy
omas may be managed with nonsteroidal ant-inflammatory
drugs or may require narcotic analgesics in the initial pe.
riod. Common times for presentaton of degenerating
leiomyomas are during pregnancy and in the immediate
postpartum perodo

UTERINE ANOMALlES
In adolescents who present with congenital uterine or lower
genital tract anomalies as a source of pelvic mass, surgical
intervention is warranted after appropriate evaluation. An
imperforate hymen or transverse vaginal septum may be sur
gically opened to create an outlet for menstrual bleeding
(Fig. 41-5). A symptomatic noncommunicating uterine horn
will require removal. These women face an increased risk
of endometriosis due to the retrograde menstruation that has
cornmonly occurred prior to their diagnosis.

ADNEXAL MASSES
Adnexal mas ses that, on evaluation, are fe1t to be consistent
with benign ovaran neoplasms will be treated
with removal via ovarian cystectomy or unilateral ooohorec
tomy. Frozen section is extremely useful in these
as a borderline tumor or carcinoma may then be
ately staged and lymph node sampling obtained.

Figure 41-5
Imperforate hymen with associated hematocolpps. (From

) Reprad Med 29:376" 1984.)

Th.
with ,
lar cy
tial di
al1y f!
theral
pituit:
currel
mend
5 to 8
in me
Arup
rial h
venti41
mass.
uatedi

Chapter 41

The initial treatment for an ovaran cyst is observaton

analgescs as needed for pain. The majority of follicu
cysts resolve spontaneously wthin 4 to 8 weeks of ini
diagnosis. Hemorrhagic cysts, if self-contained, gradu
resorb without further management. Oral contraceptive
is sometimes employed to remove any influence that
gonadotrophins may have on the persistence or re
of an ovaran cyst. 5 Surgical therapy is recom
for cystic mas ses larger than 8 cm or for those from
to 8 cm that have been observed for longer than 8 weeks
menstruating women without any evidence of regression.
ruptured hemorrhagic cyst may require admission for se
hernatocrits or, with hemoperitoneum, surgical inter
with cystectomY. Women with a complex adnexal
and severe pain or an acute abdomen should be eval
surgically for torsion. An adnexus that has remained
despite torsion can be untwisted at the time of surgery.
cystectomy is performed and the ovary is stabilized with
10 prevent recurren ce. In torsion with vascular com
and infarction, salpingo-oophorectorny is required.
An endometrioma may be treated with analgesics and hor
therapy for suppression of endometriosis. Medica
that can be employed include oral contraceptives, depo
acetate, danocrine, and GnRH ago
Each of these medications has potential side effects
may produce relief of symptoms. With persistent or se
pain, operative laparoscopy or laparotomy may be em
Conservative operative therapy includes removal of
;I1Ul!1l1t;lllVll.la1S, cautery or excision of endometrial implants,
lysis of adhesions. More aggressive management might
removal of one or both ovaries. The extent of ther
depends on the severity of symptoms and the patient's
for future childbearing.
In women who present with pelvic inflammatory disease
tuboovarian abscesses, intravenous antibiotic therapy is
The Centers for Disease Control and Prevention
recommended two regimens stressing the polymi<.'l'o
etiology of acute pelvic infections and addressing the
for coverage of C. trachomatis and some penicillin
N. gonorrhoeae (Table 41-1).6 In women with C.
rac,or,au:s. a regimen using doxycycline is preferred, with
14-day course required to completely eradicate this orClindamycin, however, is felt to provide better pen
into an abscess cavity. Therefore, the combination
clindamycin and gentamicin is considered the gold stan
for treatment of tuboovarian abscesses. Ampicillin is
added to treat enterococcus. Aztreonam is a potential
for the aminoglycosides to avoid renal toxicity
renal disease is present (2 g IVq8h). In women with
, inflarnmatory disease and an intrauterine device
present, the IUD should be removed after antibiotics
begun. lf abscesses do not respond to intravenous an
. within 48 to 72 hours, drainage is indicated. Women
cultures positive for N. gonorrhoeae or C. trachoma
, should also inform their sexual partners to seek treatment.
acute pelvic inflammatory disease is experenced

PELVIC MASSES

521

Table 41-1
INPATIENT TREATMENT FOR PELVIC
INFLAMMATORY DISEASE

"Each regimen should be continued for 48 h after the patient has

shown clnica] improvement, after which doxycyclne 100 mg PO
b.i.d. (after regimen A or B) or clindamycin 450 mg PO q.i.d. (al
ternative choice for regimen B) should be continued for a total of 14
days' therapy.

by approximately 25 percent women. The risk of ectopic

pregnancy, infertlity, and chronic pelvic pain are increased,
even in "successfully" treated women.

