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Pelvic mass |
A mass in the pelvis is usually (but not always) a neoplasm. Is there a quick way to recall all the various causes while examining the pelvis? Anatomy is the key. Apply the mnemonic MINT to develop a list of the many possibilities (Table 50).
Anatomically, there are three major groups of structures: the urinary tract, the female genital tract, and the lower intestinal tract. Breaking these down into their components, there are the bladder and ureters; the vagina, cervix, uterus, fallopian tubes, and ovaries; and the rectum and sigmoid colon. In addition to these structures, the diseases of the aorta and iliac vessels, spine, and surrounding muscles and fascia must be considered. Other structures fill the pelvis from above. The small intestines, the omentum, and the appendix may be felt; even the kidney may drop into the pelvis.
1. Bladder. Prominent conditions that must be considered here are stones, diverticula, Hunner ulcer, and carcinomas. A distended bladder is deceptive.
2. Urethra. A cystocele and urethrocele are felt easily during a pelvic examination, but if they are not, have the patient strain or stand up.
3. Ureters. A ureteral calculus or ureterocele may be felt.
4. Vagina. Vaginal carcinomas, prolapsed cervix or procidentia, rectocele, and Bartholin cysts may be felt. A foreign body (e.g., a pessary) should be considered.
5. Cervix. Carcinoma or polyps are the main considerations here, because an inflamed cervix does not usually cause a mass.
6. Uterus. Fibroids are the most likely tumor to be felt, but pregnancy, chronic endometritis, choriocarcinoma, and endometrial carcinomas all present as a mass. A retroverted uterus may masquerade as a mass in the cul-de-sac.
7. Fallopian tubes. Tubo-ovarian abscesses and endometriosis of these structures account for most cases. Ectopic pregnancy is always possible.
8. Ovary. Ovarian cysts and carcinomas must be considered as well as endometriosis.
9. Rectum. Carcinoma, abscesses, diverticula, and prolapse are good possibilities here. Feces may masquerade as a mass.
10. Sigmoid colon. Again, the disorders mentioned in the section on the rectum (see page 385) must be considered. Granulomatous or ulcerative colitis may present as a mass.
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TABLE 50. Pelvic Mass |
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11. Arteries. It is unusual for an aortic or iliac aneurysm to be felt here, but they should be kept in mind.
12. Spine. Deformities of the spine (e.g., lordosis), tuberculosis (Pott disease), and metastatic or primary malignancies of the spine (e.g., myeloma) may present as a pelvic mass.
13. Miscellaneous. A pelvic kidney may be felt. An inflamed segment of ileum (regional ileitis) or the appendix should be considered, as should omental cysts and adhesions.
Approach to the Diagnosis
The association with other symptoms is the key to the clinical diagnosis. A painless mass is likely to be a neoplasm, whereas a tender mass with fever suggests pelvic inflammatory disease (PID) or a diverticular abscess. Obviously, an ectopic pregnancy should be associated with tender breasts, frequency of urination, and morning sickness. The next logical step is ultrasonography and a gynecologic consult.
Laboratory tests include urinalysis and culture, pregnancy test, stool for blood and parasites, and vaginal cultures. A proctoscopy and barium enema may be useful. Colonoscopy, culdoscopy, peritoneoscopy, and cystoscopy may all need to be done before an exploratory laparotomy is performed.
Other Useful Tests
1. Sedimentation rate (PID)
2. Tuberculin test (tuberculosis of the fallopian tubes)
3. Catheterization for residual urine
4. Culdocentesis (ruptured ectopic pregnancy)
5. Laparoscopy (ectopic pregnancy, neoplasm)
6. CT scan of the pelvis (neoplasm, stone, diverticulum, abscess)
7. Aortogram (aortic aneurysm)
8. Exploratory laparotomy
9. Urology consult
10. Gynecology consult
