Approach to adnexal masses: Clinical sciences

Adnexal masses arise from the ovary, fallopian tube, or surrounding tissues. They may be cystic or solid, simple or complex, unilateral or bilateral. Most of these masses are benign, but an important diagnostic goal is to rule out malignancy. There are many types of adnexal masses, ranging from simple functional ovarian cysts to ovarian malignancy.

When a patient presents with an adnexal mass, the first step is to perform a CABCDE assessment. If the patient is unstable, control hemorrhage; stabilize airway, breathing, and circulation; obtain IV access; and monitor vital signs. Next, perform a focused history and physical examination, order an hCG to assess for pregnancy, and quickly obtain a pelvic ultrasound.

If the hCG test is positive, think about a ruptured ectopic pregnancy. In this case, the history will reveal unilateral pelvic pain, and possibly vaginal bleeding. The patient may report a history of fallopian tube injury, such as prior pelvic inflammatory disease or tubal surgery, and may report a delayed or missed last menstrual cycle. The physical examination may include abdominal or pelvic tenderness with possible rebound pain and guarding, and possibly an adnexal mass.

The ultrasound will demonstrate the absence of an intrauterine pregnancy and possibly an adnexal mass. In this case, consider an ectopic pregnancy and perform an operative laparoscopy. If on laparoscopy, you find an extrauterine pregnancy with bleeding or a ruptured fallopian tube, as well as intraperitoneal blood and clot, the diagnosis is a ruptured ectopic pregnancy.

As a clinical pearl: remember that methotrexate is contraindicated in unstable patients!

Okay, if the hCG is negative in unstable patients, they might have an adnexal torsion or a ruptured hemorrhagic cyst. The patient may report fever, nausea, and vomiting. The physical exam will reveal abdominal tenderness with possible rebound pain or guarding, and possibly a pelvic mass.

The ultrasound will show an adnexal mass, which represents an enlarged ovary, possibly with absent Doppler flow to the ovarian vessels; or free fluid in the pelvis. In this case, consider adnexal torsion or a ruptured cyst and perform an operative laparoscopy.

If the laparoscopy demonstrates an enlarged torsed ovary or adnexa, and possibly a blue or black ovary, diagnose adnexal torsion. On the other hand, if there’s evidence of bleeding from an ovarian cyst and intraperitoneal blood and clot, diagnose a ruptured hemorrhagic cyst.

Now that we’ve discussed unstable patients, let’s move on to stable patients. Start with a focused history and physical examination, an hCG to assess for pregnancy, and a pelvic ultrasound.

Here’s a clinical pearl! Transvaginal ultrasound is the most commonly used imaging technique for the evaluation of adnexal masses. On the other hand, CT, MRI, and PET are not recommended in the initial evaluation of adnexal masses. MRI may have superior ability compared with transvaginal ultrasound in correctly classifying malignant masses at the expense of a lower overall detection rate. However, MRI often is helpful in differentiating the origin of pelvic masses that are not clearly of ovarian origin, especially leiomyomas.

Okay, if the hCG is positive, first consider adnexal masses that are caused by pregnancy, such as ectopic pregnancy or a corpus luteum cyst. Remember that pregnancy does not exclude other types of adnexal masses and consider the full differential diagnosis in pregnant patients.

However, if the hCG is negative, your next step is to assess the patient's risk factors for malignancy. Risk factors include age greater than 55, a history of a family cancer syndrome like Lynch syndrome, or a family history of breast or ovarian cancer. If the patient does not have any risk factors for malignancy, consider benign adnexal masses; but keep in mind that malignancy may also occur without predisposing risk factors.

Let’s start with simple ovarian cysts. The patient is likely to be premenopausal and may present with intermittent unilateral pain and pelvic pressure. The physical examination may reveal abdominal or adnexal tenderness as well as adnexal fullness.

If the ultrasound demonstrates a thin smooth-walled cyst that does not have any septations, internal blood flow, or solid components, the diagnosis is a simple ovarian cyst.

Here’s a clinical pearl! Simple ovarian cysts, also called functional or physiologic cysts, most commonly occur in premenopausal women because they arise from unruptured ovarian follicles or degeneration of the corpus luteum. Generally, these cysts resolve spontaneously, but if they are persistent they can be managed expectantly with periodic ultrasound examinations.

Surgical intervention is indicated for cysts that cause persistent pain, or if there is a concern for malignancy such as an increase in size, development of loculations or solid components, or cyst measurement greater than ten centimeters. In addition, simple cysts may leak or rupture, resulting in acute pain. When ovarian cysts rupture the symptoms are usually self limited and do not require intervention.

Next, consider a hydrosalpinx. In this case, there may be a history of pelvic inflammatory disease or infertility, and the patient may report intermittent unilateral pain and pelvic pressure. The physical exam is likely to reveal abdominal or adnexal tenderness as well as adnexal fullness.

The ultrasound shows a dilated tubular cystic structure adjacent to the ovary that may contain incomplete septations but will not contain any solid components. These findings are diagnostic for a hydrosalpinx.