Adnexal Mass

There are multiple causes of adnexal mass development, and they can be classified as gynecologic or non-gynecologic.  

Gynecologic 

In pregnant individuals, ectopic pregnancy is a leading gynecologic cause of adnexal masses. Ectopic pregnancy occurs when an embryo implants somewhere other than in the uterine cavity, most frequently in the fallopian tube, and continues to proliferate and grow. Other causes in pregnant individuals are typically more benign and occur because of hormonal changes during pregnancy.  

In non-pregnant individuals, adnexal masses are commonly caused by functional ovarian cysts such as luteal cysts, which form on the surface of the ovary after ovulation. Notably, if the cyst is large, it increases the risk of ovarian torsion, a medical emergency that presents when the ovary rotates around its ligaments and interferes with the blood supply. Additionally, adnexal masses may present as multiple, small cysts on enlarged ovaries, called polycystic ovaries, which is characteristic of polycystic ovary syndrome (PCOS). Other adnexal masses include endometriomas, which are cysts that form when ectopic endometrial tissue grows in or around the ovaries, and borderline ovarian tumors, which refer to abnormal cell growths that are not invasive to surrounding tissues. Large superficial leiomyomas, which are benign, fibrous tumors of the uterus, can be mistaken for adnexal masses due to their adjacent location to the ovaries. Pelvic inflammatory disease or other conditions that cause tubo-ovarian abscesses, which are collections of pus in the ovaries and fallopian tubes, can also cause adnexal masses. Lastly, if the mass is suspected to be malignant, ovarian cancer is the most common cause.  

Non-Gynecologic 

On the other hand, non-gynecologic adnexal masses often originate from the gastrointestinal (GI) or urinary systems. These can include inflammatory masses of the appendix, colorectal cancer, as well as pelvic kidneys, which may occur when the kidneys do not fully ascend during fetal development or in individuals with kidney transplants. Lastly, breast and cancer of the GI tract, when spread to other organs, can metastasize in the pelvis, and create adnexal masses (e.g., Krukenberg tumor). 

When evaluating adnexal masses, history including a detailed gynecologic and family history, and physical examination are necessary.  

Moreover, a pregnancy test should be performed for every individual of childbearing age. In addition, if infection is suspected, blood tests may be performed to investigate for gonorrhea, chlamydia, and other sexually transmitted infections. Blood tests can also show elevated serum levels that may be indicative of malignancies and include tumor markers CA-125, CA 19-9, and CA 15-3. 

A pelvic examination with transvaginal ultrasound, which is when an ultrasound probe is inserted into the vaginal canal, can provide visualization of the structures of the reproductive tract, identify any masses, and estimate their size. In some cases, further imaging, such as computed tomography (CT) or magnetic resonance imaging (MRI), may be recommended. 

Treatment options for adnexal masses vary depending on the cause. Some masses can be treated conservatively, while others may require surgery.  

Observation is generally recommended when the appearance of the adnexal mass on ultrasonography suggests a benign growth. Most of the time, cysts up to 10 centimeters (approximately 4 inches) in diameter are benign and self-limiting. With appropriate follow-up, these masses can be safely monitored using imaging to identify if and when they grow or change.  

Surgical intervention is preferred for symptomatic masses or for those suspected to be malignant. For benign masses, minimally invasive techniques are the preferred method of intervention. Minimally invasive techniques include laparoscopy, which allows the surgeon to access the inside of the abdomen through small incisions in the skin, and similarly robotic surgery, where the surgeon controls the robotic arms from a console, allowing for enhanced precision and a magnified 3D view of the surgical site. In cases of larger or malignant cysts that cannot be extracted laparoscopically or robotically, open surgery may be required.