This simple lecture was designed as a part of the content of the basic ultrasound workshop held periodically by the department of Obstetrics & gynecology - Faculty of medicine - Mansoura university- Egypt as a part of continuous medical education program.

1. ASYMPTOMATIC ADNEXAL MASSES
ULTRASOUND EVALUATION
Osama M Warda MDOsama M Warda MDOsama M Warda MDOsama M Warda MD
Professor of Obstetrics and Gynecology
Mansoura University--EGYPT
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2. INTRODUCTION
Various disease processes can present as a clinical
problem when a patient comes to a physician’s office for
a routine gynecologic examination & an asymptomatic
palpable adnexal mass is felt.
The differential diagnosis include
1. Functional ovarian cysts (vast majority)
2. Endometriosis
3. Dermoids
4. Ovarian tumors (B9 > malig.)
5. Tubo-ovarian abscess
6. Subserous fibroids
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3. IMPORTANT CLINICAL PARAMETERS FOR DIAGNOSIS
Patient’s age;
-Pre-menopausal
-Post-menopausal
Apparent size of the mass on palpation;
? 5-6 cm, less or more
Consistency (feel) of the mass;
? cystic, soft, solid
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4. GENERAL PLAN OF MANAGEMENT
1---- FollowFollowFollowFollow----up clinical exam forup clinical exam forup clinical exam forup clinical exam for 1111----2222 menstrualmenstrualmenstrualmenstrual cycles in:cycles in:cycles in:cycles in:
Premenopausal patient
Mass is < 6cm
Mass feels cystic or soft
A- if mass disappeared well and good
B- if persisted or increased in size;
-TVS evaluation (CT or MRI rarely needed)
- Other non radiologic investigation (eg CA125) may
be needed according to imaging results
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5. GENERAL PLAN OF MANAGEMENT
2222---- A palpableA palpableA palpableA palpable adnexaladnexaladnexaladnexal mass in amass in amass in amass in a postmenopausalpostmenopausalpostmenopausalpostmenopausal woman:woman:woman:woman:
should be investigated immediately (no role for follow-up)
with TVS . Adding color Doppler increases the sensitivity
and positive predictive value in characterizing the
adnexal mass over the conventional grey scale.
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6. SIMPLE CYST
-It is the most common finding
- simple cyst is characterized by:
1. anechoic
2. smooth margins
3. unilocular
4. good sound transmission to the adjacent soft tissue
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7. SIMPLE CYST- THE OUTCOME
Simple cysts <6cm in premenopausal or <5 cm
in postmenopausal women when found are
followed up with ultrasound imaging after 1-2
months.
COCs may be used to help resolve the cyst and
prevent development of other functional
ovarian cysts as they decrease FSH level.
Most simple cysts disappear within that
period. Spontaneous regression is less likely
with cysts > 6cm.
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8. HEMORRHAGIC CYST
Bleeding in a cyst complicates the diagnosis. Variable characteristics can be seen
because of clot formation, lysis, and retraction. The cyst may have:
1. Appearance of a solid component
2. Mural nodularity
3. Septations
4. Focal wall thickening
5. Fluid debris levels
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9. HEMORRHAGIC CYST
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10. HEMORRHAGIC CYST
Thin, fibrous strands, clot retraction with convex
borders, fluid levels & homogeneous low echoes
throughout the mass with good transmission
suggest hemorrhage in this cystic mass.
Most hemorrhagic cysts will resolve spontaneously
over time but surgical excision may be necessary.
Ruptured cysts are associated with free fluid in
cul-de-sac, or even intra-peritoneal fluid.
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11. THECA LUTEIN CYSTS
Are functional cysts & usually associated with;
1- some form of GTD 2- Ovarian hyper-stimulation with ovulation drugs 3-
with spontaneous pregnancy especially mutifetal pregnancy.
The exact etiology is unknown but the are associated with high levels of HCG
Elevated pituitary FSH or increased HCG sensitivity may be involved
Are usually bilateral and multilocular
They may remain for several weeks after the removal of the offending cause
and usually asymptomatic
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12. POLYCYSTIC OVARIES
it is a complex clinical, laboratory, and ultrasound picture
ON ULTRASOUNDON ULTRASOUNDON ULTRASOUNDON ULTRASOUND:
There is a bilateral increased number of small (<There is a bilateral increased number of small (<There is a bilateral increased number of small (<There is a bilateral increased number of small (<8888mm) follicle cysts usually as manymm) follicle cysts usually as manymm) follicle cysts usually as manymm) follicle cysts usually as many
asasasas 10101010 in the periphery of a large spherical ovaries (necklace sign)in the periphery of a large spherical ovaries (necklace sign)in the periphery of a large spherical ovaries (necklace sign)in the periphery of a large spherical ovaries (necklace sign)
Mature follicles (Mature follicles (Mature follicles (Mature follicles (15151515----30303030mm) can be found in up tomm) can be found in up tomm) can be found in up tomm) can be found in up to 15151515% of cases.% of cases.% of cases.% of cases.
