Benign Pelvic and Perineal

masses
Prof (M) Dr Mohd Hashim Omar
Jabatan 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  Ovarian
 Pregnancy  Benign tumours (solid and
 Leiomyomata cystic)
 Adenomyosis  Malignant tumours (mainly
 Congenital anomalies
solid)
 Carcinoma
 Sarcoma
 Pregnancy
 Pyometra  Ligamentary
 Tubal  Endometroid
 Inflammatory(Hydro-S)  Benign tumours
 Pregnancy(ectopic) (Leiomyoma, haematoma)
 Benign tumours (adenomatoid,  Malignancy (mainly
myoma)
metastatic)
 Carcinoma
Pelvic Anatomical Consideration
 Ovaries  Uterus
 Prepubertal &  Multiparous uterus
Menopause remain symetrically
 Measure less than 2 cm larger 2-3cm larger
in its longest Diameter than nulliparous
AND not not clinically
palpable
 Smaller (atrophic) in
prepubertal &
 Fallopian Tube menopausal
 Delicate and not
palpable
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  Cystic tumor
 Condylomata  Epithelial inclusion
 Seborrheic Keratosis cyst
 Acrochordons  Bartolin’duct (abscess
(fibroepithelial polyps) or cyst
 Fibromas  Mucous cyst
 Neurofibromatosis  Hydrocoele, hernia
 Hidradenoma and/or cyst of the
 Accesory breast canal of nuck
 Sebaceous adenoma
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