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NEED TO KNOW

Assess each adnexal mass using a simple structured approach that is individualised for each patient presentation.

Knowledge of the likely aetiology of a pelvic mass allows the doctor to streamline patient care by performing the appropriate investigations without over-investigating.

Using available resources to create a risk profile for adnexal masses will ensure the patient is referred to the most appropriate clinician to manage their condition.

BACKGROUND

ADNEXAL masses are relatively

common. However, the exact prevalence is difficult to quantify as they are often asymptomatic and resolve spontaneously, particularly in pre-menopausal women. The incidence in postmenopausal women is between 5 % and 10 %. 1 About one in 10 women will undergo a surgical procedure in their lifetime for the presence of an ovarian mass. 2 Most ovarian masses are benign. Only one in 1000 symptomatic masses in women under the age of 50 is malignant, with a small increase to three in 1000 in women over 50. 2

Pelvic masses can be both gynaecological and non-gynaecological in origin( see table 1). They can occur at any age and vary widely in presentation, symptomatology, examination findings and final diagnosis. As not all adnexal masses require surgical intervention, it is crucial that accurate assessment and follow-up of known pelvic masses occur to avoid both incorrect diagnosis and missed opportunities for timely management with appropriate specialist input.

No single finding or combination of investigations can accurately diagnose

Table 1. Types of adnexal masses

Benign ovarian

Benign gynaecological, non-ovarian

Non-gynaecological

Malignant primary ovarian

Malignant non-primary ovarian

the aetiology of a pelvic mass. However, assessment of patient age; identification of risk factors, such as endometriosis or known oncogenes;

Functional cysts / luteal cysts Endometrioma Serous cystadenoma Mucinous cystadenoma Mature teratoma( dermoid, see figure 1)

Paratubal cyst Ectopic pregnancy( see figure 2) Tubo-ovarian abscess Hydrosalpinx / haematosalpinx Leiomyoma

Diverticular disease Peritoneal inclusion cysts Appendiceal pathology Colorectal cancers Bladder diverticulum Pelvic kidney

Germ cell cancer Epithelial cancers Sex cord – stromal cancers

Krukenberg tumours— commonly breast and gastrointestinal tumours Metastatic gynaecological— commonly endometrial Retroperitoneal sarcomas

imaging findings; and biochemistry results can help narrow the differential diagnosis.

An adnexal mass may be identified

in many ways. Common symptoms that prompt patient presentation include pain from rupture, haemorrhage or torsion. Pressure symptoms, such as bloating or voiding dysfunction, can arise from a mass effect. Alternatively, asymptomatic masses may be identified incidentally when initiating investigations for other reasons, such as postmenopausal bleeding or radiological staging of non-related conditions.

Symptoms such as pelvic pain, bloating, abdominal distension, changes in bowel or bladder function, dyspareunia, loss of appetite or abnormal bleeding should all trigger the treating clinician to investigate for a pelvic mass as a potential cause. Even when asymptomatic adnexal masses are found incidentally, the approach to investigation and initial management is the same as for symptomatic lesions. This includes taking a full history, performing a focused examination, initiating appropriate cascade investigations and referral for specialist opinion where appropriate.

Understanding the common causes of adnexal masses, particularly with respect to age, is crucial for the physician to initiate