Follicles >Follicles >Follicles >Follicles > 30303030mm can be seenmm can be seenmm can be seenmm can be seen
Increased ovarianIncreased ovarianIncreased ovarianIncreased ovarian echogenicityechogenicityechogenicityechogenicity (=dense(=dense(=dense(=dense stromastromastromastroma))))
A combination of follicular and ovarian volume is the most sensitive objectiveA combination of follicular and ovarian volume is the most sensitive objectiveA combination of follicular and ovarian volume is the most sensitive objectiveA combination of follicular and ovarian volume is the most sensitive objective
parameter in diagnosis. The upper limit of normal ovarian volume isparameter in diagnosis. The upper limit of normal ovarian volume isparameter in diagnosis. The upper limit of normal ovarian volume isparameter in diagnosis. The upper limit of normal ovarian volume is 15151515CmCmCmCm3333
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13. OVARIAN ENDOMETRIOSIS
- Women between 25-35 years with dysmenorrhea
- Complex and primarily cystic masses due to repeated bleeding episodes during
menses.
The focal blood collection may be anechoic or complex, with multiple EVENLY
distributed echoes, clot nodules, or debris levels
There is usually good through sound transmission
The wall is usually thickened or irregular
Septa are unusual
In severe cases, multiple collections can be seen
Treatment is essentially SURGICAL
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14. PARAOVARIAN CYST
They arise in the broad ligament derivatives ofThey arise in the broad ligament derivatives ofThey arise in the broad ligament derivatives ofThey arise in the broad ligament derivatives of mesothelialmesothelialmesothelialmesothelial orororor
periperiperiperi----mesothelialmesothelialmesothelialmesothelial structures.structures.structures.structures.
They compriseThey compriseThey compriseThey comprise 10101010% of% of% of% of adnexaladnexaladnexaladnexal cystic masses & mostly seen incystic masses & mostly seen incystic masses & mostly seen incystic masses & mostly seen in
the middlethe middlethe middlethe middle----age women.age women.age women.age women.
Although the are mostly simple cysts, they may be complicatedAlthough the are mostly simple cysts, they may be complicatedAlthough the are mostly simple cysts, they may be complicatedAlthough the are mostly simple cysts, they may be complicated
be torsion, rupture, bleeding, or infection.be torsion, rupture, bleeding, or infection.be torsion, rupture, bleeding, or infection.be torsion, rupture, bleeding, or infection.
To be diagnosed asTo be diagnosed asTo be diagnosed asTo be diagnosed as paraparaparapara----ovarian,aovarian,aovarian,aovarian,a tissue plane between thetissue plane between thetissue plane between thetissue plane between the
cyst & the normal ovary must exist.cyst & the normal ovary must exist.cyst & the normal ovary must exist.cyst & the normal ovary must exist.
The usual treatment is EXCISION as it does not respond toThe usual treatment is EXCISION as it does not respond toThe usual treatment is EXCISION as it does not respond toThe usual treatment is EXCISION as it does not respond to
hormones.hormones.hormones.hormones.
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15. HYDROSALPINX
TheyTheyTheyThey are oblong ( or retortare oblong ( or retortare oblong ( or retortare oblong ( or retort---- shape) cystic structuresshape) cystic structuresshape) cystic structuresshape) cystic structures
near the normally appearing ovary which is usuallynear the normally appearing ovary which is usuallynear the normally appearing ovary which is usuallynear the normally appearing ovary which is usually
separated by the cyst wallseparated by the cyst wallseparated by the cyst wallseparated by the cyst wall
Antibiotic/antiAntibiotic/antiAntibiotic/antiAntibiotic/anti----inflammatory treatment usually triedinflammatory treatment usually triedinflammatory treatment usually triedinflammatory treatment usually tried
with limited.with limited.with limited.with limited.
