CONDITIONS SIMULATING OVARIAN NEOPLASMS II
Mesenteric cyst. Rarely, a cyst of the mesentery of the transverse colon or small bowel or of the omentum may reach large proportions and simulate a pedunculated, freely movable, extrapelvic ovarian cyst.
Polycystic kidney. The multilocular cystic replacement of the renal cortex and medulla may reach a huge size. On abdominal palpation the possibility of a large, adherent ovarian cyst may be suggested. Intravenous pyelography may demonstrate the bilateral renal involvement and characteristic elongation and spreading apart of the calyces. Abdominal ultrasonography will demonstrate the classic cystic nature of the kidneys and cysts, if present in the liver.
Pelvic kidney. An ectopic kidney may lie low in the lumbar region, in the iliac fossa, or in the true pelvis. It may be symptomless or may give rise to sacroiliac backache and pain in the lower abdomen, radiating to the hips and thighs. Pelvic examination may reveal the lower end of a smooth, oval, retroperitoneal, ﬁxed mass with a distinctive rubbery consistency.
Retroperitoneal pelvic neoplasms. A variety of retroperitoneal tumors may be present in the pelvis and be mistaken for adherent ovarian neoplasms. They may be symptomless or associated with local or referred pain due to renal compression. On rectal or rectovaginal examination, a ﬁxed, retroperitoneal tumor may be felt behind or lateral to the rectum. Sigmoidoscopy and barium enema may reveal external compression. Retroperitoneal pelvic tumors include lipoma, ﬁbroma, sarcoma, dermoid, malignant teratoma, metastatic carcinoma, osteochondroma, and ganglioneuroma. Pyogenic infections of the sacroiliac joint, osteomyelitis of the pelvis, dissecting abscesses originating with tuberculosis of the spine, perivesical infections, and psoas abscesses must be taken into consideration.
Hematoma of the rectus muscle. As a result of direct trauma or unusual strain upon the recti muscles of the abdominal wall, rupture of the muscle ﬁbers, with a hematoma, may occur. If localized over the right or left lower quadrants, the tender tumescence and voluntary spasm may suggest an acute accident in an ovarian tumor. An ecchymosis may or may not be apparent. Its superﬁcial location may be demonstrated by tensing the abdominal muscles. The absence of palpable tumors, upon rectal or vaginal examination, will further clarify the issue.
Adherent bowel or omentum. Following pelvic surgery or as an aftermath of pelvic infections, the omentum, sigmoid colon, or small bowel may become adherent to one adnexa or the other. An irregular, matted mass may result and give the impression of a pelvic tumor.
Carcinoma of the sigmoid colon. The irregular, rather ﬁrm and often ﬁxed mass felt with carcinoma of the sigmoid may suggest a carcinoma of the ovary and vice versa. Whichever site of origin is suspected, further differentiation is indicated. Altered bowel habits, diarrhea, constipation, colicky pain, ribbon stools, and melena point to possible intestinal difﬁculty. Rectal examination, sigmoidoscopy, barium enema, and biopsy will demonstrate the presence of a lesion or ﬁlling defect.
Diverticulitis. Uncomplicated diverticulosis of the descending and sigmoid colon is frequently asymptomatic. Perforation may result in a localized abscess, the adherence of bowel, omentum, and adjacent viscera, ﬁstulous communications, granulomas, and stenosis of the bowel. A diverticulitis of the sigmoid may simulate a carcinoma of the sigmoid or ovary as well as pelvic infection.
Tuboovarian inflammatory masses. A large hydrosalpinx or tuboovarian cyst may be palpated as a thin-walled, retort-shaped, cystic structure, adherent to the uterus, broad ligament, and pelvic peritoneum.
Ascites. Ascitic ﬂuid may give the impression of a large, ﬂaccid cyst. The percussion note over an ovarian cyst is ﬂat, with tympany in the ﬂanks. On bimanual examination, ﬂuctuation may be elicited. In the presence of ascites, tympany may emanate centrally and shifting dullness may be registered in the ﬂanks. A ﬂuid wave may be transmitted.