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Problems in Family Practice the Adnexal Mass

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Problems in Family Practice the Adnexal Mass Problems in Family Practice The Adnexal Mass Don J. Hall, MD, and W. Glenn Hurt, MD Knoxville, Tennessee, and Richmond, Virginia Accurate diagnosis of the adnexal mass requires knowledge of embryology, anatomy, and physiology. Bimanual pelvic exam­ ination remains the primary and most practical means of de­ tecting and evaluating adnexal pathology. Selective use of diagnostic techniques will help determine the nature and ex­ tent of involvement. Prompt and specific diagnoses facilitate therapy and improve results. The uterine adnexae consist of ovaries, fallo­ various diagnostic possibilities, gynecologic and pian tubes, and uterine ligaments. Although most nongynecologic, and consider each in logical se­ adnexal pathology originates within one of these quence.1 It is the purpose of this article to present structures, it is often bilateral and found to involve a practical approach to the diagnosis and manag- contiguous tissues. A knowledge of embryology, ment of adnexal masses of gynecologic origin. pelvic anatomy, physiology, and gynecologic en­ docrinology and oncology is essential if one is to detect, diagnose, and treat adnexal pathology. Bimanual pelvic examination is the most practi­ Physical Examination cal means of screening for adnexal mass. Empha­ It is essential that a patient empty her bladder sis must be placed on early detection, expecially in before having a pelvic examination. She should be cases of ectopic pregnancy and ovarian tumors, if positioned on the examining table and appropri­ morbidity is to be reduced and the survival rate ately draped. Examination of the external genitalia improved. Adjunctive diagnostic techniques may is followed by an internal visual examination using be helpful but should not be used in an indiscrimi­ adequate lighting and speculum of proper size. nate manner. Correlation of data should produce a Then a bimanual, abdominal-vaginal-rectal exam­ specific diagnosis and should help in formulating ination should be performed in a systematic man­ the therapeutic approach. ner so as to palpate all pelvic organs for size, Primary care physicians are responsible for the shape, consistency, position, mobility, and the detection of adnexal pathology. They should insist presence or absence of tenderness. The cul de sac, on routine pelvic examinations and be competent rectovaginal septum, and pelvic side walls must be in performing them. They must be aware of the palpated for their contents, lymph nodes, or abnor­ mal masses. Pathologic findings should be described in detail, using scientific terminology. Diagrams may From the Departments of Obstetrics and Gynecology, Uni­ be helpful. versity of Tennessee College of Medicine, Knoxville, Ten­ Subsequent reexamination of the pelvis may be nessee, and Medical College of Virginia, Virginia Com­ monwealth University, Richmond, Virginia. Requests for necessary for technical reasons or if the patient is reprints should be addressed to Dr. Don J. Hall, Department uncooperative. If the rectum is filled with feces, of Obstetrics and Gynecology, University of Tennessee Col­ lege of Medicine-Knoxville, 1924 Alcoa Highway, Knox­ the bowel should be evacuated with a laxative or ville, TN 37920. enema prior to reexamination. If the patient is un- 0094-3509/82/010135-06$01.50 ® 1982 Appleton-Century-Crofts THE JOURNAL OF FAMILY PRACTICE, VOL. 14, NO. 1: 135-140, 1982 135 THE ADNEXAL MASS cooperative, obese, or otherwise difficult to exam­ pelvic masses. It is the procedure of choice in ine, the opinion of a second examiner may be evaluating ovarian pathology because of its ability helpful. The examination may be conducted while to distinguish cysts from complex and solid mas­ the patient is anesthetized, or one of the newer ses. It cannot, however, provide a histologic diag­ imaging techniques, such as ultrasonography, may nosis, nor is it a substitute for proper surgical be used. management or pelvic examination. The size, configuration, and consistency of pal­ Computerized tomography will detect and pable masses may be determined. Inspection, aus­ measure pelvic masses of 2 cm or greater in diame­ cultation, percussion, and palpation of the abdo­ ter with precision. It offers an advantage over ultra­ men is necessary to evaluate bowel function, to sonography in the visualization of bowel, ureters, determine direct, indirect, or rebound tenderness pelvic musculature, and bone. The technique or rigidity, and to demonstrate the presence or ab­ has proved especially useful in gynecologic oncol­ sence of ascites. ogy because it defines the extent of paracervical and parametrial involvement, determines the re­ sectability of neoplasms, and can be used to direct Diagnostic