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Assessing a Pelvic Mass

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Clinical History

Symptoms: Pelvic pain, bloating, abnormal uterine bleeding, urinary symptoms, or bowel changes.
Menstrual history: Regularity, heaviness, and associated symptoms.
Obstetric history: Parity, history of pelvic surgeries, or previous cesarean sections.
Family history: History of cancers (ovarian, breast, endometrial).

Physical Examination

Inspection: Abdominal distension or visible mass.
Palpation: Location, size, mobility, consistency, and tenderness of the mass.
Speculum and bimanual examination: Assess for cervical pathology, uterine size, adnexal mass, and tenderness.

Investigations

Ultrasound: First-line imaging to assess characteristics of the mass (cystic, solid, complex).
CA-125 levels: For ovarian cancer screening, especially in postmenopausal women.
CT/MRI: Further imaging for complex cases or pre-surgical planning.

Possible Causes

Gynaecological Causes:
- Ovarian cysts or tumors
- Fibroids
- Endometriosis
- Pelvic inflammatory disease (PID)
- Pregnancy-related causes (ectopic pregnancy, molar pregnancy)
Non-Gynecological Causes:
- Urinary: Bladder or ureteric tumors
- Gastrointestinal: Appendiceal abscess, diverticulitis, bowel tumors
- Retroperitoneal masses

Management

Referral to gynecology or oncology for suspicious masses
Surgical intervention may be necessary for large, painful, or complex masses
Follow-up imaging for benign findings

Common Causes

Cause	Clinical Features	Diagnostic Tests	Management
Ovarian Cyst	- Often asymptomatic - Pelvic pain (if torsion or rupture occurs) - Irregular menstrual cycles - Bloating or pressure in the abdomen	- Ultrasound: Simple cysts, complex cysts - CA-125: To rule out malignancy (usually low in benign cysts)	- Observation: For small, asymptomatic cysts - Surgical removal: If large, symptomatic, or suspected malignancy (laparoscopy or laparotomy) - Hormonal therapy: For recurrent functional cysts
Ovarian Cancer	- Persistent bloating - Pelvic/abdominal pain - Early satiety - Unexplained weight loss - Urinary urgency or frequency	- Ultrasound/CT: Solid mass, irregular borders - CA-125: Often elevated - Biopsy: Definitive diagnosis	- Surgery: Debulking surgery to remove as much of the tumour as possible - Chemotherapy: Following surgery or for advanced disease - Radiotherapy: In certain cases or palliative care
Uterine Fibroids	- Heavy menstrual bleeding (menorrhagia) - Pelvic pressure - Dysmenorrhea (painful periods) - Urinary frequency/retention (if large)	- Ultrasound: Hypoechoic, solid mass - MRI: For further characterization in larger fibroids	- Medical therapy: Hormonal therapy (e.g., GnRH agonists) - Surgical intervention: Myomectomy (for fertility preservation) or hysterectomy (definitive treatment) - Uterine artery embolization: For reducing fibroid size
Endometriosis	- Chronic pelvic pain - Dysmenorrhea - Pain during intercourse (dyspareunia) - Infertility	- Ultrasound: Endometriomas ("chocolate cysts") - Laparoscopy: Gold standard for diagnosis	- Medical treatment: Hormonal therapy (e.g., OCPs, GnRH agonists) - Surgical management: Laparoscopic excision of endometrial tissue - Fertility treatment: Assisted reproductive techniques if infertility is a concern
Tubo-Ovarian Abscess	- Acute pelvic pain - Fever, chills - Vaginal discharge - Abdominal tenderness	- Ultrasound: Complex adnexal mass - CBC: Elevated WBCs - Cervical swabs: For culture of pathogens (e.g., chlamydia, gonorrhea)	- Antibiotics: Broad-spectrum IV antibiotics - Surgical drainage: If unresponsive to medical management or in severe cases - Follow-up: Ultrasound to ensure resolution of abscess
Ectopic Pregnancy	- Missed period - Lower abdominal pain - Vaginal bleeding - Shoulder pain (if rupture)	- Pregnancy Test: Positive (hCG elevated) - Transvaginal Ultrasound: No intrauterine pregnancy seen, adnexal mass	- Medical management: Methotrexate for early, unruptured ectopic pregnancy - Surgical intervention: Laparoscopic salpingectomy or salpingostomy for ruptured ectopic pregnancy - Follow-up: Monitor hCG levels until they return to zero
Pelvic Inflammatory Disease (PID)	- Lower abdominal pain - Fever - Abnormal vaginal discharge - Painful urination or intercourse	- Pelvic Exam: Cervical motion tenderness - CBC: Elevated WBCs - Ultrasound: Thickened fallopian tubes, possible abscess	- Antibiotic therapy: Broad-spectrum antibiotics for bacterial infection - Hospitalization: For severe cases or tubo-ovarian abscess - Sexual partner treatment: To prevent reinfection

Approach

Category	Details
History	- Menstrual history (irregular bleeding, menorrhagia) - Reproductive history (parity, infertility) - Symptoms (pain, bloating, urinary frequency, weight loss) - Family history of ovarian or uterine cancer - Previous pelvic surgeries or endometriosis
Physical Examination	- Abdominal palpation for tenderness, mass size, and mobility - Pelvic examination (cervical motion tenderness, adnexal mass) - Assess for signs of ascites or other systemic involvement
Investigations	Ultrasound (transvaginal and transabdominal): Initial imaging to evaluate the mass (solid, cystic, size, vascularity). CT/MRI: Further characterization of complex masses, involvement of adjacent organs. CA-125: Tumour marker for ovarian cancer (elevated in malignancy but also in benign conditions). CBC, electrolytes, LFTs: To evaluate general health and systemic involvement. Pregnancy test: Rule out ectopic pregnancy in reproductive age women.
Common Causes	Benign: Ovarian cysts, fibroids, endometriosis, tubo-ovarian abscess. Malignant: Ovarian cancer, endometrial cancer, metastatic disease. Pregnancy-related: Ectopic pregnancy, molar pregnancy. Non-gynaecological: Appendiceal abscess, bladder tumours, diverticular disease.
Management	Observation: For small, asymptomatic, or functional cysts (reassess with follow-up imaging). Medical treatment: Hormonal therapy for endometriosis or fibroids, antibiotics for infections. Surgical intervention: Laparoscopy or laparotomy for suspected malignancy, large masses, or symptomatic lesions. Oncological referral: If malignancy is suspected, multidisciplinary approach with chemotherapy, radiotherapy, or debulking surgery may be required.

PLEASE NOTE LEGAL ADVICE: The contents are under continuing development and improvements and may contain errors of omission or fact. Feedback vital and always welcome at drokane at gmail.com. This is not to be used for the assessment, diagnosis or management of patients. It should not be regarded as medical advice. It is only for educational purposes. Please adhere to your local protocols. If you are unwell please seek healthcare advice from your doctor. This does not replace senior or specialist advice. If you do not accept this then please do not use the website. If you need medical advice, please consult a doctor or other appropriate medical professional. If you are a medical professional and you need advice then speak to your senior or colleagues.

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