sign in sign up
<<
Home , Adnexal mass, Corpus luteum cyst, Pelvic tumor

Problems in Family Practice

The

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 , 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 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 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 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 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 , 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 (>6 cm in diame­ ovarian tumors (ie, cystic ) 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 . Ec­ the . 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 , 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 . 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 cysts. The ingestion of exogenous hormones re­ Luteoma of pregnancy sults in negative feedback on the pituitary gland to Polycystic ovaries 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 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. 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 and its effect on the Endometrial . Usually the corpus luteum cyst will Tubal carcinoma regress. Only rarely does it rupture and cause in- Nongynecologic Origin traperitoneal hemorrhage. When this does occur, Nonneoplastic however, it may create the diagnostic dilemma of Appendiceal abscess whether the patient has a ruptured corpus luteum Diverticulosis cyst or ruptured ectopic pregnancy. Both may be Adhesions of bowel and omentum associated with or irregular uterine Peritoneal cyst bleeding, an adnexal mass, progestational changes Feces in rectosigm oid of the endometrium, and intraperitoneal hemor­ Urine in bladder Pelvic kidney rhage. Pregnancy tests, laparoscopy, and ultra­ Urachal cyst sonography have been employed to differentiate Anterior sacral meningocele these conditions; however, both conditions re­ Neoplastic quire prompt exploratory laparotomy. Carcinoma The theca lutein cyst is encountered in­ Sigmoid frequently and is most often associated with ges­ Cecum tational trophoblastic disease or pregnancy. Such Appendix cysts result from the luteinization of the ovary by Bladder human chorionic gonadotropin (HCG). These Retroperitoneal cysts are usually bilateral, multicystic, and may Presacral become quite large. A decrease in HCG levels, by treatment of trophoblastic disease or completion of pregnancy, leads to spontaneous regression of the cyst. Polycystic (Stein-Leventhal fluid. These cysts usually regress through absorp­ syndrome) is usually associated with bilaterally tion of fluid or spontaneous rupture. Rupture may enlarged ovaries containing multiple, subcortical produce sudden pain in the lower abdominal area follicular cysts. Patients with this condition are and subsequent examination would reveal the ab­ typically obese, hirsute, anovulatory, infertile,

THE JOURNAL OF FAMILY PRACTICE, VOL. 14, NO. 1, 1982 137 THE ADNEXAL MASS and have irregular menses. These patients should death. Patients with lesser degrees of infection, receive a diagnostic evaluation by one trained in namely, those with pelvic peritonitis without ad­ gynecologic endocrinology and . nexal masses, also require hospitalization and in­ Endometriosis is a common cause of an adnexal tensive antibiotic therapy as the patient’s fertility mass.5 Over one half of patients with endometrio­ is at stake. sis have ovarian involvement. Endometrial cysts of the ovary, termed “,” may reach 20 cm in diameter. They are referred to as Nonneoplastic and Nonovarian Masses “ chocolate cysts” because of the thick brown Ectopic pregnancy may occur as frequently as 1 fluid they contain resulting from the degradation of in 150 pregnancies. Many such pregnancies are its bloody contents. A leaking or ruptured cyst asymptomatic when first seen; others may be may cause peritoneal irritation, dense adhesions, associated with acute symptoms and often with and pelvic organ fixation. Endometriotic involve­ shock due to intraperitoneal hemorrhage.7 There is ment of the cul de sac and uterosacral ligaments usually a history of amenorrhea, nausea, breast produces tender, nodular thickenings which may tenderness, lower abdominal pain, and vaginal be confused with the nodularity of ovarian car­ spotting. Standard urine pregnancy tests are posi­ cinomatosis. Endometriosis may “fix” the uterine tive in approximately 50 percent of the cases. The fundus in a retroverted position within the cul de newer radioimmunoassays of serum for the beta sac. The disease is common in the third and fourth subunit of HCG are positive in over 90 percent of decade and may be associated with increasingly the cases. On pelvic examination, the may severe secondary , low backache, appear cyanotic and be of soft consistency. The , irregular , and infertil­ uterine corpus may be slightly enlarged, and a ten­ ity. Diagnostic laparoscopy will define involve­ der mass may be palpable in the adnexa just lateral ment and help determine the need for medical to the . Rupture of the pregnancy causes the and/or surgical therapy. mass to be ill-defined or nonpalpable. Upon exam­ The tubo-ovarian inflammatory complex usu­ ination and palpation, the cul de sac may appear ally results from incompletely treated or unre­ full. If culdocentesis is performed, the recovery of solved subacute or chronic pelvic inflammatory nonclotting blood is presumptive evidence of in­ disease.6 Although usually thought of as being of traperitoneal hemorrhage and requires immediate gonococcal origin, it may be of multimicrobial laparotomy. Ultrasonography and laparoscopy origin due to any one of a number of aerobic or may be of help in the diagnosis of an unruptured anaerobic organisms. The inflammatory “cyst” or ectopic pregnancy. They are of little benefit once tubo-ovarian “ abscess” is not a true cyst, but is rupture has occurred. rather a walled-off area of infection surrounded by The pyosalpinx or hydrosalpinx may be unilat­ pelvic structures. Symptoms may include lower eral or bilateral and may occur as a result of sal­ abdominal and , urinary tract symp­ pingitis. A pyosalpinx represents a more acute toms, rectal discomfort, and infertility. Pelvic process with purulent material within the lumen of examination reveals either unilateral or bilateral the . It is usually present with lower adnexal or cul de sac masses which are tender and abdominal and pelvic pain, fever, leukocytosis, somewhat ill-defined. Movement of the uterus and a very tender ovoid mass. The hydrosalpinx causes pain by stretching its peritoneal attach­ develops as a result of the partial resolution of a ments. Occasionally, the abscess will occur as a pyosalpinx or as a result of the sealing off of either fluctuant mass above the inguinal ligament or in end of the fallopian tube and the continued se­ the cul de sac and upper rectovaginal septum. In cretion of its mucosal lining. Usually, the hydro­ either case, surgical drainage is indicated. A more salpinx is asymptomatic; however, it may be acute inflammatory process may be present with associated with chronic pelvic pain, dyspareunia, high fever, chills, leukocytosis, diarrhea, and and a sense of pelvic fullness or pressure. ileus. The toxic patient requires hospitalization, Congenital anomalies of the mullerian system frequent evaluation, and intensive therapy as in- and vestigal remnants of the wolffian system traperitoneal leakage or rupture of a pelvic abscess should be considered in the differential diagnosis may cause generalized peritonitis, shock, and of the adnexal mass. The bicornuate uterus may be

