This document discusses pelvic masses, leiomyomas (uterine fibroids), low abdominal pain, and pelvic inflammatory disease (PID). It begins by defining pelvic masses and describing common causes such as leiomyomas. It then discusses symptoms, diagnosis, and management of leiomyomas. The document outlines signs and potential causes of both acute and chronic lower abdominal pain. Finally, it defines PID, describes risk factors and classifications, and provides epidemiological information about PID.

2. Texila American University
OBSTETRICS AND
GYNAECOLOGY
Dr Yahavivi Aguila Nogueira.
Specialist in Family Medicine.
Specialist in Obstetrics and Gynecology.
Medical Registrar of MOH
Master in Comprehensive Care to Woman.
Assistant Professor of ISCM Havana. Cuba.

3. DIDACTIC LECTURE 11
TOPIC 8
TITLE: PELVIC MASS, LOW
ABDOMINAL PAIN AND
PELVIC INFLAMMATORY
DISEASE.

4. SUMMARY
 Pelvic mass.
 Leiomyoma.
 Low Abdominal Pain.
 Pelvic Inflammatory Disease.

5. PELVIC MASS.
Pelvic masses are common clinical findings
and may involve the reproductive organs or
non gynaecologic structures. They may be
identified in asymptomatic women during
routine pelvic examination or may cause
symptoms. Typical complaints include pain,
pressure sensations, dysmenorrhea, or
abnormal uterine bleeding. Although most
pelvic masses are acquired lesions, a few
arise as congenital anomalies.

6. PELVIC MASS.
As a part of evaluation, laboratory tests are typically
uninformative, but levels of serum -human chorionic
gonadotropin (-hCG) or tumor markers may be
helpful. Initially, imaging with sonography is
preferred, but computed tomography (CT) or
magnetic resonance (MR) imaging may be useful if
the nature of the mass is still uncertain. Treatment of
pelvic masses varies with patient symptoms, age,
and risk factors. Although medical management is
possible for many of these masses, for others,
surgical treatment offers the highest success rates.

7. PELVIC MASS.
Prepubertal Girls
The majority of gynecologic pelvic masses in this
age group involve the ovary. Even during childhood,
the ovaries are typically active, and many of these
masses are functional cysts. Neoplastic lesions
usually are benign germ cell tumors, and mature
cystic teratomas (dermoid cysts) are the most
common. Malignant ovarian tumors in children and
adolescents are rare and account for only 0.9
percent of all malignancies in this age group.

8. PELVIC MASS.
Adolescents
For the most part, the incidence and type of ovarian
pathology found in adolescents is similar to those
seen in prepubertal girls. With the onset of
reproductive function, however, pelvic masses in
adolescents may also include endometriomas and
the sequelae of pelvic inflammatory disease and
pregnancy. Gynecologic masses present a special
diagnostic challenge in children and adolescents,
because benign neoplasms greatly outnumber
malignant ones, and their clinical signs and
symptoms are often nonspecific.

9. PELVIC MASS.
Reproductive-Aged Women
A number of genital tract disorders cause pelvic
masses in adult women. Uterine enlargement due to
pregnancy, functional ovarian cysts, and leiomyomas
are among the most common. Endometrioma,
mature cystic teratoma, acute or chronic tubo-
ovarian abscess, and ectopic pregnancies are other
frequent causes.

10. PELVIC MASS.
Postmenopausal Women
With the cessation of ovulation and reproductive
function, the causes of pelvic mass also change. Simple
ovarian cysts and leiomyomas are still a common
source. Although atrophy of leiomyomas typically follows
menopause, uterine enlargement can still be noted in
many women. Importantly, malignancy is a more
frequent cause of pelvic masses in this demographic
group. Uterine tumors, including adenocarcinoma and
sarcoma, have associated uterine enlargement. In
addition, ovarian cancer accounts for nearly 4 percent of
cancers among all women, with an estimate of over
25,000 new cases diagnosed annually in the US.

