Pediatric Annals

Special Issue Article 

Adnexal Masses in Adolescents

Jennifer L. Northridge, MD

Abstract

Adnexal masses in adolescents, such as functional cysts, are often benign and can usually be managed expectantly since they typically regress on their own. The most common ovarian neoplasm in adolescents is a benign cystic teratoma. Both functional cysts and benign cystic teratomas are associated with ovarian torsion. Of concern, ovarian torsion requires a high level of suspicion when adolescents present with acute abdominal pain, as almost one-half of cases have no associated adnexal masses. The most common malignant adnexal masses in this age group include germ cell tumors, followed by epithelial cell tumors. Finally, ectopic pregnancy and tubo-ovarian abscesses must be considered in the differential diagnosis of adnexal mass, as delays in treatment may seriously affect an adolescent's health and future fertility. Obtaining an accurate history, including a sexual history, requires reviewing this history with the adolescent privately. Management of adnexal mases should prioritize fertility preservation. [Pediatr Ann. 2020;49(4):e183–e187.]

Abstract

Adnexal masses in adolescents, such as functional cysts, are often benign and can usually be managed expectantly since they typically regress on their own. The most common ovarian neoplasm in adolescents is a benign cystic teratoma. Both functional cysts and benign cystic teratomas are associated with ovarian torsion. Of concern, ovarian torsion requires a high level of suspicion when adolescents present with acute abdominal pain, as almost one-half of cases have no associated adnexal masses. The most common malignant adnexal masses in this age group include germ cell tumors, followed by epithelial cell tumors. Finally, ectopic pregnancy and tubo-ovarian abscesses must be considered in the differential diagnosis of adnexal mass, as delays in treatment may seriously affect an adolescent's health and future fertility. Obtaining an accurate history, including a sexual history, requires reviewing this history with the adolescent privately. Management of adnexal mases should prioritize fertility preservation. [Pediatr Ann. 2020;49(4):e183–e187.]

Adnexal masses of the ovary, fallopian tube, or surrounding tissues are common in adolescents. They are usually benign, and often can be managed expectantly. For example, the most common ovarian cyst in adolescents are functional cysts, which typically regress in 8 weeks.1 Surgery is indicated for suspected malignancy, torsion, persistent mass, and acute abdominal pain.1 The median age at ovarian cancer diagnosis is 63 years, with only 1.3% of ovarian cancers occurring in women age 20 years or younger.2 The incidence of ovarian malignancy in adolescents is difficult to ascertain. Nonetheless, a recent analysis of clinical cases for patients younger than age 20 years who required surgery found that only 9% of ovarian masses were malignant.3 Germ cell tumors are the most common ovarian malignancies in children and adolescents, followed by epithelial cell tumors.1 The differential diagnosis of a pelvic mass, appropriate diagnostic testing, and clinical management emphasizing fertility preservation in this age group will be reviewed in this article.

Differential Diagnosis

Pelvic masses may have gynecologic origins (eg, benign or malignant ovarian masses, ectopic pregnancies, tubo-ovarian abscesses, and congenital anomalies), as well as nongynecologic origins (eg, pelvic kidneys and metastatic tumors) (Table 1). Obstructive lesions, including transverse vaginal septum or imperforate hymen, may present with cyclic or chronic pain and pelvic mass in adolescents when menstrual fluid accumulates within the vagina (ie, hematocolpos) or within the uterus (ie, hematometra).4 Less commonly, uterovaginal agenesis (ie, Mayer-Rokitansky-Küster-Hauser syndrome) may present with primary amenorrhea and pain, the latter symptom especially if the mass contains functioning endometrium.4

Differential Diagnosis of Adnexal Mass in Adolescents

Table 1:

Differential Diagnosis of Adnexal Mass in Adolescents

Diagnostic Testing

Evaluation of adnexal masses begins with a detailed gynecologic history obtained alone with the adolescent patient, after first reviewing that a sexual history will remain confidential except in limited situations where a physician is a mandated reporter. Acute onset of abdominal or pelvic pain may indicate a hemorrhagic cyst or an ectopic pregnancy. Ovarian torsion may present as acutely worsening pelvic pain that is unilateral and intermittent. A more indolent course of progressive pelvic pain that is associated with fever, chills, vomiting, and vaginal discharge may indicate a tubo-ovarian abscess.1