138 THE JOURNAL OF FAMILY PRACTICE, VOL. 14, NO. 1, 1982 THE ADNEXAL MASS

Table 2. Clinical Findings Suggestive of Benign abdominal fullness or pelvic discomfort due to or Malignant Adnexal Masses pressure on adjacent organs such as the bladder or rectum. Large masses rise out of the true pelvis Benign Malignant and may cause abdominal enlargement with var­ icosities and edema of the lower extremities. Pain Unilateral Bilateral is an uncommon symptom and is usually due to an Cystic Solid Mobile Fixed accident such as degeneration, torsion, infarction, Smooth Irregular or impaction deep within the pelvis. The majority No ascites Ascites of ovarian neoplasms are asymptomatic until they Slow growth Rapid growth become quite large, unless they undergo one of the Young patient Older patient accidents referred to, or if malignant, they invade contiguous structures or metastasize. Compres­ sion against the urinary and intestinal systems may result in symptoms of urinary frequency, inconti­ nence, constipation, and pain on defecation. Tor­ mistaken for an adnexal mass and a blind uterine sion and infarction are associated with pain, horn may cause cyclic pain because of a develop­ nausea, abdominal distention, and fever9 and re­ ing . Hysteroscopy, hysterosalpin- quire immediate laparotomy. Functioning ovarian gography, laparoscopy, and/or laparotomy may be tumors rarely may be associated with precocious required. puberty, menstrual irregularities, postmenopausal bleeding, virilization, or masculinization.10 The cystic teratoma, or dermoid cyst, is an un­ Neoplastic Ovarian Masses usual benign ovarian neoplasm frequently dis­ Ovarian neoplasms are either benign or malig­ covered during the initial pelvic examination of a nant. Although no one characteristic is indicative young patient. The cyst is usually asymptomatic, of either a benign or a malignant neoplasm, the often bilateral, frequently anterior to the uterus, association of clinical findings given in Table 2 can and may contain calcifications or teeth. Treatment help distinguish these two groups. involves surgical removal of the cyst with preser­ Ovarian neoplasms in the reproductive age vation of the ovary in these young patients. group which are unilateral, cystic, and less than 6 Ovarian carcinoma is rarely diagnosed in the cm in diameter are likely to be benign and may be truly asymptomatic patient in a routine pelvic observed for regression over a period of six to examination. Vague symptomatology, especially eight weeks. Persistence after this period of time of gastrointestinal origin, such as bloating, flatu­ requires further evaluation. All ovarian neoplasms lence, indigestion, or abdominal fullness, should that are solid or greater than 6 cm in diameter suggest the possibility of ovarian carcinoma and require immediate investigation. Ovarian enlarge­ the need for a thorough pelvic examination. Un­ ment in the premenarchal or postmenopausal fortunately, patients when first seen often have female must be investigated promptly, since the evidence of ascites and metastatic disease. Ascites ovaries are not undergoing cyclic function and for in the female should be considered to be due to physiologic reasons, should not be enlarged.8 The ovarian carcinoma until proven otherwise. Para­ postmenopausal ovary is usually small and centesis is not recommended as it may rupture a atrophic and, if palpable, is statistically suspect for large cyst, mimicking ascites, and disseminate containing a malignancy. This association has be­ malignant cells. Patients who are suspected of hav­ come known as the postmenopausal palpable ing ovarian carcinoma should be investigated ovary (PMPO) syndrome. It requires prompt in­ promptly, utilizing sigmoidoscopy, cystoscopy, vestigation as most ovarian occur after intravenous pyelography, barium enema, and in menopause. selected cases, ultrasonography and computerized Symptoms of ovarian neoplasms are usually tomography in preparation for staging laparotomy.11 dependent on their size, rate of growth, and posi­ Laparotomy should be performed by a surgeon tion within the pelvis or abdomen. Initial symp­ familiar with gynecologic surgery for malignant toms are somewhat vague and consist of lower disease.

