Cases pelvi transcript — SMP305 lecture transcript

Yes, no. So my name's Hannah Mistry, I'm one of the consultants at Rotherham NHS Foundation Trust. I've been asked to give you this lecture on benign pelvic masses. Is that all big enough for you all? I mean, I think that's the biggest I can get it anyway. Alright, fine. Um, so I mean, what we're gonna do, um, is talk about common pelvic masses that you might present to you, uh, interpret, uh, taking a focus history, um, and then interpret abdominal and pelvic examinations, selecting the appropriate investigations to investigate these masses and identifying any red red flags and emergencies. OK. So I don't think many people would present to you saying I have a pelvic mass. Please can you tell me what it is and what's going on? So how might patients present to you with a with a pelvic mass? How might they present, so not often do women come to you and say I have a lump in my pelvis or I have a lump in my abdomen. Um, what might they, what might they present to you with? Pain. Pain, abdominal pain or pelvic pain, good? Unexpected. Yeah, so associated symptoms more often than not. So they might not present with the mass itself but they might have symptoms associated, so pain, unscheduled bleeding or er abnormal bleeding. Any other symptoms. Think about where the pelvic organs.

Change like bowel habits. Exactly, so pressure symptoms, so change to bowel, change to bladder habits if there's masses pressing on their other organs. Good. Anything else? A lump, so they might present with something in the vagina, something in the labia, something that's not been there some er before they've noticed a lump down below. I can feel something when I'm lying flat. So they might be lying flat and they might be able to palpate something in their pelvis, not really noticeable or before or it's something new. Something getting bigger. Um, might be more often than not. It depending on the location, you might, it might be an incidental finding of a pelvic mass. So ovarian masses um. Uh, cervical masses might be incidental, OK, but oftentimes, um, they'll have some symptoms or they'll, you know, once you've identified that there is a, a a mass in the pelvis, they'll in retrospect notice some change to their, their bowel, bladder, bleeding patterns, OK? So in looking at benign pelvic masses, we're gonna be focusing on different areas of the pelvic organs. So we're looking at the uterus, tubes, ovaries, er vagina, labia, these kinds of areas, OK. And again we're specifically focusing on benign masses. I think you'll have you'll have another lecture on um non ben on cancerous or non benign masses. So starting with our history. Um, so we've already said what their presenting complaint might be. Um, lumps, mass, menstrual changes. So in terms of pain, I've given you the answers already. So if they're, you know, presenting, most commonly masses that are increasing in size, if they're in the pelvic area, they're gonna. Press on the on the peritoneum, you're going to have symptoms associated with that um stretching of the peritoneum or irritation so they often present with pain. So what kind of features are we looking for in the pain, what kind of questions might you be asking about pelvic pain associated with a mass? Yeah, so pain, that's with each cycle, good. Yeah, so is it localised or generalised abdominal pain? It, you know, that might tell you where it's coming from, which, which organ. Good.

The severity, like how painful it is. Yeah, severity, good. Anything else? What else might you want to be asking them about their pain? When did it start? Yeah, so the duration, so they've noticed is it, is the, if they've noticed a mass or is the, is the pain getting worse and worse? Is it static, have they just noticed it always there day to day? Oh. Any, uh, um, so do they get pain with their, with menstruation? Do they get pain during intercourse, pain during activity? It's all gonna be part and parcel of trying to find out what might be going on and where, where this, where it might be arising from, which organ might be affected and also how it's affecting their day to day lives, OK? So we've talked about pain and kind of what might, what might be, what features might be present. What are the triggering factors, are there anything that makes this potential symptom worse or better? What kind of triggering factors, we've talked about sex might make this worse. What else might make symptoms worse in gynaecology? Activity, exercise, er menstruation, so it's really key to find out the symptoms in relation to the menstrual cycle. If they've had previous infections, so the gynaecological history that you need their previous um sexual history is really really important. So taking a good comprehensive history about the past medical, gynaecological history, obstetric history is really really important. And we've talked about um menstruation in in relation to any pelvic mass, you're always gonna want to find out a bit more about the menstrual history. So by these, by this, you know, features that you want to be wary of are menorrhagia, it's menorrhagia. So excessive or heavy menstrual bleeding, dysmenorrhea, you all know these terms, what's dysmenorrhea? Pain or excessive pain associated with menstrual bleeding? Amenorrhea. No menstrual bleeding, so it's important that you're able to kind of summarise, so you need to know what you're asking the patient in terms of their menstrual history, how often. You know how many days does their period last for? Is it excessive for them, how often they're having to change their pads? What's the pain like associated with their period? Is the pain just there when they're menstruating or does the pain arise before or after bleeding, er the men menstruation? Are they getting regular periods, are their periods coming regularly, or are they getting bleeding in between periods? Are they not having a period at all? Could they be pregnant? Could, you know, what, why, why are they not getting any menstrual periods? So taking a good comprehensive history for any female presenting potentially with a pelvic mass or presenting with pain, bloating, menstrual changes is really, really important. Obviously you might get effects of we've talked about er mass effect, so bowel, bladder symptoms, abdominal distention, bloating. And depending on what the maths is and we're obviously talking about this going forward, you need to ask about their sexual history, so any fever, abnormal vaginal discharge um taking their sexual history and risks of STI OK. So obstetric history and fertility wishes, so what kind of things am I concerned about in the obstetric history? What is their obstetric history, what is it? What does it contain? What are you asking about? Yeah so how many previous pregnancies, so gravidity, how many previous pregnancies they've had.