Techniques fine needle biopsy. Obese patients are more easily Although the pelvic examination remains the studied by computerized tomography, which can primary means of detecting adnexal masses, diag­ be used to assess resolution of the pathological nostic techniques are available for locating and process following therapy. It has the disadvantage further defining the pathological process. To the that imaging is accomplished by using ionizirtg information obtained by sigmoidoscopy, barium radiation. enema, and intravenous urography now can be added information from laparoscopy, ultrasonog­ Adnexal Masses raphy, and computerized tomography. Adnexal masses may be of gynecologic or of Patients with lower bowel complaints or pelvic nongynecologic origin. In either circumstance, it is masses are candidates for sigmoidoscopy and of primary importance to determine whether they barium enema. Intravenous urography is part of are of a neoplastic or nonneoplastic variety.3 In the evaluation of patients with urinary symptoms the case of gynecologic masses, it is also important and pathologic masses within the pelvis. Plain to know if the mass is of ovarian origin, for patho­ films of the pelvis may detect calcifications within logical enlargement of the ovary (>6 cm in diame­ ovarian tumors (ie, cystic teratomas) and ter) must be considered potentially malignant until leiomyomas. proven otherwise. Laparoscopy is of value in determining the na­ A classification of adnexal masses is given in ture of pelvic disease, the presence of intraperito- Table 1, and it will serve as an outline for the neal extension, and the presence of ascites. further discussion of this topic. Specimens may be obtained for histologic and cytologic evaluation. In general, laparoscopy is ill-advised if there is a definite indication for ex­ Nonneoplastic Ovarian Masses ploratory laparotomy. Physiologic ovarian cysts occur frequently be­ Pelvic ultrasonography is an accurate means of cause the ovary is a dynamic organ with cyclic determining the location, size, extent, and consis­ function. The preovulatory ovary contains graa­ tency of pelvic masses.2 It is capable of detecting fian follicles, and the postovulatory ovary contains obstructive uropathy, ascites, and metastasis. Ec­ the corpus luteum. Failure of the graafian follicle topic and intrauterine pregnancies can be detected to rupture or regress may lead to the development and differentiated. The technique may be used to of a follicular cyst, whereas failure of the corpus assess the results of therapy. The ultrasonic exam­ luteum to regress in a nonpregnant patient may ination is rapidly performed, does not expose the lead to the development of a corpus luteum cyst. patient to ionizing radiation, and is readily avail­ Follicular cysts are usually less than 6 to 8 cm in able in most medical centers. Since it can be per­ diameter and may cause menstrual irregularities. formed in any body plane, it is the preferred They are smooth surfaced, mobile, slightly tender screening technique for determing the presence of upon palpation, and are filled with a straw colored 136 THE JOURNAL OF FAMILY PRACTICE, VOL. 14, NO. 1, 1982 THE ADNEXAL MASS Table 1. Classification of Adnexal Masses sence of the cyst. If the cyst is less than 6 cm in diameter, it may be managed conservatively with Gynecologic Origin biweekly examinations until regression is docu­ Nonneoplastic mented. If regression fails to occur during six Ovarian weeks of observation, or if enlargement occurs, Physiologic cysts exploratory laparotomy is indicated. Some au­ Follicular thors have advocated the use of oral contracep­ Corpus luteum tives for treatment in patients with functional Theca lutein cyst cysts. The ingestion of exogenous hormones re­ Luteoma of pregnancy sults in negative feedback on the pituitary gland to Polycystic ovaries Endometriosis decrease gonadotropin stimulation of the ovary Inflammatory cysts and assist regression of the cyst. A patient taking Nonovarian oral contraceptives rarely develops a physiologic Ectopic pregnancy cyst. The presence of an ovarian cyst in a patient Congenital anomalies on oral contraceptives is reason for concern and Embryologic remnants should be investigated, as this patient should not Tubal be ovulating and is incapable of forming either fol­ Pyosalpinx licular or corpus luteum cysts. Hydrosalpinx The corpus luteum cyst occurs less frequently Neoplastic and will vary in size, depending on the amount of Ovarian (see WHO classification4) hemorrhage within the cyst. It is often associated Nonovarian Leiomyoma with menstrual irregularities due to the prolonged Paraovarian cyst secretion of progesterone and its effect on the Endometrial carcinoma endometrium. Usually the corpus luteum cyst will Tubal carcinoma regress. Only rarely does it rupture and cause in- Nongynecologic
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