THE JOURNAL OF FAMILY PRACTICE, VOL. 14, NO. 1, 1982 139 THE ADNEXAL MASS

The recommended classification of ovarian presented. While each patient requires individual tumors is that of the World Health Organization management, some broad recommendations can and is based on histologic criteria. be made. In general, expectant management is justified only when an asymptomatic physiologic cyst is suspected. Most other categories require Neoplastic Nonovarian Masses prompt investigation in varying degrees; nonneop- The leiomyoma, or “fibroid,” is a common, lastic, infectious, benign neoplastic or obstetrical benign pelvic tumor of smooth muscle origin aris­ processes may require general gynecologic con­ ing in the uterus. These tumors usually cause the sultation because of the high proportion of patients uterus to become nodular and often become so that will require gynecologic surgery of some enlarged that it presents an abdominal mass. Sub- variety for definitive diagnosis and treatment. serous myomas may become pedunculated and In addition, patients with endometriosis and form an adnexal mass. Such masses are solid, tubal disorders may require subspecialty consul­ readily moveable, and nontender. The myomas tation with a reproductive endocrinologist, espe­ may grow to such size so as to cause pressure on cially when reproductive potential is at stake. the bladder and produce urinary frequency and Those patients considered to have malignant urgency. Pressure on the colon by the myomas disease require extensive evaluation, staging, and may produce constipation and pain on defecation. treatment. In these patients, subspecialty consul­ Infarction of the myoma often produces acute tation with a gynecologic oncologist should be pain, nausea, vomiting with fever, and a patient considered. who appears severely ill. Submucous and intra­ While diagnostic tools, including radiologic mural leiomyomas may cause significant menor­ studies and laboratory determinations may be of rhagia. The inability to distinguish a leiomyoma valuable assistance in the differential diagnosis of from an ovarian tumor on pelvic examination is an the adnexal mass, these cannot replace a pertinent indication for additional diagnostic procedures, medical history, a thorough pelvic examination, including surgery. Patients with leiomyomas lo­ and comprehensive knowledge of pelvic pathol­ cated so as to preclude adequate palpation of the ogy. ovaries should be considered candidates for myomectomy or hysterectomy. Paraovarian cysts, both benign and malignant, may arise from wolffian remnants within the broad ligament and form adnexal masses. These must be References evaluated, usually by laparotomy. 1. Kajanoja P, Procope BJ: Nongenital pelvic tumors found at gynecologic surgery. Surg Gynecol Obstet Extension of metastasis of endometrial or cer­ 140:605, 1975 vical carcinoma may form an adnexal mass. These 2. Fleischer AC, James AE Jr, Millis JB, et al: Differen­ masses are usually hard, nodular, and inseparable tial diagnosis of pelvic masses by gray-scale sonography. Am J Roentgenol 131:469, 1978 from the uterus. These patients usually have ir­ 3. Creasman W T: The adnexal mass: Its diagnosis and management. Contemp Ob/Gyn 9:45, 1977 regular uterine bleeding and can be diagnosed by 4. Servo SF, Scully RE, Sobin LH: Histologic Typing of fractional dilatation and curettage or cervical Ovarian Tumors. International Histological Classification of Tumors, No. 9. World Health Organization, Geneva, 1974 biopsy. Carcinoma of the fallopian tube is a rare 5. Buttram VC, Betts JW: Endometriosis. Curr Probl lesion but can be detected as an adnexal mass. It Obstet Gynecol 11 (2):1, 1979 6. McNamara MT, Mead PB: Diagnosis and manage­ can be diagnosed by laparoscopy or laparotomy ment of the pelvic abscess. J Reprod Med 17:299, 1976 and is usually found in the elderly patient in the 7. Halpin TF: Ectopic pregnancy: The problem of diagnosis. Am J Obstet Gynecol 106:227, 1970 sixth and seventh decade of life. The management 8. Barber HRK, Graber EA: Managing ovarian tumors of fallopian tube malignancies is similar to that of of childhood and adolescence. Contemp Ob/Gyn 3:123, 1974 ovarian . 9. Lomano JM, Trelford JD, Ullery JC: Torsion of the uterine adnexas causing an acute abdomen. Obstet Gynecol 35:221, 1970 10. Laverty CRA, Brown JB, Fortune DW: Hormonal Summary function of ovarian tumors. Contemp Ob/Gyn 5:77, 1975 11. Griffiths CT, Grogan RH, Hall TC: Advanced ovarian Guidelines for the diagnosis and management of cancer: Primary treatment with surgery, radiotherapy and the adnexal mass in the female patient have been chemotherapy. Cancer 29:1, 1972

140 THE JOURNAL OF FAMILY PRACTICE, VOL. 14, NO. 1, 1982