Differentials
Ovarian cancer
SIGNS / SYMPTOMS
Postmenopausal woman (>65 years); there may be family history of ovarian cancer or breast cancer (BRCA-1 or BRCA-2 positive), symptoms of dyspepsia, bloating, increased abdominal girth, weight loss, and physical findings of fixed adnexal mass and ascites.
INVESTIGATIONS
Ultrasound findings of a cyst >10 cm diameter, multiloculated or with thick-walled septae and solid areas, and high blood flow; elevated cancer antigen (CA)-125 levels of ≥35 U/mL.
Histopathology of the ovary will confirm the diagnosis of ovarian cancer.[50]
Ovarian torsion
SIGNS / SYMPTOMS
Right or left lower quadrant pain. Occasionally presents with mass in the right or left lower quadrant.
INVESTIGATIONS
Ultrasonography shows ovarian cyst and decreased blood flow.
Polycystic ovary syndrome
SIGNS / SYMPTOMS
Unknown etiology but present in 6% to 10% of women of reproductive age. The clinical history is usually typical, with menstrual irregularity, infertility, hirsutism, oily skin, scalp hair loss, obesity, and acne.
INVESTIGATIONS
Pelvic ultrasound findings that suggest diagnosis include: 12 or more follicles in each ovary measuring 2 to 9 mm in diameter, and/or increased ovarian volume (>10 mL) in either or both ovaries; endometrial lining >5 to 7 mm indicates endometrial thickening.[51]
There may be elevated serum 17-hydroxy-progesterone, total and free testosterone, dehydroepiandrosterone sulfate, and prolactin.
Uterine/broad ligament fibroid
Pelvic inflammatory disease
SIGNS / SYMPTOMS
Usually occurs in women between 20 and 40 years of age.
Presents with bilateral lower quadrant tenderness, usually within 5 days of the last menstrual period.
Purulent discharge from cervical os.
INVESTIGATIONS
Endocervical swab may confirm pelvic inflammatory disease due to Chlamydia trachomatis or Neisseria gonorrhoeae.
Acute salpingitis
SIGNS / SYMPTOMS
Usually occurs in women between 20 and 40 years of age.
Presents with lower quadrant tenderness, usually within 5 days of the last menstrual period.
There may be a purulent discharge from cervical os.
INVESTIGATIONS
Ascending infection is often polymicrobial or due to Chlamydia trachomatis or Neisseria gonorrhoeae.
Tubo-ovarian abscess
SIGNS / SYMPTOMS
The incidence of tubo-ovarian abscess formation among adolescents with a known diagnosis of pelvic inflammatory disease ranges from 17% to 20%.[31]
INVESTIGATIONS
Ultrasound or CT scan may distinguish this from an ovarian cyst.
Hydrosalpinx
SIGNS / SYMPTOMS
No differentiating signs or symptoms. May result from chronic salpingitis.
INVESTIGATIONS
Transvaginal ultrasound and MRI can further delineate this from an ovarian cyst.
Endometriosis
SIGNS / SYMPTOMS
A history of painful menstrual cramps (dysmenorrhea), especially if unrelieved by NSAIDs and progressively worsening and continuous.
The prevalence of endometriosis in the general population is 5% to 15%, but the incidence of endometrioma formation has not clearly been identified.
Single digit exam followed by bimanual and rectovaginal exams may reveal pelvic mass (ovarian endometrioma), fixed and retroverted uterus, or uterosacral ligament nodularity and tenderness.
INVESTIGATIONS
Transvaginal ultrasound is diagnostic for ovarian endometrioma, but may not detect early disease.
Rectal endoscopic ultrasound may be of value in patients with suspected deep pelvic endometriosis or involvement of the colon/rectum.
Histopathology will confirm the diagnosis of endometriosis or endometrioma, with endometrial-like glandular lining cells and changes of chronic hemorrhage (fibrosis and hemosiderin-containing macrophages) in cyst wall stroma.
Ectopic pregnancy
SIGNS / SYMPTOMS
Missed menstrual period, lower quadrant pain, or pelvic pain with some degree of vaginal bleeding or spotting. Cervical motion tenderness may be present on pelvic examination.
INVESTIGATIONS
Human chorionic gonadotropin hormone level is high in serum and in urine.
Ultrasound reveals an empty uterus and may show a mass in the fallopian tubes.
Threatened miscarriage
SIGNS / SYMPTOMS
Missed menstrual period, abdominal pain, or pelvic pain with vaginal bleeding. May present with hemorrhage and shock.
INVESTIGATIONS
Human chorionic gonadotropin hormone level is high in serum and in urine.
Ultrasound may reveal fetus in the uterus or hemorrhage.
Acute appendicitis
SIGNS / SYMPTOMS
The clinical history is usually typical for appendicitis, with central and right-sided lower abdominal pain and associated fever, anorexia, nausea, and vomiting.
INVESTIGATIONS
Abdominal ultrasound and CT scan show appendix wall thickening, wall enhancement, and inflammatory changes in the surrounding tissues.
CBC shows leukocytosis.
Pelvic adhesions with bowel loops
SIGNS / SYMPTOMS
Gastrointestinal disturbances such as ileus or small bowel obstruction are much more likely due to adhesions; 75% of small bowel obstructions involve adhesions to some extent.[54]
INVESTIGATIONS
Functional cine MRI: witnesses the visceral slide during Valsalva; 90% accuracy for identifying adhesions of bowel loops.[54]
Crohn disease
SIGNS / SYMPTOMS
Young adult with fever, nausea, vomiting, diarrhea, right lower quadrant pain, and localized tenderness, with change in bowel habit, colicky pain, passing of blood and mucus per rectum.
INVESTIGATIONS
CT scan may show intra-abdominal abscess.
Contrast study of the small bowel and colon may show stricture or a series of ulcers and fissures (cobblestone appearance) of mucosa.
Colonoscopic appearance shows cobblestone pattern of mucosal ulceration.
Histopathology of a large bowel biopsy will show transmucosal inflammation, fibrosis, and scanty granulomas.
Ureteric stone
SIGNS / SYMPTOMS
Pain is usually colicky in nature and severe in intensity. May be referred to the labia and associated with hematuria.
Fever usually absent.
INVESTIGATIONS
Urinalysis positive for blood.
Leukocytosis usually absent.
Abdominal x-rays or tomogram may show calcified stone.
Pyelography and CT scan without oral and intravenous contrast confirm the diagnosis.
Primary tubal cancer
SIGNS / SYMPTOMS
No differentiating signs or symptoms.
INVESTIGATIONS
Transvaginal ultrasound and MRI can further delineate this from an ovarian cyst.
Ultrasound findings include sausage-shaped cystic structures with papillary projections.
Cancer antigen (CA)-125 may be elevated in later-stage disease.[7]
Doppler imaging may provide added benefit.
Histopathology will confirm the diagnosis of tubal carcinoma.
Pelvic varicosities
SIGNS / SYMPTOMS
No differentiating signs or symptoms.
INVESTIGATIONS
Transvaginal ultrasound and MRI can further delineate this from an ovarian cyst.
Doppler imaging may provide benefit.
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