11. PELVIC MASS.
OTHERS:
Bowell cancer.
Pelvic Lymphoma.
Pelvic Kidney.
Pelvic Spleen.

12. LEIOMYOMAS
Leiomyomas are benign smooth muscle
neoplasms that typically originate from the
myometrium. They are often referred to as
uterine myomas, and are incorrectly called
fibroids because the considerable amount of
collagen contained in many of them creates a
fibrous consistency. Their incidence among
women is generally cited as 20 to 25 percent,
but has been shown to be as high as 70 to 80
percent in studies using histologic or
sonographic examination.

13. LEIOMYOMAS
Risk factors:
Age
Obesity
Early menarche
Nuliparity
African-American race
Affected family member

14. CLASSIFICATION OF LEIOMYOMAS
Leiomyomas are classified based on their location
and direction of growth. Subserosal leiomyomas
originate from myocytes adjacent to the uterine
serosa, and their growth is directed outward. When
these are attached only by a stalk to their progenitor
myometrium, they are called pedunculated
leiomyomas. Parasitic leiomyomas are subserosal
variants that attach themselves to nearby pelvic
structures from which they derive vascular support,
and then may or may not detach from the parent
myometrium.

15. CLASSIFICATION OF LEIOMYOMAS
Intramural leiomyomas are those with growth
centered within the uterine walls. Finally,
submucous leiomyomas are proximate to the
endometrium and grow toward and bulge into
the endometrial cavity. Only about 0.4 percent of
leiomyomas develop in the cervix . Leiomyomas
have also been found less commonly in the
ovary, fallopian tube, broad ligament, vagina,
and vulva.

17. SYMPTOMS.
Most women with leiomyomas are
asymptomatic. However, symptomatic patients
typically complain of bleeding, pain, pressure
sensation, or infertility. In general, the larger the
leiomyoma, the greater the likelihood of
symptoms.

18. SYMPTOMS.
Bleeding
This is the most common symptom and usually
presents as menorrhagia. The pathophysiology
underlying this bleeding may relate to dilatation
of venules. Bulky tumors are thought to exert
pressure and impinge on the uterine venous
system, which causes venular dilatation within
the myometrium and endometrium. Accordingly,
intramural and subserosal tumors have been
shown to have the same propensity to cause
menorrhagia as submucous ones.

19. SYMPTOMS.
Pelvic Discomfort and Dysmenorrhea
A sufficiently enlarged uterus can cause pressure
sensation, urinary frequency, incontinence, and
constipation. Rarely, leiomyomas extend laterally to
compress the ureter and lead to obstruction and
hydronephrosis. Although dysmenorrhea is
common, in a population-based cross-sectional
study, Lippman and co-workers (2003) reported that
women with leiomyomas more frequently had
dyspareunia or noncyclical pelvic pain than
dysmenorrhea.

20. SYMPTOMS.
Infertility and Pregnancy Wastage
Although the mechanisms are not clear,
leiomyomas can be associated with infertility. It is
estimated that 2 to 3 percent of infertility cases are
due solely to leiomyomas. Their putative effects
include occlusion of tubal ostia and disruption of the
normal uterine contractions that propel sperm or
ova. Distortion of the endometrial cavity may
diminish implantation and sperm transport.
Importantly, leiomyomas are associated with
endometrial inflammation and vascular changes
that may disrupt implantation.

21. DIAGNOSIS.
On vaginal examination: uterus enlargement,
irregular contour, firm consistence.
Abdominal ultrasound.
Saline-infusion sonography (SIS)
Hysteroscopy.
Hysterosalpingography (HSG).
MRI.
CT scan.

23. MANAGEMENT.
Observation
Regardless of their size, asymptomatic leiomyomas
usually can be managed expectantly by annual
pelvic examination (American College of
Obstetricians and Gynecologists 2001). If
assessment of the adnexa is hindered by uterine
size or contour, some may choose to add annual
sonographic surveillance .

24. MANAGEMENT.
Drug Therapy
In some women with symptomatic leiomyomas,
medical therapy may be preferred. In addition,
because leiomyomas typically regress
postmenopausally, some women choose medical
treatment to relieve symptoms in anticipation of
menopause. In others, medical therapy, such as
GnRH agonists, are used as a preoperative adjunct
to surgery.