DIVERTICULlTIS
Women with acute diverticulitis generally require hospital
izaton for bowel rest, intravenous fluids, and broad-spec
trurn antibiotics. "Triple therapy" (e.g., ampicillin, gen
tamycin, and metronidazole) remains the gold standard in
the unstable septic patient, although newer single-agent
antibiotics (ampicillin/sulbactam, Impipenumlcilastatin or
ticarcillin clavulanate) may be employed for more stable
patients with local peritoneal signs. Recurrent attacks may
prompt surgical resection. Severe attacks with peritoneal
signs, suspected abscess, or perforation require intravenous
antibiotics and surgical drainage or resection. A diverting
colostomy and resection may be performed acutely, with re
anastomosis accomplished at a second operation.

COLORECTAL CAI\JCER
In colorectal cancer, total resection of the tumor is the op
timal management. Tumor-related symptoms of gastroin
testinal bleeding or obstruction may require immediate man

522

Part IV

EMERGENCY GYNECOLOGIC DISORDERS IN THE REPRODUCTlVE AGE

agement that may result in a less radical procedure. There

fore, when possible, a complete preoperatve workup for ex
tent of disease and presence of metastases should be per
formed. This includes a chest radiograph, liver function
studies, plasma CEA level, and complete colonoscopy. Af
ter resection, women should be followed for 5 years with
semiannual exams, repeat CEA levels (which have been
shown to be very sensitive for tumor recurrence), and peri
odie endoscopic or radiographic surveillance of the large
bowel. Radiaton therapy is commonly used after resection
in cancers that penetrate the serosa or involve regionallymph
nodes. This therapy reduces the r1sk of local recnrrence but
does not appear to prolong survival. Chemotherapy has had
only marginal benefit with advanced cancers.

LYMPHOMA
Therapeutic options for the management of lymphomas are
based on histologic subtype and, less frequently, stage.
Therefore, tissue biopsy of sufficient quantity to determine
pathologic and immunologic subtype is of primary impor
tance. Other studies commonly employed to evaluate extent
of disease include a complete blood count, chemistries, Uver
function studies, semm protein electrophoresis, chest radi
ograph, CT of the abdomen and pelvis, and bone marrow
biopsy. Surgical staging is not routine in non-Hodgkin Iym
phoma and is controversial in Hodgkin lymphoma. Radio
therapy may cure over 80 percent of patients with 10calized
Hodgkin lymphoma and chemotherapy over 50 percent of
cases with disseminated disease. Non-Hodgkin Iymphoma

may similarly be treated with radiaton and chemotherapl

but with less promsing results. Women with disease
tant to conventional or salvage regimens may be given
dose chemotherapy or combined chemotherapy and
ton therapy with bone marrow transplantation.

References
1. Leibsohn S, d'Ablaing G, Mishell DR Jr,
Leiomyosarcoma in a series of hysterectomies
for presumed uterine leiomyomas. Am J Obstet
162:968, 1990.
2. Hibbard LT: Adnexal torsion. Am J Obstet
152:456, 1985.
3. Hager WD, Eschenback DA, Spence MR, et al:
for diagnosis and grading of salpingitis. Obstet
61:113,1983.
4. Friedman AJ, Hoffman DI, Comite F, et al: Treatment
leiomyomata uteri with leuprolide acetate depot: A
ble-blind, placebo-controlled, multicenter study.
Gynecol77:720, 1991.
5. Steinkampf MP, Hammond KR, Blackwell RE:
monal treatment of functional ovaran cysts: A
ized prospective study. J?ertil Steril 54:775, l
for Disease Control and Prevention: 1993 Sexually
mitted diseases: Treatment guidelines. MMWR
1993.
6. Centers for Disease Control and Prevention: 1993
ally transmitted diseases: Treat ment guidelines. !
42:75, 1993.