Yeah. And Yeah, so after 20, how many deliveries after 24 weeks gestation? So their parity, so gravidity and parity. What else in their obstetric history might I be concerned about? Yeah, uh caesarean sections or vaginal births. We're moving away from using normal, abnormal, please be wary. um and vaginal or caesarean, it's probably better, safe. OK. Um, systemic symptoms, so fever, weight loss, urinary or gastrointestinal symptoms, OK? So the kind of what we're wanting to approach any any kind of complaints in gynaecology, you won't be you know far off if you're asking a lot of these questions, OK, you'll probably get a good overview of uh what's going on with that patient if you're asking most of these questions. Alright? Examination. It's an invasive exa so any gynaecological examination is invasive. In relation to pelvic masses. Probably are going to need to do an examination. So you probably start off with your abdominal examination and you then you want to do, you want to kind of go on to do your your er pelvic examination. How do we approach a pelvic examination? So with regards to your abdominal examination, we're looking at any abdominal scars, distention, tenderness, any localised tenderness, palpate any masses, but kind of, you know, with regards to abdominal examination, especially if it's an acute mass, you probably want to look for signs of rebound, tenderness, guarding, that might tell you a bit more about what's going on. OK? You go onto your speculum examination which might tell you a little bit more about the vagina and cervix and what's happening there. So you're looking at for any abnormal or offensive discharge, bleeding, you're looking at the health of the cervix, does that look normal? um and you know any any discharge or any any changes to the cervix which might tell you a bit about what's going on. So you can see here I've demonstrated by manual examination. Now this is probably gonna be quite painful for women who are not under an anaesthetic, so in any situation obviously chaperoning is very important, gaining consent, but you're not gonna be able to examine a patient really to kind of this depth. We can all see that clearly, but that's the aim of your examination. What you're trying to do is trying to squeeze the uterus, get a feel of the uterus between both hands. So the dominant hand usually in the vagina and the non dominant hand on the pelvis in the suprapubic region and you're trying to feel the uterus between your hands, OK? What you're trying to feel for. Now should you norm in a non pregnant patient, should you normally be able to palpate the uterus, do we think? What size is it normally? You all, you all know these, surely.

Probably about 5-6 centimetres, size of a pear, does that not, not, does anybody normally tell you that? So, so normally on bimanual examination without any masses it outside of pregnancy you really might not be able to feel palpate a a uterus. OK, so if it's enlarged, especially if it's above the symphysis pubis, if you're palpating it in the abdomen, um, that's probably not normal unless they're pregnant, obviously. OK, so you're trying to palpate the uterine size. Is it smooth, are there any lumps on the uterus, if you can feel it. um and you're also gonna assess for any adnexal masses. I've used the word cervical excitation, we're moving, and this is not my presentation, the we're moving away from using terms such as cervical excitation, so what we use it we we use cervical motion tenderness. So when you're palpating the cervix. Is it causing pain? OK, when you're trying to palpate that uterus between your two hands, is it causing pain? OK. In terms of I I had a picture. Um, of adnexal masses, really what you're trying to do is move your hands kind of towards the adnexa, so move the dominant hand, the one that's in the vagina, more towards each ovarian fossa, so right and. Left and you might be able to palpate ovarian masses. So normally, can we palpate ovaries on by manual examination? No, ovaries are usually about 3 to 4 centimetres in size. They sit behind the uterus nicely tucked away in their ovarian fossa, sorry, towards the pelvic side wall. Um. If they're enlarged, so usually more than 5 centimetres, you might be able to palpate them depending on where they are. You might be able to palpate them in the adnexa. If they're stuck together behind the uterus, you might be able to feel them in the pouch of Douglas, so behind. The cervix where if you put your fingers behind. I don't know if you can you see my cursor, yeah. So just behind the uterus you might be able to palpate enlarged ovarian masses, so this is the ovary here just behind isn't it? So if that was enlarged, you might be able to feel that behind er the uterus in the pouch of

