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Pelvic Mass

by David H. Barad, MD, MS

A pelvic mass may be detected during routine gynecologic examination.

Etiology

Pelvic masses may originate from gynecologic organs (cervix, uterus, uterine adnexa) or from other pelvic organs (intestine, bladder, ureters, skeletal muscle, bone).

Type of mass tends to vary by age group.

In infants, in utero maternal hormones may stimulate development of adnexal cysts during the first few months of life. This effect is rare.

At puberty, menstrual fluid may accumulate and form a vaginal mass (hematocolpos) because outflow is obstructed. The cause is usually an imperforate hymen; other causes include congenital malformations of the uterus, cervix, or vagina.

In women of reproductive age, the most common cause of symmetric uterine enlargement is pregnancy, which may be unsuspected. Another common cause is fibroids, which may extend outward. Common adnexal masses include graafian follicles (usually 5 to 8 cm) that develop normally but do not release an egg (called functional ovarian cysts). These cysts often resolve spontaneously within a few months. Adnexal masses may also result from ectopic pregnancy, ovarian or fallopian tube cancers, benign tumors (eg, benign cystic teratomas), or hydrosalpinges. Endometriosis can cause single or multiple masses anywhere in the pelvis, usually on the ovaries.

In postmenopausal women, masses are more likely to be cancerous. Many benign ovarian masses (eg, endometriomas, myomas) depend on ovarian hormone secretion and thus become less common after menopause.

Evaluation

History

General medical and complete gynecologic histories are obtained. Vaginal bleeding and pelvic pain suggest ectopic pregnancy or, rarely, gestational trophoblastic disease. Dysmenorrhea suggests endometriosis or uterine fibroids. In young girls, precocious puberty may indicate a masculinizing or feminizing ovarian tumor. In women, virilization may indicate a masculinizing ovarian tumor; menometrorrhagia or postmenopausal bleeding may indicate a feminizing ovarian tumor.

Examination

During the general examination, the examiner should look for signs of nongynecologic (eg, GI, endocrine) disorders and for ascites. A complete gynecologic examination is done. Distinguishing uterine from adnexal masses may be difficult. Endometriomas are usually nonmobile cul-de-sac masses. Adnexal cancers, benign tumors (eg, benign cystic teratomas), and adnexal masses due to ectopic pregnancy are mobile. Hydrosalpinges are usually fluctuant, tender, nonmobile, and sometimes bilateral. In young girls, pelvic organ masses may be palpable in the abdomen because the pelvis is too small to contain a large mass.

Testing

If the presence or origin (gynecologic vs nongynecologic) of a mass cannot be determined clinically, an imaging test can usually do so. Usually, pelvic ultrasonography is done first. If it does not clearly delineate size, location, and consistency of the mass, another imaging test (eg, CT, MRI) may. Ovarian masses with radiographic characteristics of cancer (eg, a solid component, surface excrescences, irregular shape) require needle aspiration or biopsy. Tumor markers may help in the diagnosis of specific tumors (see Tumor Immunodiagnosis).

Women of reproductive age are tested for pregnancy; if the test is positive, imaging is not always necessary (see Ultrasonography) unless ectopic pregnancy is suspected. In women of reproductive age, simple, thin-walled cystic adnexal masses that are 5 to 8 cm (usually graafian follicular cysts) do not require further investigation unless they persist for > 3 menstrual cycles.

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