25. MANAGEMENT.
Drug Therapy
Nonsteroidal Anti-Inflammatory Drugs.
Androgens: danazol , gestrinone.
GnRH Agonists: Leuprolide acetate 3.75 mg depot
IM monthly
GnRH Antagonists: cetrorelix, Nal-glu
Antiprogestins: Mifepristone

26. MANAGEMENT.
Uterine Artery Embolization
This is an angiographic interventional procedure
that delivers polyvinyl alcohol (PVA) microspheres
or other particulate emboli into both uterine arteries.
Uterine blood flow is therefore obstructed,
producing ischemia and necrosis.

28. MANAGEMENT.
Surgical Management
Myomectomy.
Hysterectomy.

30. LOW ABDOMINAL PAIN
Acute and chronic lower abdominal pain are
common complaints in office and emergency
room settings. However, they vary dramatically by
definition, predominant etiologies, and
neurophysiology. The mechanisms underlying the
perception of pain are not yet fully defined but
appear to involve interactions between
neurologic, psychological, immunologic, and
endocrine factors

32. ACUTE PAIN
Periumbilical : Appendicitis (early) Small bowel
obstruction, Gastroenteritis, Mesenteric ischemia,
Abdominal aortic aneurysm rupture or dissection.
Right lower quadrant: Appendicitis, Inflammatory
bowel disease, Ovarian tumor, Ovarian
torsion, Ectopic pregnancy, Pelvic inflammatory
disease, Tubo-ovarian abscess, Pyelonephritis,
Perinephric abscess, Urolithiasis,
Gastrointestinal malignancy, Right-sided
diverticulitis, Ileocolitis, Gastroenteritis, Hernia.

33. ACUTE PAIN
Suprapubic: Irritable bowel disease,
Ovarian tumor, Ovarian torsion, Ectopic
pregnancy, Pelvic inflammatory disease, Tubo-
ovarian abscess, Dysmenorrhea, Colonic
disease, Diverticulitis, Cystitis, Nephrolithiasis
Left lower quadrant: Irritable bowel disease,
Ovarian tumor, Ovarian torsion, Ectopic
pregnancy, Pelvic inflammatory disease, Tubo-
ovarian abscess, Pyelonephritis, Perinephric
abscess, Nephrolithiasis, Sigmoid diverticulitis,
Ileocolitis, Gastroenteritis, Hernia,
Gastrointestinal malignancy.

34. ACUTE PAIN
Diffuse
Gastroenteritis, Bowel obstruction, Peritonitis,
Mesenteric ischemia, Irritable bowel disease,
Diabetic ketoacidosis, Porphyria, Uremia,
Hypercalcemia, Sickle cell crisis, Vasculitis,
Heavy metal intoxication, Opiate withdrawal,
Familial Mediterranean fever,
Hereditary angioedema

35. ACUTE PAIN
Suprapubic: Irritable bowel disease,
Ovarian tumor, Ovarian torsion, Ectopic
pregnancy, Pelvic inflammatory disease, Tubo-
ovarian abscess, Dysmenorrhea, Colonic
disease, Diverticulitis, Cystitis, Nephrolithiasis
Left lower quadrant: Irritable bowel disease,
Ovarian tumor, Ovarian torsion, Ectopic
pregnancy, Pelvic inflammatory disease, Tubo-
ovarian abscess, Pyelonephritis, Perinephric
abscess, Nephrolithiasis, Sigmoid diverticulitis,
Ileocolitis, Gastroenteritis, Hernia,
Gastrointestinal malignancy.

36. CHRONIC PAIN
Gynecologic
Extrauterine: Adhesions, Adnexal cysts
Chronic ectopic pregnancy
Chlamydial endometritis or salpingitis
Endometriosis, Neoplasia of the genital tract
Ovarian retention syndrome, Ovulatory pain
Postoperative peritoneal cysts
Residual accessory ovary
Subacute salpingo-oophoritis (chronic PID)

37. CHRONIC PAIN
Gynecologic
Uterine
Adenomyosis
Atypical dysmenorrhea or ovulatory pain
Cervical stenosis
Chronic endometritis
Endometrial or endocervical polyps
Intrauterine contraceptive device
Leiomyomas
Symptomatic pelvic floor relaxation

