benign pelvic and perineal masses - prof hashim
TRANSCRIPT
Benign Pelvic and Perineal masses
Prof (M) Dr Mohd Hashim OmarJabatan Obstetrik & Ginekologi
Fakulti Perubatan, UKM
Introduction
Recognition of a pelvic or perineal mass requires a complete familiarity with con stitutes normal female pelvic anatomy
Definition of “Normal” differs depending on pubertal status, phase of menstrual cycle, occurrence of menopause, previous surgery and known intercurrent disease.
Gynaecologic and Obstetrical Pelvic Masses
Uterine Pregnancy Leiomyomata Adenomyosis Congenital anomalies Carcinoma Sarcoma Pyometra
Tubal Inflammatory(Hydro-S) Pregnancy(ectopic) Benign tumours (adenomatoid,
myoma) Carcinoma
Ovarian Benign tumours (solid and
cystic) Malignant tumours (mainly
solid) Pregnancy
Ligamentary Endometroid Benign tumours
(Leiomyoma, haematoma) Malignancy (mainly
metastatic)
Pelvic Anatomical Consideration
Ovaries Prepubertal &
Menopause Measure less than 2 cm
in its longest Diameter AND not not clinically palpable
Fallopian Tube Delicate and not
palpable
Uterus Multiparous uterus
remain symetrically larger 2-3cm larger than nulliparous
Smaller (atrophic) in prepubertal & menopausal
Pelvic Mass
Size Preferably the mass is describe as anterior or
posterior, midline, left or right to a given reference point ( usually Uterus)
Most often, uterine size is compared and describe as the size of pregnant uterus at a given gestation period
Measurement in cm is preferred
Pelvic Mass
Mobility or Fixation The ovaries, fallopian tube, and uterus are
suspended by pliable, distensible ligaments Highly mobile
usually the uterus move with the mass if the mass arising from the uterus.
Inflammatory lesions, malignancy, endometriosis, previous radiotherapy and previous surgery diminishes mobility
Pelvic Mass
Consistency To differentiate the mass is solid, cystic or
both component. Benign, simple ovarian cyst are smooth and
soft (cystic) Ovarian malignancy, fibroid are solid
Pelvic Mass
Tenderness Tender uterus is typically adenomyosis or
endometritis Salpingitis or tubal pregnancy will result in
tenderness to palpation or cervical motion Torsion and infarction of mass can also lead
to tenderness
Pelvic Mass
Shape and Symmetry Uterus is a symmetric structure
Enlargement of any of its components can lead to an irregular enlargement
Symmetrical enlargement suggest pregnancy or adenomyosis
Diagnosis and management of pelvic masses
Premenarchal Female No Physiologic ovarian lesion or pregnancy-related
masses Mainly related to congenital anomalies involving
Complete or partial duplication of Mullerian system Benign or malignant ovarian cyst (germ cell) Congenital cyst of mesonephric system Pelvic kidney
A careful history and examination including EUA, IVP and serum tumour markers (AFP and Beta HCG) as well as karyotyping should always be done.
Cont.
The sexual abuse also should be role out Pelvic inflammatory disease and pelvic abscess Chronic haematomas secondary to forced sex
Diagnosis and management of pelvic masses
Menstruating Female Intrauterine and ectopic pregnancy are always a
diagnostic consideration Careful menstrual history, sexual activity and
pregnancy symptoms Pattern of menstrual cycle, amounts and any pain
should be asked Association factors eg. Fever, pain, dyspareunia
and progression Constitutional symptoms
Diagnosis and management of pelvic masses
Postmenopausal Female Pelvic mass is consider omnious Consider malignant Functional cyst do not enter into the
differential diagnosis Fibroid and endometriosis get smaller or
better during menopause Silent PID lead to pelvic abscess should be
considered
Benign Uterine lesions
Leiomyomas of Uterus The most common tumour of uterus 20-40% in women over 35 years old Frequently cause no symptoms It is the commonest indication for
hysterectomy Growth of fibroid is faster and incidence of
fibroid in black women
Cont (fibroid)
Pathology Is discrete and may be single or more Cut surface has a glistening, white colour with a
characteristic whole-like trabeculation Pseudocapsul comprised of compressed cell on the
outer layer Occur in several location, cervix, uterus, broad
ligaments. Symptoms may related to the size and site of the
fibroid
Cont (fibroid)
Pathogenesis Aetiology is not established Hormonal influence on the growth of
leiomyomas is obvious Growth rapidly during pregnancy , OCP,
PCOS, granulosa cell tumour Rarely before menarrche and regress after
menopause
Cont (fibroid)
Secondary Changes of Fibroid Because of sparce in blood supply, fibroid are
subjected to severe degenerative changes Hyaline degeneration is the most common and not clinically
significant and lead to Calcification Cystic degeneration is an extreme form of hyaline
degeneration Red degeneration occur in pregnancy and menopause
The main symptom is pain due to congestion and swelling Sarcomatous degeneration is rare.