Douglas. OK? Any questions about examination in in gynaecology? So if we look at ovarian masses, OK. Uh, so this is the ovary here. So in this we're talking about kind of adnexal and ovarian masses, and again benign masses. Um, that's what we're kind of talking, well, that's what we're looking at today. So what you might find, so this is the uterus in the middle, yeah, fallopian tubes here. Ovaries here just sit attached to the uterus by their the ovarian ligament or the utero ovarian ligament, OK? But they also have their own blood supply coming via the infundibular pelvic ligaments, OK? And lots of different masses that can arise um that within the uterus. Uh sorry, from the ovaries. History. Often ovarian cysts, ovarian masses, quite asymptomatic. Um, an incidental finding. Only if they're significantly enlarged would you find pelvic pain or pressure symptoms. Most of the time in ovarian masses, benign or not, people present with changes to, um, abdominal circumference, a sensation of bloating or fullness, early satiety. loss of appetite, but they might actually notice their trouser size has all gone up because of the bloating or distention due to the mass. So they're not eating as much, but they're actually either putting on weight or their um their, you know, their clothes are not fitting because they're too small due to that increased um the mass. They are associated with menstrual irregularity, er potentially intermenstrual bleeding. OK. Usually associated with intermenstrual bleeding. Any acute pain um suggests that it's twisted, so it's torted or that it might have ruptured. On examination, you might actually find that you might be able to feel a mass in the adnexa. You can feel it behind the uterus. Oftentimes benign masses are not tender unless they've tutted. um and you know, they're they're usually like we said, an incidental finding picked up on scans due to other symptoms. So actually someone presenting with bloating, fullness. Menstrual irregularities, you go on to do your examination and your ultrasound um which might actually identify a mass. So we use pelvic ultrasound a lot in gynaecology and obstetrics obviously. um it's very, it's quite sensitive in picking up ovarian masses. It allows us to assess the size, morphology, vascularity, any internal structures. If the cyst is unilocular or multilocular tells us a lot of information. That's usually on transvaginal ultrasound scan. OK? Transvaginal ultrasound scan very very um quite sensitive. CA 125. CA 125 is a tumour marker. We tend to use it in the postmenopausal status or if there are any suspicious features of the cyst on

the ultrasound. Do premenopausal women need investigations for for when you find a um ovarian cyst? So postmenopausal, we know that the ovaries are quiescent, they're finished functioning, they're not producing follicles. So any cysts or masses found on the ovary or in the adnexa in a postmenopausal woman, we would want to investigate. Even if they're over 1 centimetre. Yeah, so if they're 1 centimetre or more, and in the postmenopause, we would investigate. OK. What about premenopausal women? How often do you think premenopausal women get ovarian cysts? Are they common or uncommon? OK, let's go with that. Common or uncommon? Common? Why are they common? So you'll, you get a cyst occurring with every menstrual cycle. What's that cyst call called? The follicle, so the corpus luteum, so when you, when you ovulate after ovulation occurs, you get the development of the corpus luteal cyst from the ovary that's ovulated, OK? That sustains a pregnancy and then it provides progesterone hormones in early pregnancy. OK, and other hormones, OK. But so cysts occur with every menstrual cycle. So depending on the time that you scan a woman you might see a corpus luteal cyst. How big do you think these corpus luteal cysts get? If they occur with every cycle, women don't normally notice

them. How often? How big can they get? About 3 to 4 centimetres maximum, OK? So do they all need investigation? No. So any cyst more than 5 centimetres. And if it's persistent, so if you measure, if you repeat the scan in 6 to 10 weeks and it's still there, then you would investigate. If it's changed or gotten bigger. Obviously if it's gotten smaller or resolved, then you might not need to continue investigations. In a premenopausal woman, any cyst, ovarian mass or adnexal mass you'll see written on ultrasound scans, more than 5 centimetres, you probably would investigate. Normally that's with a repeat scan, depending on the features. Ah, so yeah, this is where you palpate your adnexa, OK, so part of your vagina, uh, assessment in ovarian masses is palpating in the adnexa, so one hand in the vagina, one hand in what each of in in the iliac fossa to try and palpate for any adnexal masses. So if it's normal, if there's no masses, you won't be able to feel anything. There are different types of ovarian cysts or adnexal masses that you might find. We've talked about one of them. Functional cyst. OK, the corpus luteum or the follicular cyst as part of the normal menstrual cycle. Yeah. They often disappear with by the end of that menstrual cycle.

