KEY POINTS:
- Adnexal mass can be painful or painless (when painless often found incidentally on imaging)
- Urgent surgical intervention is indicated for
- Suspicion of ovarian torsion (less likely if mass < 6cm)
- Concern for bleeding (hemorrhagic cyst and evidence of free fluid)
- Concern for ectopic pregnancy (see ‘Related Topics’ below)
- Diagnostic characteristics that are helpful
- Flow to ovary on U/S (presence of flow does not rule out periodic torsion, and lack of flow is only suggestive of torsion, ovarian torsion is a clinical and surgical diagnosis)
- Simple vs complex cyst
- Solid components, presence of nodules, septae, papillations
- Size of cyst/mass
- Previous imaging for comparison
- Patient age and menstrual status
- Current fertility treatment or recent IVF
- Signs of free fluid or ascites in pelvis/abdomen
- Known gyn conditions such as endometriosis
- Signs of infection (see ‘Related Topics below’)
- History of bowel disorder
- Ovarian (adnexal) torsion is a surgical emergency
- Signs include: Severe, sudden onset abdomino-pelvic pain | Rigid abdomen | Nausea | Vomiting |Elevated WBC | Fever (sometimes present)
- Prompt intervention can usually save the ovary/adnexa
- The adnexa should always be untwisted, any cysts removed; oophoropexy can be considered but is not standard of care
- Even if the ovary appears necrotic, generally it will recover with re-establishment of blood flow | Routine oophorectomy is not standard of care
- Non-painful incidental adnexal mass is not a surgical or GYN emergency and can be evaluated and treated as outpatient
BACKGROUND:
- Masses that present as pain in ER and are managed emergently differ by age
Pre-Pubescent and Adolescent Patients
- High proportion of ovarian masses are torsion or malignancy (Oltmann et al. J Pediatr Surg, 2010)
- 30% of ovarian torsions are in adolescents (Ashwal et al. Obstet Gynecol, 2015)
- Can also see pain with Mullerian anomalies and onset of menses if non-communicating (remnant uterine horn, high vaginal septum)
Premenopause
- Torsion is suspected whenever the mass is >6 cm
- Pregnancy related adnexal masses can present with localized or diffuse abdominal pain
- Ectopic pregnancy (see ‘Related Topics’ below)
- Corpus luteum cyst: Larger in early pregnancy, will recede | Often diagnosed in setting of bleeding and pain in early pregnancy, are not a source of pain
- Theca lutein cysts: Seen primarily in women with ovarian hyperstimulation, IVF cycles, but can be seen in multiple gestation or molar pregnancy | Can be associated with diffuse abdominal pain and significant bloating
- Other gyn diagnoses on the differential in this age group include
- Hemorrhagic cyst
- Endometrioma
- Mullerian anomaly
- Necrosing pedunculated leiomyoma
- Less likely to cause pain, but could be incidental finding
- Functional cyst
- Dermoid cyst
- Cystadenoma
- Leiomyoma
- Infectious
- TOA (see ‘Related Topics’ below)
- Bowel disorder
- Appendicitis
- Diverticulitis
Postmenopause
- With an ovarian mass, cancer must be considered and ruled out
- Unless urgent surgical abdomen, this is best referred to GYN oncology
- According to SEER data the average age at diagnosis of ovarian cancer is 63, and 69.4% of women are >55 years at diagnosis (ACOG PB 174)
- Features of concern: size >10 cm | Complexity | Solid components | Free fluid/ascites | Flow on color doppler | Symptoms (bloating, abdominal distention) | Anorexia | Bowel obstruction)
- Torsion is less likely but a possibility in this population
- Infection
- TOA possible (see ‘Related Topics’ below)
- Diverticulosis | diverticulitis
- Appendicitis
- Bowel mass | Colon cancer
Note: Patient Age is Helpful in Determining Likelihood of Malignancy | While diagnosis would require surgical and pathologic evaluation, counseling of a patient in the ER can help manage expectations
Work-Up
History
- A complete menstrual history
- History of pelvic pain
- Sexual history
- Recent physical activity, including riding on rollercoasters
- History of pelvic masses or disorders such as endometriosis
Physical exam
- Vital signs for signs of volume depletion or acute bleeding, sepsis
- Abdominal exam including bowel sounds, rebound, guarding
- Pelvic exam for bleeding, purulence, cervical motion tenderness, palpable mass,
Imaging
- Ultrasound (preferably transvaginal) is the preferred imaging modality for gynecologic related adnexal mass
- Other modalities have not been shown to be superior for diagnosis, though MRI can help distinguish between ovarian and other etiologies of pelvic masses (AIUM practice parameter)
Laboratory testing
- CBC for WBC and Hgb/ Hct
- Pregnancy test
- Tumor markers are not immediately helpful, but may be sent in anticipation of need for oncology workup and include (AFP, CA-125, b-hCG, CEA, CA 19-9, Inhibin and Lactate dehydrogenase)
Management
- Minimally invasive surgical options are preferred for management of adnexal masses
- Laparoscopic management is first line
- If torsed ovary (or fallopian tube) found at laparoscopy it should be untorsed/untwisted
- If a large cyst is present it can either be removed or I&D
- Oopherpexy is not standard of care
- Many studies show that the appearance of black or blue ovary is not indicative of necrosis, and while 72 hour window for recovery of function has been proposed, there is evidence the ovary can recover after longer torsion time (Cohen et al. J Am Assoc Gynecol Laparosc, 2001)
- Fertility preservation and maximal preservation of ovarian tissue is paramount for premenopausal woman or adolescent
- Endometrioma resection is associated with decreased ovarian reserve
- Patients should be counseled regarding limited evidence to support surgical excision
- Reserve for suspicious features, progressive symptoms and large cysts
- Cyst size
- Simple cysts <10 cm: Generally can be safely followed with low malignant potential even in post-menopausal women (Modesitt et al. Obstet Gynecol, 2003)
- >6 cm: Torsion risk increases
- Cyst aspiration:
- Appropriate for TOA
- Should be avoided if any concern for malignancy
PRIMARY SOURCES:
Santos et al. J Pediatr Adolesc Gynecol, 2015
This case series assessed 29 female children (mean age 10.9 yrs) who underwent laparoscopic detorsion
- The mean duration of pain was 77.5h (+/- 78.8h)
- In 72.4% of cases the ovary was described as “dusky or purple”
- No patients required re-operation for removal of ovary
- No cases of ovarian vein thrombosis were detected
- At follow up U/S (avg time to f/u 8.1 months) 28/29 showed follicles on the effected side
PROFESSIONAL RECOMMENDATIONS:
ACOG Committee Opinion 783
ACOG addresses torsion specifically in adolescents and emphasizes the following points in regards the management of suspected torsion
There are no clinical or imaging criteria sufficient to confirm the preoperative diagnosis of adnexal torsion
Doppler flow alone should not guide clinical decision making
A surgeon should not remove a torsed ovary unless oophorectomy is unavoidable, such as when a severely necrotic ovary falls apart
REFERENCES:
ACOG Practice Bulletin 174: Evaluation and Management of Adnexal Masses
ACOG Committee Opinion 783: Adnexal torsion in adolescents
AIUM Practice Parameter for the performance of ultrasound of the female pelvis (2020)