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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Zahir Ali Shaikh, MD[2]

Vaginal/Vulvar mass differential diagnosis

Diseases Clinical manifestations Para-clinical findings Gold standard
Symptoms Physical exam Lab Findings Imaging Histopathology
Abnormal

vaginal bleeding

Abnormal vaginal dyscharge Pelvic

pain

Itching or

burning of the vulva

Other Genitourinary/ Gastrointestinal symptoms B symptoms Abdominal pain Gynecological examinations Abdominal

mass

HPV Pap smear STI Panel Ultrasound MRI CT Scan
Cervical cancer[1][2][3][4][5][6][7][8] + + + +

+

+ ± ±Chlamydia T2-weighted MRI :
  • Ovoid, heterogeneous tumor distending the cervical canal with stromal involvement.
PET/CT scan:
Cervical polyp[9]
  • Postcoital
  • Intermenstrual
  • Postmenopausal
  • Bleeding after exam
+
  • Mass on exam
  • Hyper/hypoechogenic masses with or without cysts
  • Filling the endocervical or vaginal canal
  • Epithelial cells with no nuclear atypia/mitoses
  • Hysteroscopy /Biopsy
Cervical leiomyoma[10][11][12][13][14][15][16][17]
  • Heavy/prolonged menstrual bleeding
  • Intermenstrual bleeding
+ +
  • Urinary retention
  • Constipation
  • Infertility
  • Bowel obstruction
  • Increase in pregnancy/labor complications
+
  • Large,irregular pelvic mass
±
  • Well circumscribed hyperechoic mass
T2-weighted MRI:
  • Hypointense masses
  • Homogeneous

enhancement

  • Red degeneration
  • Spindle shaped smooth muscle cells
  • Mature adipocytes
  • Extracellular matrix consist of collagen,fibronectin.
  • Clinical diagnosis/ and
  • Ultrasound
Cervical lymphoma[18][19][20]
  • Postmenopausal bleeding
+
  • Difficulty urinating
  • Post-coital pain
+ +
  • Larrge uterine/cervix mass
  • Irregularity
+
  • Well-defined, solid, concentric, hypoechoic mass
MRI:
  • Intramyometrial infiltrative nodules
Diffuse heterogeneous uterine cervical mass & hypoechoic enlarged iliac lymph nodes
  • Small tumor cells with large nuclei
  • High mitoses and proliferation
  • Biopsy
  • diffuse large B-Cell lymphoma (DLBCL) most frequent type.
Cervical sarcoma[21][22]
  • Intermentrual
  • Postmenopausal
± +
  • Post-coital pain
  • Fullness in pelvic
± +
  • Cervical mass
  • Lump protruding from vagina/vulva
+
  • Endometrial mass with heterogeneous echogenicity
MRI:
  • Endometrial polypoid mass
  • Hypointense hypervascular solid components
N/A
  • Mitotic index
  • Cellular atypia
  • Coagulative necrosis
  • Biopsy
Cervical erosion(Ectropion)[23][24][25][26][27]
  • Light bleeding after pelvic exam
  • Spotting
+ + ±
  • Post-coital pain
  • Painful cramps
  • Pain after sex
+ - N/A N/A N/A
  • Squamous metaplasia
  • Vascular ectasia
  • Lymphocytic infiltration
Cervicitis[28][29][30][31]
  • Intermenstrual bleeding
  • Postcoital
  • Bleeding after pelvic exam
+ +
  • Itching
  • Pain during urination
  • Pain during sex
  • Painful menstruation
  • May have fever only
+/-
  • Red,inflammed swollen cervix
  • Inflammation/irritation of vulva/vagina
  • Chlamydia
  • Gonorrhea
  • Herpes simplex
  • Trichomonas vaginalis
To detect complications like PID N/A N/A N/A
IUD use[32][33][34]
  • Heavy bleeidng
± +
  • Itching
  • Painful menstruation
+/-
  • Strings of IUD device
  • Signs of inflmmation
  • Discharge
  • Bleeding
± To detect IUD location and pregnancy N/A N/A N/A Physical exam and utrasound
Pelvic inflammatory diseases[35][36]
  • Bleeding after sex
  • Intermenstrual bleeding
+ +
  • Itching/burning
  • Pain during sex
  • Painful menstruation
  • Burning sensation during urination
  • Pain during bowel movement
  • Fever
±Abdominal