In women on um progesterone contraceptions, progesterone only contraception can cause the persistence of these follicular cysts. Why? Because it's progesterone, progesterone can help the maintenance of these cysts. OK? So it's not that progesterone contraceptions cause the cysts, but they can help promote the persistence of ovarian, functional ovarian. OK. So you might find some women who are on long term progesterone only contraception, they might present with more persistent er every time they have a scan or if they're getting pain or other symptoms, they might see a cyst on each scan. Inadvertently you might end up, you know, doing surgery on that patient, but it's really because of the persistence of a follicular of a normal functional cyst. Endometrioma. OK, so this is uh probably a laparoscopy. Can you all see clearly as it's not too bright in here. All right. You've got this and you've got the slides I think, haven't you? So This is a large endometrioma, so this is a a laparoscopic image, I imagine. And this is the uterus you can see just behind. This is the right ovary, fallopian tube hanging over the top. OK. Large endometrioma on the left. So it's associated with endometriosis, as you might imagine. So it's the presence of endometrial-like tissue on the surface of the ovary or within the ovary itself. OK, so normally what happens is that you get endometriosis developing on the surface of the ovary. It invaginates and it forms and then, you know, the two halves of the ovary stick together and it actually looks like a cyst within the ovary. OK, that's the, that's the the one of the theories as to why endometriomas develop. Contains endometriotic fluid which looks like melted chocolate, so often called chocolate cysts. OK, so when you puncture these cysts, when you try to do a a cystectomy trying to remove the endometrioma from the ovary um. Inadvertently you might you might rupture that cyst, it's often happens and you get, you see this lovely dark brown endometriotic fluid. Symptoms that patients usually present with, they don't present with a mass or a or a lump, they might actually present with more often more often than not they present with pelvic pain.

OK? Dysmenorrhea. And these are common symptoms associated with endometriosis. Um You might also present with dysp pyrenia, so pain during intercourse. Often you can imagine if you've got a large ovarian. OK, uh, an endometrium. Benign neoplasms, so these are quite um quite common as well. Again, so anybody know what this one is? I've got, I, I mean, I've given you the answers, so it's one or the other. This is a benign cystic teratoma, yes, or a dermoid cyst. OK? Often seen on scan as a quite highly vascular um ovarian mass, adnexal mass containing internal echoes. They might be quite bright so you can see teeth here. Bye. Can I just have 2 seconds? Yeah, yeah, uh, your next lecture at 10 o'clock's been cancelled. Mike Rogers, he's got clinical pressures, so he can't make it. Your slides are on Minerva, so you're welcome to sit in here if you just wanna chill out. really, really sorry, don't shoot the messenger. Thank you. So benign cystic teratomas or fibroids often seen, um, on scans. They are, you know, they are a cyst associated with the cell lines of connective tissue, types of connective tissue that you might see, and that's why you get the development of the hair, teeth, bones, ribs. Um, they are, they once identified, it's timing of when to remove them, when to perform the cystectomy, so they're never going to get smaller. So you might identify them at potentially on ultrasound scans at 23 centimetres, um. You might choose to operate actually when they're only above 5 centimetres because inadvertently if you're doing any surgery to the ovarian tissue you are going to damage ovarian tissue so um yeah so they will, they will need removing, they will need excising. Fibromas again can grow to quite large sizes. They're solid masses arising from the ovary and cystadenomas, so um they often grow to quite large sizes. You can see here, this looks like it's about 30 centimetres. So again they're not going to disappear, they're not going to resolve. So quite persistent, usually grow to quite large sizes um cystadenomas and um often present either incidentally or with pressure symptoms. Yeah.

OK. Fallopian tube masses, OK. Other pelvic organs, so how might masses in the fallopian tube present to you? Oh, should we start with what are the common masses seen in the fallopian tubes? Anybody know, anybody want to give me any answers? Eectopic pregnancies are usually lovely, so good common fallopian tube masses, ectopic pregnancies. Anything else? Anything else, any other fallopian tube masses or things that can happen to fallopian tubes as a result. swellings of the fallopian tubes? Hydrosal pinks, hematosal pinks, pyosal pinks. So anything within that can get inside a fallopian tube and cause it to swell. So often presents acutely. So certainly with ectopic pregnancy. Often presents quite in a in an acute preg um um an acute situation. So any any person with a positive pregnancy test, unilateral pre uh unilateral pelvic pain. You need to rule out an ectopic pregnancy or is an ectopic pregnancy until um proven otherwise. OK? So you might get a lot of women um people presenting with a positive pregnancy test and pain on one side. It's a very common presentation in early pregnancy, so it's your job to decide whether that it's a an an ectopic pregnancy, do they need to stay in hospital, do they have they ruptured? What kind of signs or symptoms might you see if a if an ectopic pregnancy is ruptured? Ruptured ectopic pregnancies.

