An ectopic pregnancy is seen as a hyperechoic mass immediately adjacent to, but separate from, the ovary. The ectopic is labeled with the arrow and is to the right of the normal appearing ovary (corpus luteum present).
Adnexal torsion
Another gynecologic pelvic mass presenting as an emergency is adnexal torsion. Patients experiencing torsion usually have acute onset of pain, often with nausea and vomiting. They may have signs of peritoneal irritation such as rebound or guarding. The overall prevalence is about 2.7%.[9] Torsion occurs more commonly on the right.[9] Adnexal pathology is present in about 50%–80% of torsed adnexa.[9] In the setting of torsion, the ovary tends to have a rounder, more edematous appearance with increased volume (Figure 19-2). The use of Doppler flow imaging alone to make the diagnosis of adnexal torsion is unreliable and clinical judgment should always be used over Doppler studies. Doppler flow studies are very sensitive; when flow is absent, this is essentially diagnostic. However, when flow is present, there is a high false negative rate. In studies of surgically confirmed ovarian torsion, up to 60% had blood flow present on Doppler studies.[10, 11]
A torsed adnexa without an obvious ovarian mass. The ovary is abnormal in its size, shape, and edematous appearance. It is uniformly hyperechoic and does not have crisp borders typically seen with a normal ovary.
Once the diagnosis is made, prompt intervention is needed to save the ovary and prevent future sequelae including necrosis, febrile illness and potential sepsis. Laparoscopic surgery is recommended with untwisting of the adnexa. The decision to remove any associated pathology after detorsing the adnexa can be a difficult one. Most associated cysts are physiologic and do not require removal. When a pathologic cyst is present, such as with a mature teratoma, it is beneficial to the patient to have the lesion removed to prevent recurrence. Surgery on ischemic and edematous adnexa can, however, result in bleeding. The bleeding risk must be weighed against the risk of recurrence and the risk of a second operative procedure if removal is delayed as some authors suggest.[11] Once the adnexa is detorsed, the return of ovarian function is quite good even if the intraoperative appearance is worrisome. In a review of five studies looking at subsequent ovarian function as measured by follicular development, subsequent appearance on ultrasound, as well as function during ovarian stimulation, 88%–100% of detorsed ovaries regained normal function.[11]
Tubo-ovarian abscess
A tubo-ovarian abscess (TOA) may be diagnosed in an acutely ill patient. TOAs are typically found in patients presenting with acute pelvic inflammatory disease (PID). Physical exam findings include fever, cervicitis, cervical motion tenderness, and abdominal pain. The patient may have a palpable mass in the adnexa. Imaging of the adnexa may show a pyosalpinx; this is a dilated tubular structure filled with complex fluid. Typically, pyosalpinx is seen by transvaginal ultrasound with an estimated sensitivity ranging from 83% to 93%.[12, 13] Pelvic inflammatory disease complicated by tubo-ovarian abscess requires inpatient admission and intravenous antibiotic therapy. If the patient does not improve, surgical drainage may be necessary. It is important to recognize this type of pelvic mass because the diagnosis of TOA excludes the possibility of outpatient management and necessitates inpatient parenteral treatment for PID.
Nonemergent management of pelvic mass
Uterine myomas
The most common pelvic masses are uterine myomas. The etiology, diagnosis, and management of uterine leiomyomata will be discussed in detail in Chapter 20. It is important to consider uterine myoma in the differential diagnosis of a uterine mass, but they should also be considered when a mass is located adjacent to the uterus, or even in the adnexa as pedunculated myomas are often confused with complex ovarian masses.
