Adnexal Masses in Adolescents
May 2009 – by R. Schenken, MD
The prevalence of adnexal masses in adolescents is unknown, but they are relatively uncommon. Only about 6% of ovarian neoplasms are found in adolescents and less than 25% of these are malignant.1,2 Non-neoplastic lesions account for 75-98% of adolescent adnexal masses detected by ultrasound.1,2
Adnexal masses can arise from the ovaries and other pelvic structures. The differential diagnosis includes:
- Ovary: functional cysts (follicular, corpus luteum); endometriosis; benign neoplasms (teratomas, serous and mucinous cystadenoma); and malignant neoplasms (germ cell, sex-cord or stromal tumor, epithelial carcinoma); torsion
- Tube: tubo-ovarian abscess, hydrosalpinx, ectopic pregnancy.
- Vaginal/Uterus: Anomalies (oblique vaginal septum, Mullerian anomalies)
- Gastrointestinal: appendiceal abscess
- Other: Paratubal cysts, peritoneal inclusion cysts, pelvic kidney
Adolescents with adnexal masses usually present with symptoms. Abdominal pain is the most common followed by distention, nausea and vomiting, abdominal distention, and endocrine manifestations such as precocious puberty, uterine bleeding, amenorrhea, or virilization. Palpable abdominal or pelvic masses are present in 55-83%.3 A careful assessment of the patient's pain is essential. Cyclic monthly pain suggests vaginal or uterine anomalies. Acute pain suggests torsion, ruptured or hemorrhagic ovarian cyst, ectopic pregnancy, tubo-ovarian or appendiceal abscess. Disruption of menstrual cyclicity, sexual activity, contraceptive practices and sexually transmitted disease exposure should be discussed. Pelvic exam is often impossible or inadequate in virginal adolescents or those with severe pain. It may be possible to palpate the adnexa on rectal exam. Relevant laboratory testing may include _ -HCG, CBC, gonorrhea and chlamydia screening, and tumor markers. Imaging modalities are critical in the evaluation and may include ultrasound, CT scans, or MRI. Ultrasound can be transvaginal or transabdominal, with the latter preferred in virginal patients. Morphologic scoring systems to assess malignant potential may be used, but they have not been validated in adolescents. Most assign low risk scores to ultrasound findings of sonolucent cysts with smooth walls and absence of thick septations and solid components. MRIs are the preferred imaging modality for suspected vaginal and uterine anomalies.
Management of suspected functional ovarian cysts is expectant with serial ultrasound imaging. Oral contraceptives do not hasten resolution of existing cysts. Patients with suspected hemorrhagic functional cysts may also be followed if clinically stable and pain is medically manageable. Suspected torsion requires surgical intervention to preserve ovarian function if possible and because other disorders are found in over one-half of patients with a diagnosis of torsion.4 Endometriomas require surgical removal as medical therapy will not significantly decrease their size. Neoplasm requires surgical intervention and a gynecologic oncologist should be involved when imaging suggests a malignancy. Pelvic infections are managed with antibiotics and surgical intervention when indicated. Hydrosalpinx may be managed expectantly if it has the characteristic ultrasound appearance of a sonolucent, elongated, extraovarian structure. Ectopic pregnancy may be managed with methotrexate or surgical intervention in patients with contraindications to medical management. Anomalies resulting in menstrual outflow obstruction and appendiceal abscesses are managed surgically. Paratubal and inclusion cyst appearing as extraovarian, sonolucent structures may be followed with serial ultrasound imaging.
- Kanizsai B, Orley J, Szigetvari I, et al. Ovarian cysts in children and adolescents: Their occurrence, behavior, and management. Journal of Pediatric and Adolescent Gynecology 1998; 11:85.
- Wu A, Siegel MJ. Sonography of pelvic masses in children: Diagnostic predictability. American Journal of Roentgenology 1987; 148:1199.
- Pfeifer SM, Gosman GG. Evaluation of adnexal masses in adolescents. Adolescent Gynecology, Part I: Common Disorders 1999; 46(3):573-592.
- Hibbard LT. Adnexal torsion. American Journal of Obstetrics and Gynecology 1985; 152:456.