Say that again. Fever. Fever, not so common. Not common because it can irritate the peritoneum enough to cause like a mild pyrexia but not really. Not one of the most presented main symptoms. So So sudden onset unilateral pelvic pain, OK, but that might quickly progress if it's ruptured if the fallopian tube is ruptured, you might get progression to generalised pelvic pain. Collapse, so if you've got a significant amount of blood in the peritoneum or in the, in the pelvis, you might have collapsed. Shoulder tip pain? Why might people get shoulder tip pain? So irritation of the diaphragm, if the, if the pregnancy is ruptured, if the ectopic pregnancy is ruptured and you get bleeding in the, the peritoneum right up to the level of the diaphragm, you're gonna get shoulder tip pain. That's probably quite severe or signs of a quite an unwell person. Anything else? They're gonna guarding, rebound tenderness, they're gonna be quite unwell, they're gonna have signs of hypotension and possibly shock. OK? Again, Another laparoscopic image, so most of these are managed and dealt dealt with laparoscopically. This is a uterus in the middle. You can see here is the fallopian tube on the left, fallopian tube on the right, ovary on the right. These here are the round ligaments you can see just behind. Oh in uh you know, they're in the front of the uterus, the fallopian tube sits behind the round ligaments. OK. Huge mass filling the fallopian tube, OK? Um, and with this is normally managed by excising the fallopian tube, so a salpingectomy or salpingostomy, you make an incision over the top of the fallopian tube and take out the pregnancy from it. Not done so often, but it can be done. OK, so this is a probably a a an ectopic that hasn't ruptured. cos you're not, there's not that much blood in the pelvis, but a huge mass. OK. So, yeah.

Hydrosal pinks. Again, often presents with pelvic pain, so they might not, you know, the fallopian tubes are not very big, they're not gonna be able to palpate a mass. But they often present with other symptoms associated. Fallopian tubes are actually very sensitive because they they're the peritoneum runs over the top of the fallopian tube. So any stretching, anything that dilates that fallopian tube, um, will cause severe, significant pain. OK, because peritoneum is the parietal peritoneum, very sensitive. It will, any stretching, any disruption to the parietal peritoneum will cause pain. So hydrosal salpings generally they tend to present with pelvic pain, er pain during menstruation, so dysmenorrhea, likely fertility problems. Vaginal discharge might be associated if they've got infection, so often associated with STIs or ascending STIs. So this is a um an image of a HSG, hysterosalpingogram, which is an X-ray image. So you inject dye um through the vagina, through the cervix into the uterus and you flush that dye through er the uterus and in the hope that the the the. The fallopian tubes are patent and so here you can see at the top it's quite narrowed, so stenosed fallopian tubes, there's no um the dye fills the fallopian tube but it doesn't come out at the end. So this shows kind of bilateral hydrosalpi. OK, quite swollen throughout. And blocked. Um, similar images, so similar images you would see with any other fluid filling a fallopian tube. So hydrosalpinx, hematosalpin, so blood filling a fallopian tube, or, um, pyosalpix, pus. OK. So you think about the symptoms that might present with um those kind that that where you might find pyosalpinx might be a history of an STI ascending STI with fever, generalised lower abdominal pain, etc. abnormal vaginal discharge, a history of unprotected sex, etc. etc. OK. Ovarian torsion. So just as a, you know, as an acute presentation, um, it's a clinical diagnosis, I've written it in red. Sudden onset unilateral pelvic pain. So why might this not be an ectopic pregnancy? Pregnancy test is negative. It's very uncommon to get ectopic pregnancy presenting alongside an ovarian torsion, OK? Um, you'd be very unfortunate if you got both. Very unlikely. So sudden onset unilateral um pelvic pain. Yeah, pregnancy test negative. You might be thinking, they've ruled out appendicitis, you might be thinking of um ovarian torsion, if there's an ovarian cyst, OK? Symptoms are very similar, you can see to that with. ectopic pregnancies, so collapse, loss of consciousness, vomiting, nausea, peritonism, so guarding, rebound, tenderness. The difference in ovarian torsion because this is is what you can see here, um, because of that torsion, because of the um necrosis of the tissue, you will get raised inflammatory markers, er, mild pyrexia. And um so those are the signs and symptoms that might differentiate your um fallopian tube masses from ovarian masses. OK. Symp like I said, so symptoms might be quite similar, but your examination, your investigations will help you to discern whether this is ovarian, was it fallopian. That might help more.

OK. You can identify ovarian torsion on ultrasound scan, traditionally it is a clinical diagnosis, but what you might see, this is an ultrasound scan image is what we call a whirlpool sign. So that here, that whirlpool sign where the. Um, the vascularity is kind of going in this nice round, um, pattern, and that would reflect that torsion of the, this looks like it's like the ovary and the tube has torted around its pedicle. So we've talked about some of the differential diagnoses haven't we? Sudden onset unilateral pelvic pain, you might be wondering about an ectopic pregnancy, ovarian cyst accident, so it could have just ruptured, it could be ovarian torsion, OK? Ovarian torsion is usually associated with a history of ovarian cysts, especially cysts greater than 5 centimetres. OK? Um, so if you think about in your history, people who have had, um, fertility treatments such as IVF, um, if their ovaries are, you know, if they've got ovarian hyperstimulation they're at, they're at risk of ovarian torsion. So usually those cysts, the, the, the dangerous size of these cysts is between 5 to 7 centimetres, OK, because once the cyst gets bigger, it's kind of wedged in the pelvis. So once it gets around 9, 1012 centimetres, that cyst is kind of wedged there in the pelvis, not got as much room to move around and taut on itself. So that dangerous size, between 5 to 7 centimetres, generally speaking. Is when these cysts are at risk of torsion, sort of twisting on their pedicle. Any questions so far?

