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Adnexal Masses in Adolescents

5/1/2009 - Robert S. Schenken, MD

Editor:  Paula J. Hillard, MD

REVISED PEARL - February 2015

The prevalence of adnexal masses in adolescents is unknown.  While the diagnosis of a “ruptured ovarian cyst” is a common for adolescents presenting with abdominal and pelvic pain, often this default diagnosis represents only the ultrasound findings of a normal cystic follicle and does not truly explain the pain.  Less than 25% of ovarian neoplasms in adolescents are malignant.  The most common neoplasm during adolescence is a benign cystic teratoma (dermoid).

The differential diagnosis includes:

  • Ovary:  functional cysts (follicular, corpus luteum); endometriosis; benign neoplasms (teratomas, serous and mucinous cystadenoma); malignant neoplasms (germ cell, sex-cord or stromal tumor, epithelial carcinoma); torsion
  • Tube:  tubo-ovarian abscess, hydrosalpinx, ectopic pregnancy.
  • Vagina/Uterus:  Anomalies (obstructing longitudinal vaginal septum, Mullerian anomalies, imperforate hymen)
  • Gastrointestinal:  appendiceal abscess
  • Other:  Paratubal cysts, peritoneal inclusion cysts, pelvic kidney

Adolescents with adnexal masses can present with symptoms, although even large masses may be asymptomatic.  Abdominal pain may be due to torsion, cyst rupture, or hemorrhage into a cyst.  Other symptoms may include abdominal distention or endocrine manifestations such as precocious puberty, uterine bleeding, amenorrhea, or virilization. Nausea and vomiting may occur with torsion.  Cyclic pain suggests vaginal or uterine anomalies.  Acute pain suggests torsion, a ruptured or hemorrhagic ovarian cyst, ectopic pregnancy, or tubo-ovarian or appendiceal abscess.  Disruption of menstrual cyclicity, sexual activity, contraceptive practices and sexually transmitted disease exposure should be discussed and confidentiality assured.

Pelvic examination may not be appropriate or revealing in adolescents who are virgins or those with severe pain.  It may be possible to palpate the adnexae on rectal examination.  Initial laboratory testing must include βhCG, as adolescents may not acknowledge voluntary or involuntary sexual activity.  Other relevant laboratory testing may include CBC, gonorrhea and chlamydia, and tumor markers.  Imaging is critical in the evaluation and would typically start with ultrasound; MRI or CT may be required. Ultrasound can be transvaginal or transabdominal, with the latter preferred in patients who are virgins. Morphologic scoring systems to assess malignant potential may be used, but have not been validated in adolescents.  Ultrasound findings of a sonolucent cyst with smooth walls and the absence of thick septations and solid components indicate a low risk of malignancy.  MRI is the preferred imaging modality after an initial ultrasound for suspected vaginal and uterine anomalies.

Management of functional cysts is expectant with serial ultrasound imaging.  Oral contraceptives do not hasten resolution of existing cysts.  Patients with suspected hemorrhagic cysts should be followed if clinically stable and the pain can be managed medically.  Torsion requires prompt surgical intervention to preserve ovarian function. Additional disorders are found in over half of patients with the diagnosis of torsion. Endometriomas generally require surgical removal as medical therapy will not significantly decrease their size.  Neoplasms require surgical intervention, and a gynecologic oncologist should be involved when imaging suggests malignancy. Aydrosalpinx 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.  Anomalies resulting in menstrual outflow obstruction are managed surgically.  Paratubal and inclusion cysts appearing as extraovarian, sonolucent structures that may be followed with serial ultrasound imaging.

Further Reading:

ACOG Practice Bulletin. Management of adnexal masses. Obstet Gynecol. 2007;110(1):201-214. 

Levine D, Brown DL, Andreotti RF, et al. Management of asymptomatic ovarian and other adnexal cysts imaged at US Society of Radiologists in Ultrasound consensus conference statement. Ultrasound Q. 2010;26(3):121-131.

Kelleher CM, Goldstein AM. Adnexal masses in children and adolescents. Clin Obstet Gynecol. 2015;58(1):76-92.

Initial approval 5/2009;  Revised 2/2015; Reaffirmed 7/2016

 

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