In infertility treatment excision or disconnection isIn infertility treatment excision or disconnection isIn infertility treatment excision or disconnection isIn infertility treatment excision or disconnection is
recommendedrecommendedrecommendedrecommended
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16. TUBO-OVARIAN ABSCESS
The US appearanceThe US appearanceThe US appearanceThe US appearance varies according to their appearance at thevaries according to their appearance at thevaries according to their appearance at thevaries according to their appearance at the
time of stabilization of the inflammatory process.time of stabilization of the inflammatory process.time of stabilization of the inflammatory process.time of stabilization of the inflammatory process.
The mass may be purely cystic, have thick septa, have multipleThe mass may be purely cystic, have thick septa, have multipleThe mass may be purely cystic, have thick septa, have multipleThe mass may be purely cystic, have thick septa, have multiple
loculationloculationloculationloculation, and contain complex debris., and contain complex debris., and contain complex debris., and contain complex debris.
A more serious diagnosis such as benign or malignantA more serious diagnosis such as benign or malignantA more serious diagnosis such as benign or malignantA more serious diagnosis such as benign or malignant
neoplasm must be considered because both conditions are quiteneoplasm must be considered because both conditions are quiteneoplasm must be considered because both conditions are quiteneoplasm must be considered because both conditions are quite
similar on ultrasound.similar on ultrasound.similar on ultrasound.similar on ultrasound.
TuboTuboTuboTubo----ovarian abscesses are usually removed surgically (ovarian abscesses are usually removed surgically (ovarian abscesses are usually removed surgically (ovarian abscesses are usually removed surgically ( althoughalthoughalthoughalthough
asymptomaticasymptomaticasymptomaticasymptomatic) as masses do not change over time.) as masses do not change over time.) as masses do not change over time.) as masses do not change over time.
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17. OVARIAN NEOPLASM
Ovarian neoplasm; 80% benign, 10-15% malignant, and
5% are metastases.
Age range for benign t is 20-45y, for malignant is 40-65y.
Ovarian tumors are usually cystic & less commonly solidOvarian tumors are usually cystic & less commonly solidOvarian tumors are usually cystic & less commonly solidOvarian tumors are usually cystic & less commonly solid
Ultrasound criteria suggesting malignancy include:
Bilateral tumorsBilateral tumorsBilateral tumorsBilateral tumors
HeterogeneousHeterogeneousHeterogeneousHeterogeneous echogeneityechogeneityechogeneityechogeneity
Presence of intraPresence of intraPresence of intraPresence of intra----cystic septa, multiplecystic septa, multiplecystic septa, multiplecystic septa, multiple loculesloculesloculeslocules
Presence of papillae (intraPresence of papillae (intraPresence of papillae (intraPresence of papillae (intra----cystic, or extracystic, or extracystic, or extracystic, or extra----cystic)cystic)cystic)cystic)
Presence of intraPresence of intraPresence of intraPresence of intra----cystic solid partscystic solid partscystic solid partscystic solid parts
Presence of ascitesPresence of ascitesPresence of ascitesPresence of ascites
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18. OVARIAN NEOPLASM- CYSTADENOMAS
SerousSerousSerousSerous cystadenomacystadenomacystadenomacystadenoma
MucinousMucinousMucinousMucinous CystadenomaCystadenomaCystadenomaCystadenoma
Papillary serousPapillary serousPapillary serousPapillary serous cystadenomacystadenomacystadenomacystadenoma
SerousSerousSerousSerous cystadenocarcinomacystadenocarcinomacystadenocarcinomacystadenocarcinoma
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19. OVARIAN NEOPLASM- SOLID TUMORS
Granulosa cell t
Immature solid teratoma
Brenner
Germ cell t
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20. OVARIAN NEOPLASM- DERMOID CYST
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21. SUBSEROUS MYOMA
UUUUsually appearssually appearssually appearssually appears ecogenicecogenicecogenicecogenic, similar to the, similar to the, similar to the, similar to the
uterine walluterine walluterine walluterine wall
Sometimes it appears with variable sizeSometimes it appears with variable sizeSometimes it appears with variable sizeSometimes it appears with variable size
hyperecchogenichyperecchogenichyperecchogenichyperecchogenic areas due to calcificationareas due to calcificationareas due to calcificationareas due to calcification
Sometimes it may appear with mixedSometimes it may appear with mixedSometimes it may appear with mixedSometimes it may appear with mixed
echogenicityechogenicityechogenicityechogenicity (complex mass) due to cystic(complex mass) due to cystic(complex mass) due to cystic(complex mass) due to cystic
degenerationdegenerationdegenerationdegeneration
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22. THANK YOUTHANK YOUTHANK YOUTHANK YOU
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