Please feel free to ask. We've talked about Pio Salpinks. Oh, they're quite small images, aren't they? Sorry, I can't make it any bigger, um. Here we've got the uterus in the middle, again laparoscopic images, most of tubo, ovarian um masses problems can be dealt with laparoscopically most of the time unless they're just very huge or the patient's very unwell. So uterus in the middle, fallopian tubes coming in the middle, they've got your bowel getting involved. um nice lovely green, yellow fluid in the pelvis. OK. And this is an as as a often as a result of either STIs or ascending pelvic infection. So we know STIs can cause ascending pelvic infection, um coils, so any intrauterine devices can be associated with ascending pelvic infection. OK? Uh, so you get sudden onset pelvic pain, it might be generalised, but lots of pus in the pelvis, fluid in the pelvis. I think these images are showing really what can happen as a result, so you get a lot of adhesions as a result of, um, this infection. So it's imperative that it gets treated early um usually medically with antibiotics, but if symptoms aren't resolving or the patient's still in quite a lot of pain, you have a low threshold for taking them to theatre and trying to wash away this fluid. The symptoms that they usually present with. Um, pelvic pain, vaginal discharge, fever is quite a predominant symptom. Cervical motion tenderness, gosh, I need to change these lines, don't I? And adnexal tenderness. So your investigations, full blood count, CRP pregnancy test, usually an ultrasound scan as well. Often managed with antibiotics or drainage. OK. uterine masses. Benign uterine gland when it's enlarged if you do a a vaginal examination, examination, so one finger inside the er vagina um looking laterally. Often the Bartholin's gland er can get blocked. So this is the Bartholin glands provides lubrication to the vagina. um so can get worsening symptoms during intercourse. OK? And it can be quite tender, erythematous, if it's infective, so if it's an abscess might be associated with um quite you know it's quite tender, erythematous, hot. it might be associated with overlying cellulitis. So it's a clinical diagnosis really. Not really any um other tests you might do. Um If you are concerned about overlying you know severe systemic infection associated with an abscess, you would give er um systemic antibiotics, but often you would marsupialize it, have I got a picture of that. um so incise over the. Over the um the labia minora, really it's just on the edge of the of the vagina. Um, and um, open up the drain the abscess and open up the gland.

OK. Red flags you might be um worried about. Severe pain, big red flag, acute onset, sudden onset severe pain, um, requiring morphine. Patient measures it more than 8 out of 10. Um, OK. Any signs of sepsis or hemodynamic instability? Any postmenopausal pelvic mass, so they might be quite stable, you, you, you know, you want to escalate urgently. So a new onset mass within the pelvis. OK? Anything that's rapidly enlarging or anything that's suspicious of malignancy, so they're more symptoms, OK? Symptoms. OK. So in summary, always exclude pregnancy, that's gonna help you a lot in coming to a diagnosis of a pelvic mass. If your pregnancy test is negative, an acute pain, a unilateral pain, always think of contorsion or infection. Examination findings are always important because then they're gonna guide how they're gonna assist your history taking, especially in finding out any severity of pain um and then they're gonna guide the urgency of. ations Generally speaking, in gynaecology and obstetrics, ultrasound is the first line imaging. You won't go wrong if you request a transvaginal ultrasound scan. In most cases, OK? I've got a few cases. I think you've all got them on your slides. It's 10 o'clock, we've got, I know we're running over a little bit. I wondered if I normally I split you into 3 groups with 3 cases. I wonder if we can. There's one group here if you do case one. You've all got the slides, case one. If you split yourselves into half. If you do case 2 and you at the back do case 3.

We all sit together. I'll give you about 10 minutes and then we can discuss your cases together. Ex. I. For the scan. Yeah. Yeah, that's like that's like. No. Ankles. So. I just sit down. What. I That To my I know. So. That is What's me. If you do try right Yeah. I D But it might be. Basically. It could be it could be. OK. walking. it's all right. I. I I think You can't do. You can still be yeah that's to be to be. Assuming that. It's. Thank you. Yeah I. I. Oh. Yeah, I think that's a bad person. I think the scalp if she wants to. I think it's just spell. So. T. It. Yeah. It. It's like, it's like gone. Yeah, for your eyes. It's all. I everything. Yeah So. Yeah, I guess. Yeah a hysterectomy. Yeah That No. So they'll say. I it's like so I just. Right Yeah It. I mean like it sounds. I. Did it turn up like it was. And like I talk about like brothers. But what's true, but it's not necessarily like a heavy weight like you can still bloated. Yeah. I OK that makes sense.

