💡 A pelvic mass refers to any abnormal growth or swelling in the pelvis. It may be benign or malignant, and causes range from ovarian cysts to ectopic pregnancy or ovarian cancer. A systematic approach is crucial, as presentation can vary from incidental finding to life-threatening emergency.

📖 Clinical History

Symptoms: Pelvic/abdominal pain, bloating, abnormal bleeding, urinary frequency, constipation, early satiety.
Menstrual history: Cycle regularity, menorrhagia, dysmenorrhoea.
Reproductive history: Infertility, parity, previous ectopic pregnancy.
Obstetric/surgical history: Prior caesarean, pelvic surgery, endometriosis.
Family history: Ovarian/breast/endometrial cancer (consider BRCA, Lynch syndrome).
Systemic symptoms: Weight loss, fever, night sweats (malignancy/infection).

🩺 Physical Examination

General: Cachexia, pallor, lymphadenopathy, signs of endocrine disturbance.
Abdominal: Distension, palpable mass (size, mobility, tenderness, consistency), ascites.
Pelvic exam: Speculum → cervical lesions/discharge; bimanual → uterine size, adnexal masses, mobility, tenderness.
Systemic: Signs of liver disease (cirrhosis/ascites), bowel obstruction, urinary retention.

🔬 Investigations

🖥️ Ultrasound (TV + TA): First-line to assess mass (solid vs cystic, septations, vascularity).
🧪 CA-125: Tumour marker, elevated in ovarian cancer but also benign disease.
📸 CT/MRI: Further evaluation, staging, surgical planning.
🧪 Bloods: CBC (anaemia, infection), U&E, LFTs.
🧫 Swabs: If PID suspected.
🤰 Pregnancy test: Rule out ectopic pregnancy or molar pregnancy in reproductive-age women.

📊 Causes of Pelvic Mass

Cause	Clinical Features	Diagnostic Tests	Management
🌸 Ovarian Cyst	Often asymptomatic; pain if torsion/rupture; menstrual irregularities	Ultrasound (simple/complex); CA-125 if suspicious	Observe small cysts; surgery if large/symptomatic; hormonal therapy for recurrence
🎗️ Ovarian Cancer	Bloating, pain, early satiety, weight loss, urinary symptoms	USS/CT (solid, irregular mass); CA-125 raised; biopsy for diagnosis	Surgery (debulking); chemotherapy; radiotherapy in select/palliative cases
🌿 Uterine Fibroids	Menorrhagia, dysmenorrhoea, pelvic pressure, urinary frequency	Ultrasound; MRI for complex cases	Medical (GnRH agonists, OCPs); myomectomy (fertility); hysterectomy; uterine artery embolisation
🔥 Endometriosis (endometrioma)	Chronic pelvic pain, dysmenorrhoea, dyspareunia, infertility	USS (chocolate cysts); laparoscopy gold standard	Hormonal suppression; laparoscopic excision; ART if infertility
🦠 Tubo-ovarian Abscess (PID complication)	Fever, pelvic pain, vaginal discharge, adnexal tenderness	USS (complex mass); CBC (↑WCC); cervical swabs	IV antibiotics; surgical drainage if refractory
🤰 Ectopic Pregnancy	Missed period, pelvic pain, bleeding, shock if rupture	Positive hCG; TVUS (adnexal mass, empty uterus)	Methotrexate (early); laparoscopic surgery (ruptured)
🧫 Pelvic Inflammatory Disease	Lower abdominal pain, fever, discharge, dyspareunia	Clinical exam (cervical motion tenderness), CBC, USS	Broad-spectrum antibiotics; admit if severe
💩 Non-gynaecological (appendix, bowel, bladder)	GI/urinary symptoms ± pelvic mass	CT/MRI; endoscopy for GI causes	Treat underlying cause: surgical excision or oncological therapy

⚠️ Red Flags

Postmenopausal woman with new adnexal mass
Ascites with pelvic mass (think ovarian cancer)
Unexplained weight loss, anorexia
Acute abdomen with mass (torsion, rupture, ectopic)

💉 Management Principles

🔎 Observation: Small, benign-appearing cysts → repeat scan in 6–12 weeks.
💊 Medical: Hormonal therapy (fibroids, endometriosis); antibiotics (PID/abscess).
🔪 Surgery: Ovarian cystectomy, myomectomy, hysterectomy, oncological debulking.
🤝 Referral: Suspected malignancy → MDT (gynae-oncology team).

🧑‍⚕️ Case Vignettes

Case 1: 👩 A 32-year-old woman presents with chronic pelvic pain, dysmenorrhoea, and difficulty conceiving. Ultrasound shows a left adnexal cyst with “ground glass” appearance. ✅ Likely diagnosis: Endometrioma (endometriosis). Management: Hormonal suppression (OCP, GnRH), laparoscopic excision if severe, consider ART for infertility.

Case 2: 👵 A 62-year-old woman presents with increasing abdominal girth, early satiety, and unintentional weight loss. Examination reveals ascites and a firm pelvic mass. CA-125 is elevated. ✅ Likely diagnosis: Ovarian cancer. Management: Referral to gynae-oncology team, debulking surgery, adjuvant chemotherapy, long-term follow-up.

📚 References

RCOG Green-top Guidelines: Management of Ovarian Cysts in Postmenopausal Women
NICE NG88: Heavy Menstrual Bleeding: Assessment and Management
Kumar & Clark’s Clinical Medicine, 10th Ed.

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Pelvic Mass