pain

  • Pelvic pain
  • Vaginal/vulvar tender lesion depending on microbial cause
  • Chlamydia
  • Gonorrhea
  • Enlarged fallopian tubes
  • Abscess
  • Hyperemia
  • Ectopic pregnancy/ovarian cyst/abscess
Thickened fluid filled fallopian tubes N/A May show endometritis
Endometriosis[37][38][39][40][41][42]
  • Heavy mentrual bleeding
±
  • Pelvic pain
  • Back pain
  • Painful menstruation
  • Burning/painful urination
  • Painful bowel movement
  • Pain during or after sex
  • Infertility
+
  • Tender uterosacral nodularity
  • Immobile uterus
  • Cervical motion tenderness
  • Retroverted uterus
+
  • Unilocular/multilocular cysts contating thin/thick septations
  • Increased vascularity showing increased doppler flow
  • Hyperintensity on T1 weighted images
  • Hypointensity on T2 weighted images
  • Catamenial pneumothorax, hemothorax & lung nodules
  • Visual inspection by laparascopy
Adenomyosis[43][44][45][46]
  • Abnormal uterine bleeding
+
  • Painful menstruation
  • Polypoid mass protruding into the endocervical canal.
Cervical ectopic pregnancy[47]
  • Amennorhea
  • Bleeding after pelvic exam
  • Pelvic pain
+
  • Soft and disporportionally enlarged uterus.
  • Empty uterine
  • Thickened endometrium
T2-weighted MRI:
  • Hypointense large mass

T1-weighted MRI:

  • Partially hyperintense mass
  • Necrotic hemorrhagic mass with chorionic villus
  • Hysterectomy and biopsy
DES exposure (Clear cell adenocarcinoma)[48]
  • Postcoital bleeding
+
Paget's disease of vulva to cervix[49][50][51]
  • Bleeding from lesion
  • Oozing
±
  • Itching/burning
  • Pain in vulva
  • Scaly eczematoid lesion in vulva.
  • Erythematous plaques with white scaling.
  • Inguinal lymphadenopathy in case of metastases.
  • Intraepidermal adenocarcinoma which involves epidermis
  • Biopsy of lesion
Vaginal cancer[52]
  • Postcoital bleeding