Shall we discuss as a group? Have you all had a chance to discuss the cases? Who, so we'll start with, we'll start with case one. Who, this is your group here, isn't it? OK, so 30 year old presents to the GP with severe cyclical pain and deep dysyunia, ongoing for many years. It was manageable until she had a coil removed 6 months ago, she's trying to she's trying to conceive. She's concerned about getting pregnant. She's normally fit and well, no regular medication. She's started taking Co-codamol and ibuprofen for the pain. Her periods are now regular but extremely painful. What additional information did you want to know from her history? What the parents Yeah, OK. um, why, why is that gonna help? what's good, what's gonna help? Good, so it tells you about the duration of the symptoms, OK. Good. er anything else you want to know from a history? Look like Good. Yep. Anything else? Yeah, good. So how often she's having to to change her pads? The main concern is the pelvic pain, but yet you want to know about heaviness of her periods, good. What are you looking for an examination?

Mhm. Yeah. Good. And what are you, what initial investigations might you request in the GP in the primary care, sorry. Yeah, you can request an ultrasound scan. Good. What do you think's going on with this patient? Could be, what are you, what makes you think fibroids? What are symptoms? Mhm. to go out. So anything, you know, hormonally driven kind of er conditions might be, yeah, so fibroids, endometriosis. Um, probably would be helped with any kind of long term progesterone only treatment. Anybody else, everybody can join in. She's concerned about her fertility, so you might want to ask a bit more about her fertility history. So if she's had any previous pregnancies, um, what happened? How long she's been trying to conceive. Obviously she's just had amirena coil removed 6 months ago. So probably you'd think 6 months. How might you manage your symptoms in primary care? She's already taking cocodamol and ibuprofen. Any other? I think her main symptoms are the er pelvic pain and dyspyrenia. Would you refer this patient to secondary care? What's making you want to refer her to secondary?

Just like so bad. 66. Excellent, so severe pain, chronic pain, so definition of chronic pelvic pain or chronic pain is ongoing over 3 months. Yeah, 3 to 6 months, you probably want to refer. You might want to wait for your investigations, your ultrasound scan, so you might, you know, have an idea of what might be causing the pain. Um, I think this case, so endometriosis tends to, um, have pain as quite a severe feature, so cyclical pelvic pain associated, um, you know, with pain before the start of menstruation. And it often is then settles after menstruation, requiring significant regular painkillers often associated with dyspyrenia, so you might be concerned about er endometriosis, endometriomas, OK? um if she's concerned about her fertility as well. Anything else that you thought about, anything else that you might want to ask? Or any concerns about this patient. OK, we'll move on to the second case, who had that? So 28-year-old lady presents to A&E following collapse after sudden onset right le fos pain. She vomited in A&E requiring morphine. To manage the pain, she's had a very similar episode three months ago, however, the pain settled after a couple of hours. She underwent a scan at that time which showed a 5 centimetre ovarian cyst. She's normally fit and well. examination, she's tender in the right iliac fossa with guarding. What other additional information do you need to know?

Say that again. Excellent, very good, I'm very happy about that. So that's the main thing you want to rule out, is she pregnant or not, that helps you a lot potentially with your differential diagnoses maybe? Yeah? What else would you want to know from me? Yes. Good. Contraception. And. All good. Anything else? What are your differentials and what do you think's going on and how are you gonna manage her? The differential diagnosis. Ovarian torsion, what, what factors, what risk factors does she have? For variant torsion. She's got a known ovarian cyst. Yeah. Yeah, so it resolved by itself before the pain resolved by itself before, which could have been like partial torsion of the cyst, so it could have partially torted and then now it's, it's tutting again, or partially torted and untorted, torting again, could be. Anything else, what was your other differential diagnosis? Eectopic pregnancy, it's a pregnancy test that can help you decide whether you think it's an ectopic or not. Good. OK, so I just Excellent, yeah, it could be appendicitis couldn't it? She's requiring morphine, she's guarding so ooh, which, who are you gonna ask to see her first, the surgeons or the gynaecologists, gosh, usually it's the gynaecologist. Good. Um, any other differentials? Could the cyst have ruptured? So it's a it could be an ovarian cyst accident, sudden onset pelvic pain.

