Pelvic mass

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Pelvic masses can be an indication of ovarian, cervical, endometrial or vulvar carcinoma.

Presentation

Usually, a benign ovarian cyst will present as the result of an annual health examination, acute pain, or mild discomfort due to pressure on the bowel or bladder.

Acute ovarian pain only occurs in a few instances, such as when the surface epithelium has undergone acute hypoxia, or acute stretching. However, most benign and malignant masses are slow-growing, do not tort and do not rupture, and therefore are "painless". Acute pain is also possible if the surface epithelium has undergone irritation, such as with external hemorrhage or rupture.

The lack of apparent manifestation until the late stages is why ovarian cancer has been dubbed the "silent killer" or "the disease that whispers".

With pelvic masses, primary symptoms are predominantly caused by the mass in the local area of growth, and can cause vague discomfort due to bowel and bladder fullness in the pelvis. Pain is rare, though there may be pressure on the surrounding structures. Secondary symptoms are usually the result of metastatic disease. Ascites result in abdominal distension and early satiety. Serosal masses on the bowel can cause bloating or cramping. Tertiary symptoms include appetite changes, weight loss, and energy loss.

Investigations

Five criteria are evaluated on physical examination of the ovary: size, consistency, fixation, surface contour and tenderness.

Most ovarian cancer is only detected in the late stages. Physical findings associated with advanced ovarian cancer include abdominal distension, ascites, a ballotable omental "cake", fixed, solid/cystic, nodular, or an irregular mildly tender mass. Tenderness and size do not correlate with cancer.

There are four types of ultrasound findings:

  1. Cystic
  2. Septated
  3. Complex (most cancers have this appearance)
  4. Solid

Another investigation is the CA-125, which usually means cancer in post-menopausal women with a mass, but may be negative in pre-menopausal women and false positives. ACT scan can also give a good assessment of the retroperitoneum, though it is not necessary pre-operatively.

Management

Two considerations in deciding whether or not to operate are the risk of malignancy and the risk of developing post-operative pain due to torsion, rupture or hemorrhage. Age, clinical symptoms, size and ultrasound features are used to triage ovarian masses, as are laparascopic USO, laparascopic BSO, open USO, open BSO and TAH/BSO, though god help me if I know what the hell those are.