A4. Benign adnexal masses; classification, diagnosis and therapy

Definition and epidemiology

An adnexal mass is a mass of the ovary, fallopian tube, or the surrounding connective tissue. It’s a common gynaecological problem. Adnexal masses may be malignant and so it’s important to evaluate them to determine whether it is benign or malignant.

The patient may present with gynaecological symptoms like pelvic pain or pressure, or an incidentally discovered mass.

The following conditions can form adnexal masses:

  • Benign
    • Ovarian cysts
      • Functional cyst
      • Corpus luteal cyst
    • Benign ovarian tumours
    • Ectopic pregnancy
    • Hydrosalpinx
    • Tubo-ovarian abscess
  • Malignant
    • Ovarian cancer
    • Fallopian tube cancer
    • Metastasis from stomach, breast

Only the benign ones will be discussed here.

Evaluation and diagnosis

As always, history and physical examination is important. Patients should be asked about symptoms of malignancy, like changes in urination, abdominal distension, early satiety, pelvic pain, etc.

The first choice for imaging is ultrasound, both transvaginal and transabdominal. MRi may also be used.

Features which suggest malignancy include large size (> 10 cm), solid masses, nodular masses, and thick septations. Features which suggest benignity include anechoic unilocular fluid-filled cysts with thin walls.

If imaging can’t rule out a malignancy, surgical exploration is performed to make a definitive diagnosis. Adnexal masses can’t be biopsied because it could cause cancer dissemination if it is malignant, so the adnexal mass must be removed by hysterectomy with bilateral salpingo-oophorectomy.

Ovarian cysts

There are many types of ovarian cysts. The most common are the functional cysts and corpus luteal cyst. Their benignity can usually be determined on ultrasound.

Functional or physiological cysts are formed when the Graafian follicle does not rupture but continue to grow. They are common in young women and are smooth, thin walled, and unilocular on ultrasound.

Corpus luteal cysts, also called a lutein cysts, are formed when fluid builds in the corpus luteum. There are two types, granulosa lutein cysts and theca lutein cysts. They’re associated with progesterone-only contraceptive pills and fertility drugs like clomiphene. They have thicker walls and may contain haemorrhage.

Functional and corpus luteal cysts are generally asymptomatic and spontaneously resolve within a few weeks. If they rupture, become haemorrhagic, or torsion occurs, they may cause acute pain.

Benign ovarian tumours

Benign ovarian tumours may originate from ovarian surface epithelium, germ cells, or sex cord-stromal cells. The most common benign ovarian tumours are mature teratoma (dermoid cyst), serous cystadenoma, and mucinous cystadenoma. Other types include:

  • Brenner cell tumours
  • Sex cord stromal tumours
    • Granulosa cell tumours – produce oestrogens
    • Thecomas
  • Ovarian fibromas

It is often difficult to differentiate benign ovarian tumours from malignant based on imaging. In uncertain cases, it’s better to be safe than sorry, so the ovaries should be removed surgically and examined histologically.

Tubo-ovarian abscess

A tubo-ovarian abscess usually presents with acute lower abdominal pain, fever, chills, vaginal discharge, and an adnexal mass. It’s usually a complication of pelvic inflammatory disease (PID).

We can treat it with antibiotics with or without ultrasound-guided drainage or surgery.


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A5. Adnexal inflammatory diseases; diagnosis, differential diagnosis, and therapy

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