The physical examination should include palpation of cervical, supracla vicular axillary, and groin lymph nodes, pulmonary auscultation, abdominal palpation and auscultation, and pelvic examination.1 The use of parental or medical chaperones should be a shared decision between the adolescent and her physician, per the American Academy of Pediatrics policy on chaperones.5 The rationale and need for a genital examination should be clearly explained to the adolescent patient using correct medical terms, ideally before she is undressed. Providing the patient with a sense of control by letting her know that she can stop the examination at any point may help to decrease any anxiety and discomfort.6

The genital examination for a prepubertal girl can be performed with the child supine in a frog-leg position or prone in the knee-chest position. By separating the posterior labia minora inferiorly and laterally, the vaginal introitus, hymen, urethra, and clitoris can be visualized. Neither a speculum examination or bimanual gynecologic examination are appropriate for prepubertal girls. A recto-abdominal examination, however, may be used to examine a suspected mass in this age group.6 If a patient is sexually active, a pelvic examination should include visual inspection of the cervix and vagina, and bimanual gynecologic palpation. Adnexal masses that are irregular, firm, fixed, nodular, bilateral, or associated with ascites are concerning for possible malignancy.1

The diagnostic assessment also includes pregnancy testing in reproductive-aged women. If infection is suspected, both a complete blood count and testing for gonorrhea and chlamydia with nucleic acid amplification testing are indicated. Depending on the patient history, the physician may consider obtaining a urinalysis. The American College of Obstetricians and Gynecologists (ACOG) recommends testing for alpha fetoprotein, quantitative beta-human chorionic gonadotropin, lactate dehydrogenase, and possibly CA 125 for evaluation of suspected germ cell tumors. Of note, CA 125 elevation is nonspecific and can occur with endometriosis, pregnancy, pelvic inflammatory disease (PID), noncommunicated uterine horns, ovarian fibromas, and torsed adnexa.1 If the patient is premenarchal, the physician may consider karyotype testing when evaluating a pelvic mass.7

ACOG recommends transabdominal ultrasonography rather than vaginal ultrasonography for prepubertal adolescents as well as older adolescents who are not yet sexually active.1 Ultrasound findings concerning for possible malignancy include cyst size greater than 10cm, papillary or solid components, irregularity, presence of ascites, and high color Doppler flow.8 Magnetic resonance imaging may prove helpful in classifying malignant masses and differentiating the origin of pelvic masses.1

Intrauterine Pregnancy, Ectopic Pregnancy, and Infection

Intrauterine or ectopic pregnancy must be considered when evaluating pelvic masses in adolescents. The presentation of ectopic pregnancies can range from mild cramping with abnormal vaginal spotting and dizziness to severe lower abdominal pain with associated syncope, depending on whether tubal rupture has occurred. Obtaining a confidential history to determine if a patient is sexually active and considering screening with a urine pregnancy test are essential steps in evaluating pelvic masses in this age group.9 Obtaining a confidential sexual history is also essential as adolescents and young adults are the populations at highest risk for chlamydia and other sexually transmitted infections.10 PID is defined as an infection of the upper genital tract in females, and includes endometritis, salpingitis, tubo-ovarian abscess, and pelvic peritonitis. It typically presents with pelvic or lower abdominal pain, fever, and vaginal discharge, with the pelvic examination notable for cervical motion tenderness, uterine tenderness, or adnexal tenderness.1,10 PID may also be associated with adnexal masses if pyosalpinxes or tubo-ovarian masses are present.10 Appropriate treatment with empiric, broad spectrum coverage of likely pathogens, including Neisseria gonorrhoeae, Chlamydia trachomatis, and anaerobes, can prevent long-term complications from developing, such as infertility and ectopic pregnancy.10 Hospitalization is recommended for women with tubo-ovarian abscesses, as they may benefit from tubo-ovarian abscess drainage, which can both shorten the average hospital stay and decrease the need for surgical intervention.1

Adnexal Torsion

Adnexal torsion of the ovary, fallopian tube, and/or paratubal cyst is common in the pediatric and adolescent age groups, with 30% of all cases occurring in adolescents and young women younger than age 20 years.11 In contrast to the presentation in adult woman, almost one-half (46%) of adnexal torsion in adolescents involves an ovary without an associated mass or cyst.12 When present, the most common ovarian masses associated with torsion in this younger age group are benign functional ovarian cysts and benign teratomas.13 Malignancy is extremely rare, especially among premenarchal adolescents.14–16 The risk of torsion increases when pelvic masses are larger than 5 to 7cm, which guides clinical management.16,17