Cont (fibroid)
Sign and Symptoms Compression symptoms eg. Discomfort, urinary
retention, constipation Menstrual problems: Submucosa and intramural
fibroid. Hydronephrosis and hydroureter Polycytemia in Right broad ligament fibroid Pain in red and sarcomatous degeneration
Cont (fibroid)
Treatment Conservative
Asymptomatic Pregnancy
Surgical Symptomatic Completed family : Hysterectomy Not completed family: Conservative surgery/
Myomectomy
Benign Uterine lesions
Adenomyosis Benign uterine disease caractersed by endometrial
glands and stroma found within the uterine musculature
There is hypertrophy and hyperplasia of the myometrium
Resulting a diffuse enlarged uterus There is ectopic growth of endometrial tissue The incidence is difficult to determine 50% asymptomatic
Adenomyosis (cont)
Pathology Uterus is diffusely enlarged There may be small, dark, bloody cystic area throughout
the of the uetrus within myometrium Microscopically : islands of endometrial tissue includibg
glands and stromal scattered in the myometrium 50% of patient with adenomyosis have a uterine fibroid When endometrial carcinoma is present, adenomyosis is
frequently associated Implying a common aetiology factors such as hyperestrogenism
Adenomyosis (cont)
Clinical Characteristics and diagnosis Patient is in between 40 to 50 Parous, and has symptoms of menorrhagia Menorrhagia is resistant to hormonal treatment Dysmenorrhoea in 25% of patient Diagnosis is made clinically by the symptoms and
examination of symmetrically enlarged uterus Diagnosis is only confirmed by HPE
Adenomyosis (cont)
Treatment Medical treatment
Pseudopregnancy drugs: OCP/progesterone Pseudomenopause drugs: Danazol/GnRH
Surgical treatment Hysterectomy
Benign Ovarian Mass
Functional Cyst Most commonly found during reproductive age Rarely cause symptoms or require treatment Follicular cyst
Normally only one follicle will goes to full development and ovulation
Others degenerated and the follicular fluid is absorbed Replaced by fibrous and hyaline If fluid not absorbed: Follicular cyst. Rarely beyond 7 cm diameter Decrease in size and disappear within 6-8 weeks
Functional Cyst (cont)
Corpus luteum cysts During pregnancy, CL may become cystic and
enlarged No clinical significant; however if ruptured may
confused with ectopic Rarely get twisted
Functional Cyst (cont)
Theca-lutein cysts May occur in molar pregnancy Large cyst derived from theca cells or luteinized
granulosa cells Not require treatment unless it undergone torsion,
rupture or haemorrhage Cause by excessive HCG stimulation The cyst will disappear with the disease treatment
Benign Ovarian Mass
Luteoma of pregnancy Uncommon Occur in pregnancy and is the result of excessive
response of ovarian stroma to high level of HCG Tumour disappear once pregnancy terminated Occasionally they secrete androgen and cause hirsutism
of mother,and musculinization of female fetus Tubo-ovarian inflammatory mass Para-ovarian Cyst
Cysts arise from the mesonephric remnants and located in the mesovarium
Benign Ovarian Mass
Benign neoplastic cysts Epithelial tumour
Serous Mucinous Endometrial Clear cell or mesonephroid Adenofibromas Brenner
Sex Cord Stromal Tumour Thecoma, fibroma and Sertoli-Leydig cell
Germ Cell Tumours Mature teratoma
Benign Perineal masses
Benign solid tumour Condylomata Seborrheic Keratosis Acrochordons
(fibroepithelial polyps) Fibromas Neurofibromatosis Hidradenoma Accesory breast Sebaceous adenoma
Cystic tumor Epithelial inclusion
cyst Bartolin’duct (abscess
or cyst Mucous cyst Hydrocoele, hernia
and/or cyst of the canal of nuck
Benign Perineal masses
Cystic Masses Epidermal Inclusion Cyst
Sebaceous cyst Extremely common on the vulva and usually
appear as multiple small, firm subcutaneous nodule
Ocassionally are recurrently infected with associated irritation, demanding incision and drainage
Cystic Masses (cont)
Bartholin’s duct abscess/cyst Bartholin’s gland entering the interoitus just above
the fourchette at the vaginal outlet May be dilated as the result of chronic infection
and/or cyst formation
Thank