Gynecologic Pathology as it
Relates to General Surgery
Lily Shamsnia, MD
Department of Obstetrics and Gynecology
Tulane University School of Medicine
GYN vs. General Surgery
• Many Gynecologic disorders mimic those of
General Surgery, especially regarding etiology
of acute and chronic pelvic pain, as well as the
diagnosis/treatment of an acute abdomen.
• Abdominal pain may be infectious,
inflammatory, anatomic or neoplastic
Acute right lower abdominal pain in women of
reproductive age: Clinical clues
Hatipoglu, et. al
290 female patients presenting to ED with acute abdominal pain
Patient (n=290), n (%)
Age (yr)
Acute appendicitis
224 (77.2)
21 (12-24)
Perforated appendicitis
29 (10)
22 (14-42)
Ovarian cyst rupture
21 (7.2)
24 (15-38)
Corpus hemorrhagic cyst rupture
12 (4.2)
21 (13-55)
Adnexal Torsion
4 (1.4)
24 (19-30)
Alvarado Score
Alvarado Score
Point Value
Abdominal pain migrating to RLQ
1
Anorexia or urine ketone
1
Nausea or vomiting
1
Tenderness in RLQ
2
Rebound tenderness
1
Fever
1
Leukocytosis
2
Neutrophilia
1
Scoring:
0-4: unlikely appendicitis
5-6: consistent with
dx of appendicitis
7-8: probable appendicitis
9-10: very probable
appendicitis
Symptoms/signs of appendicitis similar to many GYN disorders
Approach to Acute
Abdominal/Pelvic pain in a
Female
•
•
•
•
•
History and physical exam
Bimanual and speculum exam
UPT/ serum bHCG
Cervical cultures
Radiologic studies
DDx pelvic pain of GYN origin
•
•
•
•
•
•
•
Pelvic Inflammatory Disease (PID)
Tubo-ovarian Abscess (TOA)
Endometriosis
Ruptured or Hemorrhagic Ovarian Cyst
Adnexal Torsion
Uterine Fibroids
Ectopic Pregnancy
Pelvic Inflammatory Disease (PID)
• Inflammation and infection of the upper
female genital tract, including the cervix,
fallopian tubes, and uterus.
• Peritonitis also may be present.
• Early diagnosis and treatment to prevent longterm morbidity is key.
• An episode of PID can cause recurrent/chronic
PID, chronic pelvic pain, ectopic pregnancy,
infertility.
PID
• Ascending infection from the lower genital tract.
–
–
–
–
–
–
–
–
Neisseria gonorrhoeae,
Chlamydia trachomatics,
Diptheroids,
Gardenella vaginalis,
Mycoplasma genitalium,
Bacteroides,
Anaerobes,
Streptococci
• > 50% cases have more than one organism
isolated
PID
• Symptoms/signs mimic that of appendicitis
due peritoneal irritation and can often be
vague/ misleading
• Diagnosis missed in up to 35% of patients.
• Mucopurulant cervical/vaginal discharge is
present with PID
PID- CDC Diagnostic Criteria
• Minimal Dx Criteria– Pelvic or lower abdominal pain AND
– CMT OR uterine tenderness OR adnexal tenderness
• Additional criteria:
–
–
–
–
–
–
oral temperature >101 F
Cervical/vaginal mucopurulent discharge
WBC on microscopy of vaginal secretions
Elevated ESR
Elevated CSR
Documented gonorrhea/chlamydia cervical infection
• Most specific
– Endometrial biopsy showing endometritis
– Radiographic imaging showing thickened fluid filled tubes indicative of
infection
– Laparoscopic abnormalities consistent with PID
PID
• Ultrasound
– Transvaginal preferable
– Uterine enlargement/thickened endometrium
– Ovarian enlargement (reactive inflammation)
– Edematous distended fallopian tubes with
hypervascularity on Doppler US
• CT scan
– Pelvic inflammation and fat stranding, indistinct
tissue planes.
PID- Ultrasound
Ovary
Dilated fallopian tube
PID- CT scan
Right side , normal
Left side, thickened/inflamed
tubal wall
PID- treatment
• Outpatient: Ceftriaxone 250 mg IM PLUS Doxycycline
100 mg PO BID x 14 days +/- Metronidazole 500 mg PO
BID x 14 days
• Inpatient:
– A: Cefoxitin 2 g IV q 6 hours PLUS Doxycycline 100 mg
PO/IV q 12 hours
– B: Ampicillin/Sulbactam 3 g IV q 6 hours PLUS Doxycycline
100 mg PO/IV q 12 hours
• Diagnostic laparoscopy vs exploratory laparotomy- If
diagnosis is unclear ( i.e. PID vs appendicitis vs TOA), or
no improvement with antibiotics
PID on laparoscopy
Fitz High Curtis
• Occurs with pelvic inflammation of PID
spreads to right upper quadrant via right
paracolic gutter and involves peritoneal
surface of liver.