The most common clinical presentation of adnexal torsion is sudden, intermittent abdominal pain associated with nausea and vomiting.17 Bimanual examinations are generally not tolerated in this population. Instead, the most helpful diagnostic tool is transabdominal ultrasonography, which has a sensitivity of 92% and a specificity of 96% in detecting ovarian torsion, with findings of unilateral ovarian enlargement, evidence of ovarian edema, free fluid, and a coiled avascular pedicle referred to as a whirlpool sign.18,19 Of note, the Doppler ultrasound may be normal in as many as 60% of cases of adnexal torsion.12 There are no clinical or imaging criteria sufficient to rule out adnexal torsion. Thus, when ovarian torsion is suspected, the ACOG recommends timely intervention with diagnostic laparoscopy to preserve ovarian function and future fertility.17 Specifically, the ACOG recommends a minimally invasive approach with detorsion and preservation of adnexal structures, unless oophorectomy is unavoidable.17

Functional Ovarian Cysts and Endometriomas

Functional ovarian cysts include follicular cysts, corpus luteum cysts, and theca lutein cysts. Functional ovarian cysts are common during adolescence given its association with dysfunctional ovulation with failed involution of the preovulatory follicle or corpus luteum.20 Follicular cysts are the most common form. They are typically asymptomatic, although they can cause pain where there is torsion or rupture. Follicular cysts are unilocular and simple, ranging in size from 3 cm to 15 cm, and typically resolve over time. Conservative management is recommended with cysts smaller than 7 cm in premenopausal woman.20 Ultrasonography is recommended to reevaluate ovarian cysts at 6 to 12 weeks.1 Surgery can be considered for persistent masses. Corpus luteum cysts are more likely than follicular cysts to be painful, due to acute hemoperitoneum. Corpus luteum cysts are larger than 3 cm and have a more complex appearance that is produced by hemorrhage.7 Ovulation suppression can be considered for recurrent follicular cysts or corpus luteum cysts.13 Theca lutein cysts occur during pregnancy, and can be very large with diameters up to 30 cm.7

Endometriomas are rare in adolescents, who more typically have early stage endometriosis upon presentation. Note that endometriomas form when the ectopic endometrium forms cysts, of which 80% are found in the ovary.7 They are typically small (6 cm to 8 cm), well-defined multilocular cysts with low-level internal echoes and hyperechoic wall foci.9 Endometriosis should be suspected in women with worsening dysmenorrhea, pelvic pain, and deep dyspareunia that is unresponsive to nonsteroidal anti-inflammatory drugs and oral contraceptives.9 Although endometriosis may present with these clinical findings, adolescents often do not develop all of the following symptoms: diffuse pelvic tenderness, particularly posterior to the uterus; diminished uterine motility; cervical motion tenderness; uterosacral nodularity; and possibly an ovarian mass, especially when endometriomas are present.1 Surgical intervention for suspected endometriomas is recommended if the mass is large, symptomatic despite medical management, or growing in size, or to evaluate the mass for malignancy.1

Ovarian Neoplasms

If an adolescent patient experiences the persistence of adnexal masses for more than 6 to 8 weeks or the presence of solid masses, she is at increased likelihood of having an ovarian neoplasm and should be referred to a surgical gynecologist.9 The most common ovarian neoplasm in adolescents is germ cell tumors, specifically benign cystic teratoma. The most common metastatic lesions of the ovary in adolescents are lymphomas and leukemias.9

A benign cystic teratoma (i.e., dermoid cyst) is comprised of well-differentiated endoderm, mesoderm, and ectoderm. In a retrospective study of adnexal masses in patients age 12 to 21 years referred to a single institution, benign cyst teratomas constituted 32% of all ovarian masses requiring surgery.7 The majority of benign cystic teratomas have specific ultrasound features that are consistent with teeth or fat, and 10% to 15% are bilateral.9,20 Ultrasound imaging provides a sensitivity of 85% and a specificity of 98% for differentiating mature cystic teratomas from other ovarian masses.21 The risk of ovarian torsion with dermoid cysts is approximately 15%, which is higher than for other ovarian tumors.9 Typically, mature ovarian teratomas are treated with ovarian cystectomy to preserve ovarian tissue, rather than with oophorectomy.1,9

