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.