that, but the nodules are usually of a stony hardness. If the fibroid tumor or tumors are large enough to distend the abdomen the uterus is drawn up in the pelvis. This upward excursion of the uterus does not take place in the case of an ovarian turmor. Fibroma of the ovary has been mistaken for a pedunculated subserous fibroid. Here only an abdominal operation can clear up the diagnosis. The sound should be passed. <Callout type="important" title="Important">Fibroids are so often multiple that a lengthened canal may indicate a submucous or an interstitial fibroid and therefore indirectly point to a subserous tumor.</Callout> Before passing the sound observe strict antiseptic precau- tions and always inquire as to the elate of the last menstrua- tion. Pelvic inflammatory exudate may complicate a fibroid tumor, but is seldom mistaken for it. The mass in inflammation is brawny and fills in the chinks of the pelvis. There is a history of fever, even if it is not present at the time, as shown by the thermometer. Cancer of the pelvis, originating in the uterus or ovaries, may be mistaken for fibroid tumor, but is differentiated by the fixity of the infiltration, and the lack of definite outline of the tumor. Ascites is occasionally present in large tumors. Change of posi- tion of the patient changes the situation of the fluid, which is mapped out by its flatness to percussion. The contour of the abdomen in the case of large fibroids is dome- shaped if the fibroid is globular and single, nodular if multiple. The tumor stands out sharply on all sides when seen in profile. (See Fig. 103.) Ascites, if it is present in excess, modifies the contour. <Callout type="risk" title="Risk">Intraligamentous Fibroid Tumors.</Callout> An intraligamentous fibroid is situated at one side of the uterus, the sound showing the situa- tion of the latter if it can not be palpated. This sort <>!' tumor is low in the pelvis, often ii can be felt projecting into the v.-r Its mobility is limited because of it- attachments an<l it- situation. <Callout type="tip" title="Tip">Interstitial Fibroid Tumors.</Callout> The uterine canal is commonly 264 DIAGNOSIS OF FIBROID TUMORS OF THE UTERUS lengthened in cases of interstitial fibroids, and hemorrhage is likely to occur in these tumors. In this variety the enlargement of the uterus may be symmetrical, or it may be asymmetrical. In the lat- ter, the diagnosis is easier to make; in the former, one must rule out pregnancy. To do this it is important to get the history most carefully, having regard to amenorrhea and nausea. The elastic feel of the pregnant uterus is to be sought for, also the softening of the cervix and the bulging of the anterior segment early in preg- nancy and ballottement later. (See Chapter XXII., p. 423.) Breast changes are to be looked for, and if the tumor is large an attempt should be made to auscult the fetal heart sounds. An- other examination a month later will confirm a diagnosis of preg- nancy. A fibroid rarely becomes cystic before it has attained the size of a three months' pregnancy; therefore, an elastic tumor of less than this size is probably not a fibroid. The sound is not to be passed if there is the slightest suspicion of pregnancy. Examina- tion under ether is advisable if the abdominal walls are tense or the conditions for examination are not entirely satisfactory. Sarcoma may develop in a fibroid. In this event the tumor has grown rapidly. Only operation makes a positive diagnosis of sar- coma. <Callout type="warning" title="Warning">Submucous Fibroid Tumors.</Callout> A history of hemorrhage is present in almost all submucous fibroids. Here the diagnosis is established by the sound and, if necessary, by digital exploration of the uterine cavity. Bimanual palpation determines an increase in size of the uterus. This is true even in the case of small growths. The sound shows enlargement and distortion of the uterine cavity. If the tumor is at the fundus nothing but digital exploration will settle the question whether it is sessile or pedunculated. Some- thing may be learned often by the tactile sense transmitted through the exploring sound. To make a digital exploration of the uterine cavity the cervix is to be dilated by a series of dilators: the Hanks, followed by the Wathen or by large Simon dilators, plenty of time being taken so that rupture may not occur. In cases of hard, resistant cervices it is best to adopt the method of incision of the anterior wall of the cervix described in Chapter VII., page 94, repairing the cervix by suture after the exploration is finished. A sessile submucous fibroid of the fundus uteri may be mistaken for <Callout type="important" title="Important">DIAGNOSIS AXD DIFFERENTIAL DIAGNi adenoma or adeno-carcinoma. A piece removed and submitted to microscopic examination is the only means of distinguishing the two.</Callout> A pedunculated tumor presenting at the externa] os may be mistaken for inversion and, if sloughing, for cancer of the cervix. It is distinguished from cancer by learning that the sound may be made to sweep entirely around the tumor, thus making sure that the cervix itself is not the seat of the disease: and from inver- sion by noting, by bimanual recto-abdominal touch under ether, that the fundus uteri is in its normal situation. An inverted uterus is usually very sensitive to touch, although not invariably so. Cancer of the body of the uterus and cJiorioepitJielioma are to be excluded by the examination of tissue removed from the uterine cavity by curetting or by digital exploration, and, in the (-a-'' of chorioepithelioma, by the history of a previous labor, abortion, or hvdatidiform mole having occurred within a few weeks.
Key Takeaways
- Use the sound and physical examination to diagnose fibroids in the uterus.
- Be aware of the risk of mistaking submucous fibroids for adenoma or adeno-carcinoma.
- Always rule out pregnancy before diagnosing fibroid tumors.
Practical Tips
- Always perform a thorough history and physical examination to ensure accurate diagnosis.
- Use digital exploration carefully, especially in cases of hard cervices.
- Be cautious when dealing with large tumors as they may cause complications like ascites.
Warnings & Risks
- Do not pass the sound if there is any suspicion of pregnancy.
- Avoid mistaking submucous fibroids for adenoma or adeno-carcinoma without microscopic examination.
- Be aware that cancer can be mistaken for a fibroid tumor, especially in cases with fever and fixed infiltration.
Modern Application
While the techniques described here are historical, they provide foundational knowledge on diagnosing gynecological issues. Modern tools like ultrasound and MRI have improved accuracy but understanding these basic methods is still crucial for initial assessments and triage in emergency situations.
Frequently Asked Questions
Q: How can a fibroid tumor be distinguished from cancer of the uterus?
Cancer of the body of the uterus can be excluded by examining tissue removed from the uterine cavity through curetting or digital exploration. Additionally, if there is fever and fixed infiltration, it may indicate cancer rather than a fibroid.
Q: What should one do if they suspect a patient has an intraligamentous fibroid?
Use the sound to determine the location of the uterus and its mobility. This can help differentiate between an intraligamentous fibroid and other types of tumors, but further examination may be necessary.
Q: How can one confirm a diagnosis of pregnancy when dealing with fibroids?
Obtain a careful history for amenorrhea and nausea. Check for the elastic feel of the uterus, softening of the cervix, and bulging of the anterior segment early in pregnancy. Ballottement later can also help confirm a diagnosis of pregnancy.