Ovarian cysts, cancer, and other adnexal masses: Clinical

Adnexal masses can affect the ovary or the fallopian tube. They can develop in females of all ages, and can be discovered incidentally during a pelvic ultrasound, or when they cause symptoms like pain or pressure on the affected side.

When encountering an adnexal mass the first step is to assess whether or not it’s a medical emergency, and, if it’s not, whether the mass is benign or malignant.

Medical emergencies are adnexal masses that cause severe and abrupt pain, along with other symptoms like nausea, vomiting, fever, or vaginal bleeding.

In addition, any kind of pelvic pain or bleeding in a pregnant female during her first trimester is considered a medical emergency - so the first step is to get a pregnancy test.

If the pregnancy test is negative, the likely causes are ovarian torsion, a ruptured ovarian cyst, and a tubo-ovarian abscess.

In ovarian torsion, the ovary twists around the suspensory ligament, which suspends the ovary and contains the ovarian blood vessels within it.

Risk factors include an ovarian mass - like a cyst or cancer, and an ovary greater than 5 centimeters in diameter.

In both cases, twisting the vessel cuts of the blood supply to the ovary - causing ovarian ischemia.

An ultrasound may show that one ovary is larger than the other one, because of edema and blood pooling up in the ovarian veins, and the affected ovary might look like a twisted mass.

A Doppler ultrasound shows decreased or absent blood flow within the ovary, and the “whirlpool sign” may be present, which is when blood flow inside the ovarian vessels seems to flow in a spiral around a central axis.

Urgent surgical detorsion of the ovary is required to avoid ischemic injury and loss of the ovary and fallopian tube.

Ovaries that are hemorrhagic or edematous are more likely to be viable, than necrotic appearing ovaries.

If the ovary can’t be saved, a unilateral salpingo-oophorectomy is often done. That’s where the affected ovary and fallopian tube are removed.