+

  • Tenesmus
  • Dysuria
  • Urinary frequency
  • Constipation
  • Pelvic pain
  • Vaginal lump
  • Inguinal lymphadenopathy
Nabothian cyst[53][54][55]
  • Postcoital bleeding
+
  • Pain during sex
  • Cystic mass on exam
  • Intermediate or slightly high signal intensity on T1-weighted
  • High signal intensity on T2-weighted images
Rectal cancer[56][57][58][59][60] - - + -
  • Constipation/diarrhea
  • Absent bowel sounds
  • Rectal mass/bleeding
  • Abdominal tenderness
Weight loss + LLQ + NL + - - +/- Endoscopic/transrectal US detects tumor extent Determine tumor stage Determine tumor stage
  • Sheets or cords of malignant cells
  • Cellular atypia & pleomorphism
  • High mitotic rate
  • Necrotic debris in glandular lumina
Colonoscopy with biopsy
Submucous uterine leiomyoma[61][62][63] Menorrhagia - + -
  • Constipation
  • Urinary frequency/incontinence
  • Hydronephrosis
- + Enlarged, irregular, firm, nontender uterus + - - -
  • Trans vaginal US: well defined hypoechoic
  • Saline US: for submucous fibroids/polypoi
Provides information on no: of fibroids, size, vascularization, relationship with endometrial cavity & serosal surface Not required Not required Physical examination with Ultrasound
Uterine cancer[64][65][66][67]
  • Menometorrhagia
  • Intermenstrual bleeding
  • Postcoital bleeding
+ + -
  • Polyuria
  • Dysuria
  • Fatigue
  • Weight loss
+
  • Enlarged uterus
  • Lymphadenpathy
  • Mesenteric nodules (metastases)
+ - - - Thickened endometrial lining >4cm
  • Endometrial thickening
  • Lymph node involvement
  • Pelvic metastases
Not required
  • Endometrial malignant cells
  • Low grade type 1
  • High grade type 2
Histologic diagnosis
Vaginal lymphoma[68][69][70] + + + + Abdominal/pelvic pain - + Palpable mass between rectum & vagina +/- - - - Diffuse mass in external cervical orifice & invading the vagina Diffuse mass in external cervical orifice & invading the vagina Not required CD20 & CD79a positive Immunohistochemistry & biopsy
Vaginal polyp[71][72][73][74] Postmenopausal bleeding + + +
  • Dysperunia
  • Postcoidal bleeding
  • Dysuria
  • Constipation
- + Mass protruding from vagina +/- - - - To exclude uterine hyperplasia/carcinoma To determine the extent N/A Benign tissue/premalignant cells Excisional biopsy
Vaginal adenosis[75][76]
  • Intermenstrual bleeding
  • Postmenopausal bleeding
+/- +/- +/- - - - Palpable cysts,nodularity or ulcers - - - - N/A N/A N/A Columnar cells in the ectocervix Biopsy with histopathological examination

Differentiating [Disease name] from other Diseases

[Disease name] must be differentiated from other diseases that cause [clinical feature 1], [clinical feature 2], and [clinical feature 3], such as [differential dx1], [differential dx2], and [differential dx3].

OR

[Disease name] must be differentiated from [differential dx1], [differential dx2], and [differential dx3].

OR

As [disease name] manifests in a variety of clinical forms, differentiation must be established in accordance with the particular subtype. [Subtype name 1] must be differentiated from other diseases that cause [clinical feature 1], such as [differential dx1] and [differential dx2]. In contrast, [subtype name 2] must be differentiated from other diseases that cause [clinical feature 2], such as [differential dx3] and [differential dx4].

Differentiating [disease name] from other diseases on the basis of [symptom 1], [symptom 2], and [symptom 3]

On the basis [symptom 1], [symptom 2], and [symptom 3], [disease name] must be differentiated from [disease 1], [disease 2], [disease 3], [disease 4], [disease 5], and [disease 6].