Malignant germ cell tumors include dysgerminoma, mixed-germ cell tumor, endodermal sinus tumor, immature teratoma, embryonal tumor, choriocarcinoma, and polyembryoma.20 Of these tumors, dysgerminomas are the most common.1,9 Approximately 5% to 10% of dysgerminomas occur in phenotypically female patients with disorders of sex differentiation.9 The presence of a Y chromosome is associated with the risk of malignancy, and thus bilateral gonadectomy may be recommended based on the type of disorder of sex differentiation.22

Serous or mucinous cystadenomas account for 10% to 20% of benign ovarian neoplasms in adolescents.9 Epithelial ovarian neoplasms can be classified as benign (eg, serous or mucinous cystadeonomas), borderline, or malignant (eg, serous cystadenocarciomas and mucinous cystadenocarcinomas).9 Less than 5% of ovarian epithelial tumors in adolescents are invasive malignancies.23 Serous cystadenomas tend to be unilocular large masses that may have thin internal septations and/or papillary projections. Mucinous cystadenomas may be very large and multiloculated and may also produce low-level echoes caused by proteinaceous contents and hemorrhage.7 Surgical removal of adenomas is necessary to prevent torsion and for tissue diagnosis.9

Sex cord-stromal tumors occur more frequently in premenarchal girls and are rarely found in adolescents.9 They may be hormonally active tumors, including granulosa cell tumors and theca cell tumors that produce estrogen, and Sertoli-Leydig cell tumors that produce androgens, with or without estrogen.1,9 These tumors may therefore present as precocious puberty, abnormal uterine bleeding, hirsutism, and virilization.1 Such symptoms indicate the need for pelvic imaging.9 Fibromas arise from the ovarian stroma, and rarely show clinical signs of estrogen production. Given that many women with fibromas are asymptomatic, most patients have large fibromas before detection.7

Management of adnexal masses in adolescents should prioritize ovarian conservation to preserve fertility.1 With careful preoperative screening, laparoscopic surgery of an ovarian cyst is safe for adolescents and important for future fertility.20,24 Further, the importance of fertility preservation is evident in the Children's Oncology Group recommendation for preservation of the contralateral ovary and uterus for surgical staging of germ cell tumors.25 Finally, consultation with a gynecologic oncologist is recommended for girls and women with adnexal masses that are concerning for malignancy.1

References

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  10. Workowski KA, Bolan GACenters for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines, 2015. MMWR Recomm Rep. 2015;64(33):924. PMID:26042815
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Differential Diagnosis of Adnexal Mass in Adolescents

Ovarian torsion
Benign ovarian mass

Functional or physiologic cyst (follicular, corpus luteal, theca lutein)

Germ cell (benign cystic teratoma/dermoid)

Epithelial (serious cystadenoma, mucinous cystadenoma)

Sex-cord-stromal (granulosa cell tumor, Sertoli-Leydig cell tumor, fibroma)

Endometrioma
Malignant ovarian mass

Germ cell tumor (dysgerminoma, endodermal sinus tumor, choriocarcinoma)

Epithelial carcinoma (serous cystadenocarcinoma, mucinous cystadenocarcinoma)

Sex-cord stromal tumors

Metastatic cancer (lymphoma, leukemia)

Tubal

Paratubal cyst

Hydrosalpinx

Infectious

Tubo-ovarian abscess, pyosalpinx

Pregnancy

Pregnancy (intrauterine, ectopic)

Obstructive

Imperforate hymen

Transverse vaginal septum

Noncommunicating uterine horn

Hematometrocolpos

Gastrointestinal

Appendicitis, appendiceal abscess

Urinary

Renal cyst, urachal cyst

Rare in adolescents

Pelvic kidney, diverticular abscess, retro- peritoneal tumor, gastrointestinal cancer, uterine sarcoma

Authors

Jennifer L. Northridge, MD, is the Section Chief, Adolescent Medicine, Joseph M. Sanzari Children's Hospital, Hackensack University Medical Center; and an Assistant Professor of Pediatrics, Hackensack Meridian School of Medicine at Seton Hall University.

Address correspondence to Jennifer L. Northridge, MD, Joseph M. Sanzari Children's Hospital, 30 Prosepect Avenue, WFAN 3rd Floor, Hackensack, NJ 07601; email: Jennifer.Northridge@hackensackmeridian.org.

Disclosure: The author has no relevant financial relationships to disclose.

10.3928/19382359-20200227-01

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