• Violin-string adhesions, typically encountered
during laparoscopy, typically laparoscopic
cholecystectomy
Fitz High Curtis
Tubo-Ovarian Abscess (TOA)
• 35% of women with PID, 20-40 years old, small
percentage postmenopausal.
• 2/3 are unilateral- may lead to misdiagnosis of
appendicitis if on right side.
• Initial insult to the female genital tractinoculation and destruction of fallopian tube
epithelium  a purulent exudate with low
oxygen environment favorable for anaerobic
organisms.
• Inflammatory response induces edema, ischemia,
and necrosis of fallopian tube.
TOA
• Surrounding structures may become involved
in the expanding inflammation and walled off
abscess, including ovary, round ligament,
broad ligament, contralateral fallopian tube
and ovary, appendix, bowel, and bladder.
• With expansion, rupture of TOA can occur.
• TOAs can be the result of non- gynecologic
disease, including diverticulitis, appendicitis,
inflammatory bowel disease, and surgery.
TOA
• Polymicrobial:
–
–
–
–
–
–
–
–
E. coli,
Bacteroides
Peptostreptococcus
Enterococcus
Klebsiella
Staphylococcus
Streptococcus
H. influenza.
• N. gonorrhoeae and C. trachomatis are rarely cultured from TOAs.
• Anaerobic bacteria are present in 60-100% of TOA cultures.
TOA
• Lower abdominal pain (acute vs chronic),
nausea/vomiting
• +/- fevers/chills- up to 50% of patients are
afebrile
• If bowel is involved- anorexia/diarrhea
• Leukocytosis- present but not reliable indicator
• Palpable abdominal/pelvic mass, rebound
tenderness/guarding
• CMT, mucopurulent discharge, vaginal
discharge/abnormal bleeding
TOA- Imaging
• Ultrasound- sensitivity > 90% for diagnosis.
– Transabdominal- larger field of view for identifying adnexal
masses.
– Transvaginal- detailed view of pelvic anatomy and
vasculatyure.
• Appear complex, multilocular, cystic with thickened
walls and internal echoes/debris.
• Tubal and ovarian architecture disordered with
destruction of planes between the ovary and
developing abscess.
• Cogwheel sign- thickening of endosalpingeal folds.
TOA- Imaging
• CT scanning if diagnosis is unclear- septated
tubular structure with thickened walls.
• Hydronephrosis/hydroureter may be seen when
surrounding tissue is involved with the
inflammation.
• Gas bubbles within the fluid collection- highly
specific for TOA
• TOA vs. appendicitis- TOA was highly associated
with appearance of abnormal ovary, peri-ovarian
fat stranding, small bowel and recto-sigmoid
thickening, and free fluid in the pelvis.
TOA on US
TOA on CT
Appendicitis on US
Appendicitis- CT Imaging
TOA- Treatment
• Treat infection and preserve fertility
• Mainstay of therapy is antibiotics +/additional drainage procedures ( image guided
transabdominal or transvaginal approach)
• Parenteral antibiotics until 48 hours afebrile;
continuation of oral antibiotics for 14 days
TOA- Surgical Treatment
• 1) Concern for alternative surgical emergency
i.e. appendicitis, cholecystitis, bowel
obstruction/perforation
• 2) Failure of clinical response after 48-72
hours of medical therapy
• 3) Intra-abdominal rupture of TOA- emergent
surgery warranted due to hemodynamic
instability, sepsis, multi-system organ failure
TOA on laparoscopy
Endometriosis
• Defined as presence of endometrial glands
and stroma outside uterine cavity.
• Most accepted theory- development is
retrograde menstruation. Other theories
include coelemic metaplasia of endometrial
tissue with lymphatic spread, and
transformation of embryonic rests.
Endometriosis
• Prevalence - 7-10% in general population; up to
50% in infertile women
• 60% of women with dysmenorrhea, 87% of
women with CPP
• Symptoms- dysmenorrhea, dyspareunia, CPP,
pain with ovulation, micturition, defection
• Risks- early menarche, short menstrual cycles,
reduced parity, heavy bleeding
• Increased risk- tall /thin women, excess alcohol
and caffeine
Endometriosis
• Most common location of endometrial
implants is the ovaries, followed by
deep/central pelvis and vesico-uterine pouch
• 60% of Stage IV disease involves intestinal
tract (rectum, sigmoid, colon, appendix, small
bowel)
• With Stage IV disease- pain mediated by deep
infiltrating endometrial lesions in muscular
propria of surrounding organs
Endometriosis Treatment
• 1st line- NSAIDs and hormonal therapy
• If pain is refractory, surgical intervention is
warranted, with laparoscopic ablation or
removal (preferred) of endometrial implants
• With significant bowel/bladder involvement,
laparotomy may be required
Endometriosis
• MRI- superior for detection of
endometriomas- hyperintense signal of T1
weighted imaging or hypodense signal of T2
imaging
• CT- endometrioma appears as cystic mass
with hyderdense clot within
• US- used to assess endometrioma involving
ovary- hypoechoic cystic structure
Endometrioma on MRI
Endometrioma on US
Endometriosis on laparoscopy
Catamenial pneumothorax
• Recurrent pneumothorax occurring within 72
hours of onset of menses.
