The Clinical Problem

It is often difficult to perform a clinical examination on the female pelvis, especially if the patient is obese, is a child, or has an acute condition such as pelvic inflammatory disease. Sonography is helpful in (1) determining whether a mass is present, (2) deciding whether a mass relates to the uterus or the ovary or the adnexa, and (3) determining whether the mass has a benign appearance or might be malignant.

An adnexal mass may come to light for a number of different reasons:

 1. There may be pain on the side of the mass.

 2. The mass may be found at a routine clinical examination.

 3. Secondary obstruction of the genitourinary or gastrointestinal tract may occur.

 4. An alternative imaging technique such as a computed axial tomography (CAT) scan may show a mass.

The questions that need to be answered about an adnexal mass are the following:

 1. Is a pathologic pelvic mass present or is the supposed mass a normal anatomic variant?

 2. Is the mass uterine, adnexal, or neither?

 3. Is the mass cystic, complex, or solid? If it is cystic, does it have septa?

 4. Is there blood flow to the mass? Is the blood flow high or low resistance?

 5. Is the mass involving or invading any other pelvic structure?

 6. Are other associated findings such as ascites, metastases, or hydronephrosis present?

By using a combination of the clinical background and the sonographic appearance, a relatively specific diagnosis is usually possible. The sonographer needs the following information to perform a quality sonogram and to make sure that the sonogram is correctly interpreted:

 1. What was the date of the first day of the last period (if the patient is still menstruating)?

 2. Are menstrual cycles regular, and how long do they last?

 3. If the patient has had a hysterectomy, does she know when she ovulates?

 4. How long ago did the patient stop menstruating (if she is menopausal)?

 5. How many children has the patient had?

 6. Has the patient had pelvic surgery? Have any pelvic structures been removed?

 7. Has there been pain? If so, where is it located?

 8. If the patient is postmenopausal, is she on hormone replacement therapy?

Adnexal mass assessment is helped by sonography in the following situations:

 1. Ovarian masses in premenopausal women are usually followed for several weeks to make sure the mass is not a physiologic variant such as a corpus luteum or follicular cyst. However, if the mass is greater than 10 cm in diameter or has typical dermoid appearances, or if there are sonographic features suggestive of malignancy, immediate surgery may be elected.

 2. Particularly in obese people, it may be difficult to be certain by pelvic examination whether a pelvic mass is present. Ultrasound can help by definitely showing a mass and determining whether it is uterine or ovarian.

 3. Small cysts in postmenopausal women are common, and as long as they are echo-free, most cysts are followed with serial sonograms.

 4. Screening for ovarian cancer in at-risk patients may be helpful in women aged more than 40 years because this cancer has few signs and symptoms and usually presents when it has already metastasized. In women with a strong family history of ovarian cancer or of an associated cancer—colon, endometrium, and breast—annual sonograms for early cancer detection may be worthwhile.

Anatomy

See Chapter 29.

Technique

See Chapter 29.

Investigation of masses in the female pelvis hinges on the identification of the ovaries and the uterus. The easiest structure to find is the uterus. Always note the patient’s menstrual history. The uterus is recognized:

 1. as a structure containing a linear echogenic structure—the endometrial cavity echoes.

 2. by tracking the vagina to it; the uterus lies superior to the vagina. On some occasions, the uterus has an oblique axis.

The ovaries are recognized by:

 1. their location at the end of the utero-ovarian ligament;

 2. the presence of follicles in women who are menstruating;

 3. their proximity to the iliac vessels particularly the internal iliac vein.

Features to look for in an adnexal mass include the following:

 1. Is the mass cystic or solid? If the mass is cystic, does it contain septa or masses? Are the walls thin or fat? Are the walls smooth or irregular?

 2. Is the mass inside or outside the ovary?

 3. What is the size of the mass?

 4. Is the mass round or some other shape, such as tubular?

 5. Is there vascularity within the mass? Is the flow within the mass high or low resistance? Low-resistance flow favors malignancy.

MANEUVERS TO HELP IN THE CHARACTERIZATION OF MASSES

Endovaginal Transducer

The endovaginal transducer is essential

 1. to show mass detail—an extraovarian mass, for example, may turn out to have the shape of a dilated fallopian tube;

 2. to distinguish the uterus from an ovarian mass;

 3. to locate the site of local tenderness—the transducer is pushed toward adnexal structures and the patient reports when and where there is a painful sensation;

 4. to see whether the ovary and neighboring gut move well.

Doppler

Doppler analysis of pelvic cystic structures is of some help. Dilated veins in the region of the ovary can mimic ovarian cysts or hydrosalpinx. Malignant masses may show a low-resistance pattern. Doppler may be of assistance in determining whether an ectopic pregnancy is present, because a flow pattern with high diastolic flow (low resistance) is seen with ectopics and corpus luteum cysts. If a solid mass might be ovarian or a fibroid, use color flow to see whether vessels from the uterus enter and surround a fibroid.

Pathology

Adnexal masses can be divided into four basic groups: (1) single cystic masses; (2) multiple cystic masses; (3) complex masses; and (4) solid masses. With the clinical information and a follow-up examination, a relatively specific diagnosis can be made.

CYSTIC MASSES

Cystic masses have well-defined smooth borders, show good through transmission, and are usually spherical.

Single Intraovarian Cysts

Cystic masses may originate in the ovary or may be separate from the ovary. The differential diagnosis is different depending on whether the cyst is within or outside the ovary. Intraovarian cysts are surrounded by a rim of ovarian tissue. If the cyst is single, echo-free, and less than 2.7 cm in diameter, and if the patient is menstruating, a follicle is by far the most likely diagnosis (Fig. 30-1).

Follicular cysts (reproductive age group)

Related posts:

Possible Invasive Rectal Wall Mass or Anal Sphincter Break Prostate: Prostate Carcinoma, Benign Prostatic Hypertrophy Spinal Ultrasonography Possible Renal Mass Sonographic Abdominal Anatomy Breast Ultrasound

Stay updated, free articles. Join our Telegram channel

Join