Is uterine and adnexal tenderness common in patients with uterine fibroids?

Uterine and Adnexal Tenderness in Fibroids

Uterine and adnexal tenderness is NOT a common or typical feature of uncomplicated uterine fibroids. Fibroids are generally asymptomatic or present with painless symptoms, and the presence of tenderness should prompt evaluation for complications or alternative diagnoses.

Typical Presentation of Uncomplicated Fibroids

Uterine fibroids typically present with:

• Menorrhagia (abnormal uterine bleeding) as the most frequent symptom, often resulting in iron deficiency anemia 1
• Pelvic pressure or sensation of fullness rather than acute tenderness 2, 3
• Urinary frequency and urgency from mass effect 1, 4
• Constipation from posterior fibroid pressure 4
• Increased abdominal girth from enlarged uterus 3
• Dyspareunia (pain during intercourse) 3

Physical examination findings in uncomplicated fibroids include an enlarged, irregularly contoured uterus that is typically non-tender on bimanual pelvic examination 1. The fibroids are characterized by their location, shape, and mobility, but tenderness is not a defining feature 1.

When Tenderness Occurs: Fibroid Complications

Tenderness associated with fibroids indicates a complication requiring urgent evaluation:

Fibroid Degeneration

• Presents with severe sudden-onset pain, fever, nausea, and leukocytosis 1
• Occurs when fibroids outgrow their blood supply 1
• Requires supportive care with NSAIDs and observation 1
• This is the primary scenario where fibroids cause acute tenderness 1

Torsion of Pedunculated Fibroid

• Pedunculated or broad ligament fibroids can undergo torsion 5
• Would present with acute pelvic pain and tenderness 5
• Requires imaging to differentiate from ovarian torsion 5

Critical Differential Diagnoses

When a patient with known fibroids presents with uterine or adnexal tenderness, you must actively exclude other pathology:

Pelvic Inflammatory Disease (PID)

• Bilateral adnexal masses with tenderness are seen 82% of the time in PID versus only 17% in other diagnoses 5
• Transvaginal ultrasound findings include wall thickness >5 mm, cogwheel sign, incomplete septa, and cul-de-sac fluid 5
• Power Doppler shows hyperemia and lower pulsatility index with 100% sensitivity and 80% specificity 5

Adnexal Torsion

• Unilaterally enlarged ovary with central afollicular stroma and peripheral follicles 5
• Ultrasound has 79% sensitivity and 76% specificity for diagnosis 5
• Absence of venous flow has 100% sensitivity and 97% specificity 5

Tubo-Ovarian Abscess (TOA)

• Complex cystic mass with thick enhancing walls and loss of normal anatomic boundaries 5
• Ultrasound sensitivity of 93% and specificity of 98% 5

Endometriosis/Endometrioma

• Can coexist with fibroids 6
• Transvaginal ultrasound has 84% sensitivity for endometriotic cysts 5

Diagnostic Approach

When evaluating tenderness in a patient with fibroids:

1. Perform transvaginal and transabdominal ultrasound with Doppler as the initial imaging modality 5

   • Assess for signs of degeneration (heterogeneous appearance, cystic changes) 5
   • Evaluate for free fluid, which suggests complication 5
   • Examine adnexa separately to identify alternative pathology 5

2. Look for specific clinical features:

   • Fever and leukocytosis suggest degeneration or infection 1
   • Bilateral tenderness favors PID over fibroid complication 5
   • Unilateral tenderness suggests torsion or TOA 5

3. Consider MRI with contrast if ultrasound is inconclusive 5

   • 86% sensitivity for fibroid degeneration based on lack of contrast enhancement 5
   • Superior soft-tissue detail for evaluating complications 5

Clinical Pitfalls to Avoid

• Do not attribute new-onset tenderness to pre-existing fibroids without excluding complications or alternative diagnoses 1
• Large fibroids can displace normal ovaries, making them difficult to visualize on ultrasound—careful search with identification of bridging vessels from uterine arteries helps confirm fibroid origin 5
• Rapid fibroid growth with tenderness in postmenopausal women should raise suspicion for malignant transformation (leiomyosarcoma), though rare, and warrants urgent referral 1, 7
• Transabdominal ultrasound alone may miss pathology in patients with large fibroids—transvaginal approach is essential when feasible 5