CT seldom is indicated as a primary diagnostic procedure, although it may be helpful in planning treatment when a malignancy is strongly suspected or when a nongynecologic disorder may be present. Abdominal ﬂat-plate radiography is not a primary diagnostic procedure, although if used for other indications, it may reveal calcifications that can assist in the discovery or diagnosis of a mass. Pelvic calcifications (teeth) consistent with a benign cystic teratoma, a calcified uterine fibroid, or scattered calcifications consistent with psammoma bodies of a papillary serous cystadenoma can be seen with abdominal radiography (Fig. 14.28).
Figure 14.25 Transvaginal ultrasonogram of a complex, predominantly solid mass.
Figure 14.26 Transvaginal ultrasonogram of bilateral tubo-ovarian abscesses.
Ultrasonography or CT imaging may be appropriate to demonstrate ureteral deviation, compression, or dilation in the presence of moderately large and laterally located fibroids or other
Figure 14.27 Transvaginal ultrasonogram of an endometrioma of the ovary.
Table 14.13 Ultrasonographic Characteristics of Adnexal Masses That May Be Useful in Predicting Malignancy
Unilocular cyst vs. multilocular vs. solid components
Regular contour vs. irregular border
Smooth walls vs. nodular vs. irregular
Presence or absence of ascites
Unilateral vs. bilateral
Presence of other intra-abdominal pathology (liver, etc.) pelvic mass. Such findings rarely provide an indication for surgical intervention for otherwise asymptomatic leiomyomas.
Hysteroscopy provides direct evidence of intrauterine pathology or submucous leiomyomas that distort the uterine cavity (see Chapter 23). Hysterosalpingography will demonstrate indirectly the contour of the endometrial cavity and any distortion or obstruction of the uterotubal junction secondary to leiomyomas, an extrinsic mass, or peritubal adhesions. The techniques combining hysterosalpingography, in which ﬂuid is instilled into the uterine cavity, with transvaginal ultrasonography are helpful in the diagnosis of intrauterine pathology. Hysterosalpingography or sonohysterography may be indicated in women with infertility and uterine leiomyoma (193).
MRI may be most useful in the diagnosis of uterine anomalies, although its value rarely justifies the increased cost of the procedure over ultrasonography for the diagnosis of other pelvic masses (88).
Figure 14.28 Benign cystic teratoma (dermoid cyst) of the ovary with teeth seen on abdominal radiograph.
Management of Pelvic Mass in Reproductive-Age Women
The management of a pelvic mass is based on an accurate diagnosis. An explanation of this diagnosis should be conveyed to the patient, along with a discussion of the likely course of the disease (e.g., growth of uterine leiomyomas, regression of fibroids at menopause, regression of a follicular cyst, the uncertain malignant potential of an ovarian mass). All options for management should be presented and discussed, although it is appropriate for the physician to state a recommended approach with an explanation of the reasons for the recommendation. Management should be based on the primary symptoms and may include observation with close follow-up, temporizing surgical therapies, medical management, or definitive surgical procedures.
The management of uterine leiomyomas is dependent on the patient’s age and proximity to anticipated menopause, symptoms, patient preference, and the experience and skills of the clinician. Variability in reporting data regarding severity of symptoms, uterine anatomy, and response to therapy makes it difficult to compare different types of therapies, which include observation, medical, surgical, and radiologic-based techniques (see Chapter 15 for discussion of uterine fibroids).