• SOB, CP, cough; usually RIGHT sided
• Manifestation of thoracic endometriosis, likely
via transdiaphragmatic lymphatic/vascular
transplantation of endometrial tissue
• Confirmed by presence of endometrial glands
and stroma within pleura or diaphragm
Ruptured/Hemorrhagic Ovarian Cysts
• Most common- functional cysts, including
corpus luteal cysts/ follicular cysts, which are
more prone to rupture due to increased
vascularity as part of the menstrual cycle
• Rupture typically occurs between 20-26 days
of menstrual cycle (i.e. luteal phase, after
ovulation has occurred)
Ruptured/Hemorrhagic Ovarian Cysts
• Mittelschmerz- sensation of pain and release
of peritoneal fluid associated with physiologic
rupture of corpus luteum, cyst during
ovulation
• Ruptured cyst- most commonly right sided
• Usual symptoms- acute pain, vaginal bleeding,
nausea/vomiting, shoulder tenderness
• If associated with massive hemorrhage- signs
of circulatory collapse
Ruptured/Hemorrhagic Ovarian Cysts
• Ultrasound- thin wall, anechoic; with
hemorrhage and clotting of blood- internal
echoes appear with fluid and debris
• With massive hemorrhage- free
intraperitoneal fluid present, while cyst itself
is collapsed
Hemorrhagic Ovarian Cysts
Ruptured/Hemorrhagic Ovarian Cysts
• Hemodynamically stable- conservative
management, analgesia, observation
• Unstable- emergent surgical intervention,
even if diagnosis is uncertain
• If active/uncontrollable bleeding presentoophorectomy recommended; otherwise,
conservative management with preservation
of ovary is preferred
Ovarian Torsion
• Partial/complete twisting of adnexa around its
vascular pedicle ( infundibulopelvic ligament
and tubo-ovarian ligament)
• Vascular and lymphatic obstruction results,
leading arterial occlusion and ovarian necrosis
• Right adnexa most commonly involved,
possibly due to longer utero-ovarian ligament
on the right vs. decreased mobility of left
adnexa due to presence of sigmoid colon
Ovarian Torsion
• Commonly associated with ovarian mass (cyst,
neoplasm, etc) as a fixed point around which
adnexa may twist
• Previous pelvic surgery also increases risk,
likely due to post surgical adhesions around
which adnexa can twist
• Patients with ovarian hyperstimulation
syndrome (due to assisted reproductive
technology) also at increased risk
Ovarian Torsion
• Acute pelvic/abdominal pain; prolonged pain
associated with high risk of necrosis
• Nausea, vomiting, dysuria, urinary retention,
frequency, urgency
• Low grade leukocytosis/fever less common
• Peritoneal signs
Ovarian Torsion
• Ultrasound- gold standard
• Enlarged ovary (>5 cm) with edema
• Absent arterial/venous flow is highly specific
for torsion
• Pelvic free fluid present with
infarction/hemorrhage
Ovarian Torsion
No Doppler Flow
Ovarian Torsion
“Whirlpool sign”
Ovarian Torsion
• Preferred surgical treatment- laparoscopic
detorsion with salvage of adnexa
• Oophorectomy warranted if ovary appears
necrotic, ovarian mass present, or there is
evidence of peritonitis
• If ovary is salvageable, consider ovarian
suspension to decrease likelihood of
recurrence.
