Guidelines 2016 – Pelvic Mass
Guidelines for Nurse Practitioners in Gynecologic Settings 2016
I. DEFINITION
Mass found in adnexa, cul-de-sac, or uterus during bimanual examination
II. ETIOLOGY
A pelvic mass may be caused by any number of factors. This guideline is meant to assist the clinician in the screening and referral process.
III. HISTORY
A. What the patient may present with
1. May be asymptomatic
2. Bloating
3. Abdominal pain: generalized or localized/duration/onset
4. Flatulence
5. Dysfunctional bleeding—can be heavy
6. Amenorrhea; number of weeks
7. Vaginal discharge
8. Low back pain and/or pressure
9. Dyspareunia
10. Bowel or bladder dysfunction; chronic bowel disease
11. Prior abdominal surgery
12. Prior pelvic surgery
13. Endometriosis
14. Pregnancy history; assisted reproduction
B. Additional information to be obtained
1. LMP
2. Contraception used
3. Menstruation, pregnancy, and infertility history
4. Any change in bowel habits; last bowel movement
5. History of ovarian cysts
6. History of uterine fibroids
7. History of PID
8. History of Chlamydia or gonorrhea
9. History of IUD use
10. History of ectopic pregnancy
11. Family history
12. Results of recent Pap smear; any follow-up if abnormal
13. Diagnostic tests, including colonoscopy, laparoscopy, flexible sigmoidoscopy
IV. PHYSICAL EXAMINATION
A. Abdominal exam
1. Bowel sounds
2. Pain
3. Organomegaly
B. Vaginal examination
1. Examine cervix for discharge and presence of IUD string
2. Examine vagina for masses, lesions, discharge
C. Bimanual examination
1. Examine cervix for cervical motion tenderness
2. Examine uterus for tenderness, masses, shape, size, and consistency; prolapse
3. Examine adnexa for masses; attempt to differentiate between ovaries and bowel
4. Evaluate mass for shape, consistency, size, mobility, and tenderness
5. Examine bladder; check for cystocele
6. Check cul-de-sac for mass
7. Look for thickening or tenderness at or near uterosacral ligaments
D. Rectal examination
1. Pain, tenderness
2. Masses
3. Melena
4. Rectovaginal masses, fistulas
5. Rectocele/occult blood
V. LABORATORY EXAMINATION
A. Cultures as indicated
B. Wet prep as indicated
C. Serum pregnancy test as indicated
D. CBC with sedimentation rate; C-reactive protein
E. Ultrasound; transvaginal and transabdominal or with Doppler as indicated
F. CA-125, ovarian cancer tumor marker, as indicated
G. Consider carcinoembryonic antigen
H. Endometrial biopsy as indicated
VI. TREATMENT
A. Adnexal masses
1. If thought to be retained stool or intestinal gas, patient should have bowel prep and be reexamined
2. If thought to be ovarian in origin, the following differentiations may be made.
a. Age of patient (ovulation or using ovulation inhibitor, perimenopausal or menopausal)
b. Menstrual history
c. Indication of infection
d. Positive result of the pregnancy test
3. If ovulation is presumed, assess size of mass with ultrasound
a. If greater than 5 to 6 cm, physician referral indicated
b. If less than 5 cm and asymptomatic, reexamine after next menses; if unchanged, may
i. Recommend ovulatory inhibitor for 3 months and reexamine; if remaining after 3 months, refer to a physician
ii. Consider ultrasound as baseline; if functional cyst is confirmed, wait 2 months and repeat ultrasound
4. If on ovulatory inhibitor, do appropriate workup (i.e., ultrasound) and refer, or refer immediately depending on setting
5. If perimenopausal/menopausal
a. Do appropriate workup (i.e., ultrasound); refer for a physician evaluation as indicated
B. Uterine mass
1. Do ultrasound; small, nonsymptomatic fibroids may be followed and assessed on a 6- to 12-month basis as appropriate to setting. Large fibroids or other finding, refer to a physician.
C. Ectopic pregnancy
1. Do ultrasound; if confirmed to be ectopic, consult or refer to a physician for treatment. Current treatment includes
a. Serial serum hCG levels (< 2,000 mIU and < 50% rise in 48 hours) followed by consultation with a physician
b. Medical management (per guidelines of clinical site): consultation with or prescription by a physician
i. Methotrexate in single intramuscular dose 50 mg/m2 of body surface calculated on body weight
ii. Monitor hCG per guidelines of clinical site and possible ultrasound monitoring
c. Consult and referral for surgical management
VII. DIFFERENTIAL DIAGNOSIS
A. Inflammatory
1. Tubo-ovarian abscess
2. Appendiceal abscess
3. Diverticular abscess
B. Functional
1. Ovarian cysts
a. Follicular
b. Luteal
c. Polycystic ovaries
C. Neoplastic
1. Benign
2. Malignant
D. Anatomic anomalies
1. Pelvic kidney
2. Bicornuate uterus
E. Other
1. Ectopic pregnancy
2. Endometrioma
3. Paratubal/ovarian cyst
4. Hydrosalpinx
VIII. COMPLICATIONS
Complication of individual entity as listed in differential diagnosis
IX. CONSULTATION AND REFERRAL
As indicated by laboratory workup and physical findings indicated in
Treatment, VI
X. FOLLOW-UP
As indicated by diagnosis
See Bibliographies.
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