Stomach and pancreatic masses, and aortic aneurysms are palpable in the epigastrium and behind the umbilicus (figure 39a,b). In the latter, place your fingertips of each hand on either side of the aneurysm to demonstrate expansile pulsation and also to gain some indication of the transverse diameter (figure 39c,d). Very few aneurysms are suprarenal in origin, even when the palpating fingers cannot dip over the upper border. Aneurysms occasionally involve the common iliac arteries, in which case the aortic bifurcation may be palpable. Small aneurysms may be difficult to palpate in an obese abdomen. A normal aorta can be palpated against the vertebral bodies in a thin individual: press deeply but gently as this maneuver can produce discomfort.

Para-aortic nodes and fixed retroperitoneal or pancreatic masses can mimic aneurysms and may transmit aortic pulsation. A gastric neoplasm presenting as a mass in the epigastrium or umbilical region may be partly mobile in all directions. In the neonate, the pyloric tumor of pyloric stenosis may be palpable, after a meal, on the right side of the epigastrium. Retroperitoneal masses, hematomas and tumors may also extend into the loin and become palpable bimanually. Imaging techniques provide essential additional information to diagnosis of these lesions (figure 40).

The suprapubic region is usually resonant and empty to palpation (figure 41). The commonest mass coming out of the pelvis, which you cannot get below and is dull to percussion, is the pregnant uterus. A large bladder and ovarian masses can have similar signs; in the former the patient usually has accompanying urinary symptoms; suprapubic drainage is occationally required (figure 42).

Gynecological problems may present as acute or chronic disorders, including abdominal pain. Ovarian disease includes cystic change, and cysts may enlarge, twist, bleed and rupture. Ovarian cancer can present with vague and non-specific symptoms, such as weight loss and malaise, before gross enlargement of a pelvic mass, ascites and the symptoms of invasion and intestinal obstruction. Infection of the uterine tract may produce acute salpingitis, presenting with severe lower abdominal and back pain, and vaginal discharge, often with associated urinary symptoms. Sequelae include a hydro– or pyosalpinx.

Disorders of the body of the uterus include fibroids, endometriosis and sarcomas. Menorrhagia is a common presentation and differential diagnosis. Carcinoma of the cervix, is an important lesion to identify and treat in the early stages; this is facilitated by population screening. Pregnancy is commonly accompanied by constipation, gastroesophageal reflux and urinary tract infection, and the complications of pregnancy include antipartum hemorrhage. Other conditions, such as appendicitis, can occur in pregnancy and present problems of differential diagnoses.

Obstetric injury to the pelvic floor may interfere with its normal functions of pelvic visceral support, maintaining intrabdominal pressure in straining and coughing, and directing the presenting part in labor. This may interfere with urinary and bowel continence, and present with organ prolapse.

Gynecological examination follows the same principles as that described for the alimentary tract, with a general examination of the patient, and in the abdomen, particular attention to signs in the suprapubic region. Pelvic examination is further considered below; laparoscopy originated in the gynecological field, and is used for many diagnostic and therapeutic procedures.