Not settling. What else could it be? So, that's my email. PID or a tuber ovarian abscess, but you really need more information from a history. I think we've already mentioned the first initial investigation you're gonna do? A urine pregnancy test, yeah. So how would you manage this patient initially? People keep Say that again. So how might you investigate that? How might you tell if she needs to go straight to surgery or not? So you could get an ultrasound, traditionally it's not really clearly seen, ovarian torsion not clearly seen on ultrasound but. What other what other tests can help to identify or confirm or help your different your diagnosis of ovarian torsion if that's what you're thinking. So we've said you can get raised inflammatory markers due to necrosis, mild pyrexia, so you might want to do some blood tests, what blood tests would you do? Yeah, CRP would help your full blood count and a CRP. Good, might help confirm your diagnosis. Any other investigations? Yeah, um. Yeah, if she's she's collapsed. So. Good. So. Kind of initial management really depends on what you think your differential is, but most of them will be supportive treatments, so if she's collapsed, if she's showing signs of any instability, you might want to put a cannula in, start some IV fluids, um and um. Do some initial blood tests, continue obviously the pain relief that she's requiring and arrange some imaging. If she's not pregnant you might do a CT scan that might tell you as well, might help you to rule out appendicitis, OK? Good. A third case, a 48-year-old school teacher presents to the GP with heavy periods and urinary frequency. She's, it's worsened over the past year and her cycles are becoming very irregular. She's noticed that her abdomen is becoming bigger, her clothes aren't fitting. She's worried about cancer. She's normally fit and well. The GP prescribed iron tablets cause she did, but she didn't take these because they gave her diarrhoea. She's got 3 children, all born vaginally, previously had a sterilisation. On examination, you feel a large firm mass in the lower abdomen in the midline. It's not tender and quite mobile. What additional information do you need to find out from her? It's quite a detailed history though, to be fair. any additional information that group at the back? Yeah, so periods are becoming irregular, but yes, any bleeding in between periods? Good. Yeah, but any family history of say similar?

was Yeah, why, why she had hysterectomy. Yeah, so usually sterilisation just means either clips applied to the tubes, partial salpingectomies at a time of caesarean, but she hasn't had a caesarean or. Sometimes we used to do, but not so much these little coils into the fallopian tubes called Essure, but again. sterilisation doesn't usually mean hysterectomy. Patients would normally know if they've had their whole uterus removed. Good, yeah, but you do want to find out about it, yeah. Any other any other features that you're worried about or want to ask more about? Family history. Yep, yep, we've said that. Is there any er she's concerned about cancer. Oftentimes patients are worried about cancer if there's a strong family history of it. So yeah, you might want to find out about that. systemic. Uh, yeah, so systemic features of cancer. Do you want to know about our heavy periods? What do you wanna know? So the GP's prescribed iron tablets, what does that tell you? So systemic, so it's affecting, it's causing potentially her heavy periods are causing anaemia. Yeah, it's quite important.

Good. Yeah, so that what she means by heavy, how often are you having to change sanitary wear? Can she go to work, can she function, um. Is it causing systemic symptoms of anaemia? So you know, dizziness, headaches, collapse. Good. OK. Is she requiring blood transfusions? Iron transfusions, you know, kind of you wanna know? Um. Any other additional information? What initial investigations would you carry out in the GP in primary care? So you'd examine her good wouldn't you, because she's got this mass. You, well, she's already been examined, she's got a large mass. What other investigations might you do? Yeah. If you're still having regular periods below the age of 55, you probably would do a pregnancy test. Good. option. Is that gonna help you? What's it gonna, is it gonna help? What are you concerned about that you want to check her inflammatory marker? It's probably not You might do, I think other markers, if she's got an abdominal distention. She's her clothes are not fitting, her abdomen's becoming bigger. What did we say about Mary? Any other blood tests that might, you might do? CA 125, if you might be concerned about an ovarian mass, if her abdomen's becoming bigger, clothes aren't fitting, she's worried about cancer. OK. What other investigations might you carry out in primary care? Yeah, you could request an ultrasound, good. Would you refer this patient to secondary care? She just manage her bleeding, manage her periods.

Probably. Would you be able to reassure this patient she's worried about cancer? Can you tell her she hasn't got cancer? Yeah, she's low risk in that she's a young, fit, healthy normally fit and well, OK? What red flag symptoms does she have? She's got a mass. She's got a, a large mass. She's probably anaemic. OK. So heavy bleeding that's enough to cause anaemia is is is you know a concerning feature. Uh She's getting, you know, she's um her abdomen is getting bigger, she's got a large mass. Red flag features any weight loss, so you wanna find out, yeah, like you said about systemic concerns about cancer, weight loss, appetite. Yeah. Night sweat. Good. And what are your differential diagnoses then? Fibroids. Uterine fibroids, good, yeah. So what. Oh, sorry, um. Anything concerning about her age? Anything you might need to be mindful of? Just. Excellent, so yeah, perimenopause. Perimenopause, meno is when a time when so you're approaching the end of your fertility cycle. um you you you get a lot of anovulatory cycles so periods tend to become quite erratic. OK? They can become irregular. Anyone over the age of 45 who has a sudden change to their periods you do want to investigate to rule out any other causes like any to any concerns like cancer, endometrial hyperplasia, uterine cancer, OK? Um, but it is very common to get irregular, um, and, um, heavier bleeding in the perimenopause.

Good. Any questions about that or any of the cases that we've discussed? Good, lovely, well done. I'm sorry about your next lecture.