Diseases Clinical manifestations Diagnosis Gold standard Additional findings Others
Symptoms Physical examination
Lab Findings Imaging
Abdominal pain Bowel habits Blood in stool Weight loss General appearance Abdominal exam Rectal exam Genitourinary exam CBC Tumor markers Stool test Colonoscopy Barium enema Ultrasound CT scan
Rectal carcinoma[77][78][79][80][81] LLQ Constipation/diarrhea + + NL Anemia FOBT+ mass/polyp Apple core apearance Endoscopic/trnasrectal US detects tumor extent Determine tumor stage colonoscopy with biopsy DRE & proctoscopy detects tumor localization & extension
Rectal polyp[82][83][84] + Mucous diarrhea + + NL NL rectal mass/polyp NL NL/anemia NL FOBT+ Polyp N/A Polyp N/A colonoscopy with biopsy N/A
Anal cancer[85][86][87][88] +/- constipation/diarrhea + +/- NL NL lump/mass at anal opening NL NL/anemia N/A FOBT+ N/A N/A Determines anal cancer depth into sphincter Hypoattenuated necrotic mass on contrast CT Biopsy PET/CT detects localization of small anal tumors <2cm Sentinal lymph node biopsy detects lymph node metastases
Hemorrhoids[89][90][91][92] +/- fecal incontinence/mucous discharge + - NL/weakness,irritability NL NL iron deficiency anemia N/A blood on stool outer surface Done if colorectal cancer suspected N/A N/A N/A DRE + anoscopy anoscopy shows bulging purplish hue veins or dark, pink, glistening mass None
Rectal prolapse[93][94][95][96] Abdominal discomfort constipation/diarrhea +/- - NL NL Intermittent rectum protrusion seen NL NL/anemia N/A Mucous/blood in stool May be used for screening N/A Reveals asymmetry & any sphincter defect N/A History & physical examination DRE shows patulous anus, attenuated sphincter tone & mass Anal manometry to assess sphincter function
Foreign body[97][98][99][100] Anorectal pain and abdominal pain Constipation + - NL NL FOBT+ Foreign body Contraindicated Foreign body Foreign body Plain radiographs show presence of foreign body NL NL
Diseases Abdominal pain Bowel habits Blood in stool Weight loss General appearance Abdominal exam Rectal exam Genitourinary exam CBC Tumor markers Stool test Colonoscopy Barium enema Ultrasound CT scan Gold standard Additional findings Others
Prostatitis[101][102][103][104] LLQ/groin pain NL N/A - NL NL NL Tender/enlarged prostate leukocytosis NL/↑ PSA N/A N/A N/A
  • Focal hypoechoic regoin in peripheral prostate
  • Fluid collection suggests abscess
Edematous/enlarged prostate N/A prostate biopsy & thermograms may also be done CRP
Fecal impaction[105][106][107][108] + constipation - +/- DRE shows fecal impaction NL Mild leukocytosis N/A N/A N/A Used in softening of stool & stimulation of evacuation N/A Presence of fecal matter in colon DRE to detect fecal impaction Abdominal radiograph to detect fecal loading
Anal stenosis[109][110][111] + constipation + +/- NL NL Visual inspection shows stenosis NL NL N/A NL Contraindicated N/A N/A N/A Visual inspection with DRE Incomplete evacuation None
Hypertrophied anal papillae[112][113][114][115] - NL +/- - NL NL Firm & palpable papillae on digital examination NL NL N/A Mixed with blood N/A Smooth polyp located inside anal verge N/A N/A Visual inspection with digital examination Associated with anal fissure & anal skin tag None
Endometriosis[116][117][118] +/- Constipation - - Fatigue Mild tenderness Nodules in posterior fornix Tenderness on vaginal exam Anemia - - N/A N/A Lesions can be detected on usg Not required N/A N/A N/A
Uterine malignancy[119][120][121] - NL - + Pallor NL Pelvic mass Vaginal bleeding Anemia Hcg - N/A N/A Increased thickness of uterine wall >4mm N/A Endometrial biopsy N/A N/A
Diseases Abdominal pain Bowel habits Blood in stool Weight loss General appearance Abdominal exam Rectal exam Genitourinary exam CBC Tumor markers Stool test Colonoscopy Barium enema Ultrasound CT scan Gold standard Additional findings Others
Cervical malignancy[122] - Normal - + Pallor

Fatigue

NL Pelvic mass Anemia N/A FOBT - N/A N/A Cervical thickening Detects metastasis Cone biopsy N/A N/A
Pelvic abscess[123][124] + Nil - +/- Fluctuating mass Vaginal discharge in females leucocytosis - FOBT - N/A N/A Location and consistency of abscess Location and consistency of abscess N/A N/A N/A
Pelvic sarcoma[125][126][127] + NL/constipation +/- +/- NL/cachetic with fever presence of mass NL N/A Lleukocytosis NL N/A N/A N/A Well circusmscribed, multinodular/infiltrating mass of soft tissue attenuation CT/MRI/Biopsy PET with FDG used for staging None

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