Nonovarian adnexal masses
Several other adnexal masses do not arise from the ovary such as paratubal cysts, hydrosalpinx, or tubo-ovarian abscess. Paratubal cysts are simple, thin walled cystic structures in the adnexa that appear to be separate from the ovary. On exam, they are nearly impossible to differentiate from an ovarian cyst, but on ultrasound imaging, they move separately from the ovary. They are typically stable over time or slow growing and are less likely to regress than a simple ovarian cyst. Hydrosalpinx is a dilated tube, typically seen as filled with simple fluid on ultrasound. These are difficult to palpate on physical exam, and are typically asymptomatic. Hydrosalpinx can arise from prior pelvic infection with tubal damage, such as a prior tubo-ovarian abscess, prior ectopic pregnancy or from prior tubal surgery. Uterine myomas can also be present at the uterine cornual region or in the broad ligament and can be interpreted as adnexal masses. Physical exam is helpful in these patients as the mass will be solid, smooth, and firm, and it will move in conjunction with the uterus.
Ovarian masses
Ovarian masses can be seen at the time of imaging for a suspected mass palpated during an exam, or are often found incidentally when the pelvis is imaged for another reason. The differential diagnosis for ovarian masses is broad and cannot be covered comprehensively in this chapter, but the most common ovarian masses will be reviewed. When evaluating an ovarian mass, it is important to first classify the mass as physiologic or pathologic.
Physiologic ovarian cysts
Examples of physiologic or functional cysts include dominant follicles, corpus lutea, or hemorrhagic corpus lutea. These are the most commonly seen cysts during an ultrasound. Although normal, they are typically commented on by the interpreting physician, and the information is subsequently relayed to the patient. This can cause anxiety for the patient as these common cysts are often interpreted as being abnormal. Physiologic cysts, however, simply illustrate that the ovary is working properly, producing dominant follicles and ovulating. In this situation, reassurance can be given to the patient. The vast majority of simple cysts of the ovary resolve without intervention. Modesitt, et al. followed nearly 3,000 unilocular ovarian cysts in postmenopausal women. In those with simple cysts less than 10 cm, none developed ovarian cancer and nearly all resolved spontaneously.[14] It is suggested that simple cysts less than 5 cm do not even need repeat imaging. If the diagnosis of a physiologic cyst is less clear, or if the cyst is complex due to hemorrhage within the cyst (Figure 19-3), repeat imaging with expectant management should be the treatment of choice rather than any other intervention. Ovulation suppression should be considered if these cysts are bothersome to the patient. The recommended interval of reimaging is somewhat controversial, but most suggest around 8–12 weeks allowing time for the functional cyst to resolve completely.
Hemorrhagic cyst.
Pathologic ovarian masses – benign
A wide variety of benign masses of the ovary exist. The most common are mature cystic teratomas, endometriomas, fibromas, and cystadenomas. Each of these has a different appearance on ultrasound, findings on exam, and management.
Mature cystic teratomas, also called dermoids, are the most common benign ovarian mass seen in the premenopausal patient. They are filled with tissue from every germ cell line, giving them classic findings of internal fat, hair, and even teeth (Figure 19-6). On exam, they are usually mobile, smooth walled, and can range in size from a few centimeters to more than 10 cm. They are bilateral about 15% of the time; bilaterality should be taken into consideration when performing a physical exam and reviewing imaging studies. Because they are filled with dense tissue, mature teratomas have a higher risk of torsion than some other masses and should be removed.
Endometriomas are often diagnosed as part of the workup for clinically significant endometriosis. In patients with dysmenorrhea, a physical exam with a fixed, painful pelvic mass is suspicious for an endometrioma. These are commonly palpated in the posterior cul de sac, and are sometimes best examined with a recto-vaginal exam. On ultrasound imaging, they are filled with homogenous low-level echoes without vascularity (Figure 19-4). The homogenous material seen on ultrasound is old blood, which is seen surgically as a “chocolate cyst.” The differential diagnosis of this type of mass should include a hemorrhagic cyst as these can sometimes have a similar appearance. Reimaging of this type of cyst is recommended, and if persistent, the diagnosis of endometrioma can presumptively be made. No intervention is needed if a patient is asymptomatic. However, if the woman is symptomatic, surgery may be necessary to remove the endometrioma with fulguration of any other implant areas for pain relief.
Endometrioma.
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