38. CHRONIC PAIN
Urologic: Bladder neoplasm, Chronic urinary tract
infection, Detrusor dysynergia, Interstitial cystitis,
Radiation cystitis, Recurrent acute cystitis or
urethritis, Stone/urolithiasis, Urethral diverticulum.
Gastrointestinal: Carcinoma of the colon, Chronic
intermittent bowel obstruction, Colitis, Constipation,
Diverticular disease, Inflammatory bowel disease,
Irritable bowel syndrome

39. CHRONIC PAIN
Musculoskeletal: Abdominal wall myofascial
pain, Coccydynia, Compression of lumbar
vertebrae, Degenerative joint disease, Disk
herniation or rupture, Faulty or poor posture,
Fibromyositis, Hernias: ventral, inguinal, femoral,
spigelian. Levator ani syndrome, Low back pain,
Muscular strains and sprains, Neoplasia of spinal
cord or sacral nerve,
Neuralgia of iliohypogastric, ilioinguinal, and/or
genitofemoral nerves, Piriformis syndrome,
Rectus tendon strain,Spondylosis.

40. CHRONIC PAIN
Other
Abdominal cutaneous nerve entrapment
Familial Mediterranean fever
Neurologic dysfunction
Porphyria
Psychiatric disorders
Shingles

41. PELVIC INFLAMMATORY DISEASE.
Pelvic inflammatory disease (PID) is a general term
for acute, subacute, recurrent, or chronic infection of
the oviducts and ovaries, often with involvement of
adjacent tissues. Most infections seen in clinical
practice are bacterial, but viral, fungal, and parasitic
infections occur. The term PID is vague at best and
should be discarded in favor of more specific
terminology, which should include identification of the
affected organs, the stage of the infection, and, if
possible, the causative agent. This specificity is
especially important in light of the rising incidence of
venereal disease and its complications.

42. PELVIC INFLAMMATORY DISEASE.
There three proposed pathways of dissemination of
microorganisms in pelvic infections: Lymphatic
dissemination, typified by postpartum, postabortal, and some
IUD-related infections, results in extraperitoneal parametrial
cellulitis. The endometrial-endosalpingeal-peritoneal spread
of microorganisms, this represents more common forms of
nonpuerperal PID, in which pathogenic bacteria gain access
to the lining of the uterine tubes, with resultant purulent
inflammation and egress of pus through tubal ostia into the
peritoneal cavity. These infections are represented by
endometritis, adnexal infection, and peritonitis. In rare
instances, certain diseases (eg, tuberculosis) may gain
access to pelvic structures by hematogenous routes

43. PELVIC INFLAMMATORY DISEASE.
Risk Factors
Douching
Single status
Substance abuse
Multiple sexual partners
Lower socioeconomic status
Recent new sexual partner(s)
Younger age (10 to 19 years)
Other sexually transmitted infections
Sexual partner with urethritis or gonorrhea
Previous diagnosis of pelvic inflammatory disease
Not using mechanical and/or chemical contraceptive barriers
Endocervical testing + for N gonorrhoeae or C trachomatis

44. PELVIC INFLAMMATORY DISEASE.
CLASSIFICATION:
Silent pelvic inflammatory disease.
Acute pelvic inflammatory disease.
Chronic pelvic inflammatory disease.
OTHER:
 PID tumoral.
 PID non tumoral.

45. PID EPIDEMIOLOGY.
 PID is commonly associated with sexually
transmitted infections (STIs).
 Incidence is on rise due to rise in (STIs).
 Among sexually active women the
incidence is 1-2% per year.
 In the United States, more than 750,000
women are affected by PID each year,
and the rate is highest with teenagers and
first time mothers.

46. PID EPIDEMIOLOGY.
 About 85% are spontaneous infection in
sexually active females of reproductive
age.
 Remaining 15% follow procedures, which
favours the organism to ascend up.
 PID causes over 100,000 women to
become infertile in the US each year.

47. PID EPIDEMIOLOGY.
1. Primary organisms
Sexually transmitted
 N. Gonorrhoeae
 Chlamydia trachomatis
 Mycoplasma hominis

48. PID EPIDEMIOLOGY.
2. Secondary organisms
Normally found in vagina
 Aerobic: Non-hemolytic streptococcus, E.
coli, Group-B streptococcus and
staphylococcus
 Anaerobic: Bacteroides species-fragilis &
bivius, peptostreptococcus &
peptococcus, Bacterial Vaginosis,
Actinomyces israel.
 Mycobacterium tuberculosis and bovis.