Ovarian Torsion
Ovarian Torsion
Ovarian Torsion in Pregnancy
• Adnexal torsion is the most common
complication of an adnexal mass occurring
during pregnancy, typically in 1st and 2nd
trimesters
• If ovarian mass without torsion is noted,
surgery is performed in 2nd trimester
• If torsion is present, surgery is warranted
regardless of gestational age
Uterine Fibroids
• Most common pelvic tumor in women; consist
of hormonally responsive smooth muscle
cells, which can lead to progression during
pregnancy or with hormonal contraceptive
use, and typically regress after menopause
• Most common symptoms- abnormal vaginal
bleeding, pelvic pain and pressure
• Hydronephrosis can occur with chronic
impingement of ureter
Uterine Fibroids
Degenerating fibroids that have outgrown/lost
blood supply can present as acute abdominal
pain
Ultrasoundanechoic, irregular
cystic spaces
within the fibroid,
indicating necrosis
Ectopic Pregnancy
Defined as any
pregnancy outside
uterine cavity, most
commonly in the
fallopian tube (ampulla>
isthmus> fimbria),
abdominal cavity, ovary,
cervix, or uterine cornua
Typically occur between
6-10 weeks gestation,
and is the leading cause
of death during the 1st
and 2nd trimesters of
pregnancy
Ectopic Pregnancy
• Risk factors- previous ectopic pregnancy,
history of PID, previous pelvic surgery,
smoking, infertility, intrauterine device use
• Symptoms- pelvic pain, vaginal bleeding
• Quantitative bHCG- initial test
– if >1500 mIU/mL, pregnancy can be seen on
transvaginal US
– If > 5000 mIU/mL, pregnancy can be seen on
abdominal US
Ectopic Pregnancy
• US evaluation- 1st
evaluate if pregnancy
is intrauterine; at 5
weeks gestation
(corresponding to
bHCG between 10002000 mIU/mL) a
gestational sac
should be visible
Ectopic Pregnancy
• With ectopic pregnancy- gestational sac/fetal
pole +/- cardiac activity seen outside the
uterine cavity
• Adnexal mass separate from ovary with empty
uterus, free fluid in pelvis, tubal “donut” sign
and “ring of fire” on Doppler ultrasound
Ectopic Pregnancy on US
Ectopic Pregnancy- “Ring of Fire”
Ectopic Pregnancy
• If unruptured and hemodynamically stablecan consider conservative management with
medical therapy i.e. Methotrexate with follow
up of serial bHCG levels at day 4 and day 7
after injection, and then weekly until negative
• If bHCG fails to decrease by 15% from day 4 to
day 7 after MTX injection, consider additional
MTX injection vs. surgery
Ectopic Pregnancy
• If ruptured, emergent surgery is indicated,
especially if hemodynamically unstable
• Depending on degree of patient stability,
surgical approach via laparoscopy (preferred)
versus laparotomy, with salpingostomy versus
salpingectomy
• Salpingectomy indicated with uncontrolled
bleeding, severely damaged fallopian tube,
large gestational sac (> 5 cm)
Ectopic Pregnancy
Appendicitis in Pregnancy
• 1/800 - 1/1500 pregnancies, incidence slightly
higher in the second trimester
• Appendiceal rupture occurs more frequently
in pregnant women, especially in the third
trimester -possibly due to inconclusive
symptoms/reluctance to operate on pregnant
women delaying diagnosis and treatment;
associated with higher risk of fetal loss (36%
vs. 1.5%)
Appendicitis in Pregnancy
• Less likely classic presentation, especially in late
pregnancy
– More GI complaints
– Leukocytosis is common with pregnancy
• Pain typically originates at McBurney's point
regardless of the stage of pregnancy; however,
location of the appendix migrates a few
centimeters cephalad with the enlarging uterus
• In the third trimester, pain may localize to the
mid or even the upper right side of the abdomen
Appendicitis in Pregnancy
• US- wide variation in the diagnostic
performance during pregnancy; gravid uterus
can interfere with visualizing the appendix and
performing graded compression (particularly
in the third trimester)
• CT imaging- when clinical findings and
ultrasound examination are inconclusive and
MRI is not available
Appendectomy in Pregnancy
• Open  preferred if late gestation
• Laparoscopic
– slight left lateral positioning if 2nd trimester and
beyond
– avoid cervical instrumentation
– open entry techniques/ trocar placement under
direct visualization
– limit intra-abdominal pressure to less than 12
mmHg
Cholelithiasis in Pregnancy
• Gallstones are more common during pregnancydecreased gallbladder motility/increased
cholesterol saturation of bile
– Estrogen increases cholesterol secretion
– Progesterone reduces bile acid secretion and slows
gallbladder emptying, promoting the formation of
stones via biliary stasis
• In pregnant women with biliary colic, supportive
care will lead to resolution of symptoms in most
cases, but the symptoms frequently recur later in
pregnancy
Cholelithiasis in Pregnancy
• 1st episode - supportive care vs.
cholecystectomy (laparoscopic if in 1st/2nd
trimesters)
– low risk of fetal mortality and high risk of disease
relapse/need for urgent surgery later in
pregnancy.
• Acute cholecystitis  cholecystectomy
– If near term- conservative management is
preferable as surgery is technically difficult, with
plan for cholecystectomy 6 weeks postpartum
The End!
Questions?