49. PID EPIDEMIOLOGY.
3. Iatrogenic procedures:
favour organisms to ascend
 Endometrial biopsy
 Uterine Curettage.
 Insertion of IUD.
 Hysterosalpingography .

51. PID DIAGNOSIS.
In women who are symptomatic, symptoms develop during
or following menstruation. The most recent recommended
diagnostic criteria presented by the CDC (2006) are for
sexually active women at risk for STDs who have pelvic or
lower abdominal pain and other etiologies are not feasible.
Their diagnosis should be PID if they have uterine
tenderness, adnexal tenderness, or cervical motion
tenderness. One or more of the following enhances
diagnostic specificity: (1) oral temperature >38.3°C
(101.6°F), (2) mucopurulent cervical or vaginal discharge, (3)
abundant WBCs on saline microscopy of cervical secretions,
(4) elevated erythrocyte sedimentation rate (ESR) or C-
reactive protein (CRP), and (5) presence of cervical N
gonorrhoeae or C trachomatis.

52. PID DIAGNOSIS.
1. LABORATORY TEST:
 Complete blood count.
 C – reactive protein.
 Erythrocyte sedimentation rate.
 Urine pregnancy test, urinalysis.
 Cervical chlamydia and gonorrhoea testing.
2. ABDOMINAL ULTRASOUND.
3. LAPAROSCOPY.
4. ENDOMETRIAL BIOPSY.
5. CULDOCENTESIS.

53. PID COMPLICATIONS.
 Recurrent PID.
 Ruptured abscess.
 Chronic pain.
 Ectopic Pregnancy.
 Infertility.
 Perihepatic adhesions (Fitz-Hugh-Curtis
Syndrome)

54. PID TREATMENT.
1. MEDICAL:
 Outpatient therapy.
 Inpatient therapy.
2. SURGICAL
 Conservative.
 Radical.

55. Outpatient Therapy.
These women can be treated with antibiotics, IUD removal,
analgesics, and bed rest.
Regimens recommended by the CDC include
(1) ofloxacin 400mg PO BID or levofloxacin 500 mg PO OD for 14
days, plus clindamycin 450 mg PO QID or metronidazole 500
mg PO BID for 14 days;
(2) ceftriaxone 250 mg IM or equivalent cephalosporin (eg,
ceftizoxime or cefotaxime) IM, with probenecid 1 g orally,
followed by 14 days of doxycycline 100 mg PO BID, with or
without metronidazole 500 mg twice daily;
(3) cefoxitin 2 g IM, plus probenecid 1 g orally, followed by 14
days of doxycycline 100 mg PO BID, with or without
metronidazole 500 mg BID.
If a response to therapy is not observed after 72 hours, the patient
should be admitted for inpatient therapy.

56. PID TREATMENT.
Recommended Hospitalization Indications for
Treatment of Pelvic Inflammatory Disease
 Adolescents
 Drug addicts
 Severe disease
 Suspected abscess
 Uncertain diagnosis
 Generalized peritonitis
 Temperature >38.3° C
 Failed outpatient therapy
 Recent intrauterine instrumentation
 White blood cell count >15,000/mm3
 Nausea/vomiting precluding oral therapy

57. Inpatient Therapy.
The CDC recommends one of the following regimens:
(1) cefoxitin 2 g IV QID, or cefotetan 2 g IV BID, for at least 24
hours after the patient shows clinical improvement, followed
by doxycycline 100 mg PO BID to complete 14 days of
therapy;
(2) clindamycin 900 mg IV TID, plus gentamicin 2 mg/kg IV and
then 1.5 mg/kg IV every 8 hours (single daily dosing of
gentamicin 5-7mg/Kg may be substituted), given as above in
women with normal renal function, followed by doxycycline
100 mg BID or clindamycin 450 mg PO QID for 14 days
(3) Ampicillin/sulbactam 3 g IV QID plus Doxycycline 100 mg PO
BID

58. PID TREATMENT.
Male sex partners of women with PID should be
examined and treated if they had sexual contact
with the patient during 60 days preceding the
patient’s onset of symptoms.

59. THANKS.