Overview of Adnexal Masses:
A lump in the tissue of the adnexa is known as an adnexal masses. The structures (organs or tissues) which are either in the proximity of the uterus or are closely related to the functioning of the uterus are referred to as adnexa. These structures include the ovaries, fallopian tubes, connective tissues, ligaments and associated blood vessels.
There are various types of adnexal masses but they can be broadly classified into gynecological and non-gynecological. Masses of non-gynecological origin include appendix masses, bowel related conditions and pelvic kidney amongst others. However, in this article we will focus on adnexal masses from gynecological sources.
Gynelogical Adnexal Masses:
Gynecological adnexal masses can be further divided into ovarian, tubal, tubo-ovarian and paraovarian masses.
Tubal adnexal masses are those masses which affect the fallopian tube. The fallopian connect the ovaries to the uterus and are responsible for delivering the ovarian egg (ova) to the uterus during pregnancy. Ectopic pregnancy and hydrosalpinx are example of such masses:
Ectopic pregnancy is an abnormal case of pregnancy in which the fertilized egg does not grow inside the uterus but instead grows outside it in abnormal places like the fallopian tubes, horns of the uterus, cervix or the ovaries. This type of pregnancy happens in 1 out of every 50 cases. Such pregnancies can’t continue normally and may cause damage to maternal structures. Early detection is of utmost importance as a delay can cause severe life threatening bleeding and an emergency situation.
A hydrosalpinx is a condition wherein the fallopian tubes are blocked, resulting in a collection of fluid. Blocked fallopian tubes can cause infertility. It is technically possible to get pregnant with one working fallopian tube, but pregnancy rates are lower in such cases. Hydrosalpinx is mostly caused due to infections known as pelvic inflammatory diseases. In most of the cases, the patient may not experience any symptoms and may come to know about the condition only after diagnosis for infertility. The diagnosis of hydrosalpinx may involve hysterosalpingogram (HSG), ultrasound or laparoscopy .Treatment includes corrective surgery like neosalpingostomy or removal of fallopian tubes.
Ovarian adnexal masses:
The ovaries are almond shaped & sized organs that produce eggs for the process of reproduction. They also produce estrogen & progesterone hormones. Ovarian adnexal masses can be benign or cancerous.
An ovarian cyst is a closed sac like structure which contains fluid. Such a condition is common and can occur at any age. There are two types of ovarian cysts, the first types of cysts are functional and pathological cysts.
They are usually harmless in nature and develop during the menstrual cycle. They resolve spontaneously in 2-3 menstrual cycles, requiring no medication and just observation.
- Follicular ovarian cysts:
They are the most common type of cysts. The egg produced by ovaries moves into the uterus (womb). This egg grows in the follicle, which protects the egg with help of fluids. Normally when the egg is released, the follicle should burst but in some cases, the fluid contained by the follicle is not shredded even after releasing the egg, or in some cases the follicle does not release the egg itself. As a result such a follicle swells with fluid, and results in the formation of follicular ovarian cyst.
- Luteal ovarian cysts : Such cysts are not as common as follicular cysts. They are formed when corpus luteum is filled with blood. Corpus luteum is a tissue which is left behind after the egg is released.
Pathological cysts/Benign Neoplasms
- Dermoid cysts (cystic teratomas): Dermoid cysts are the most common type of pathological cysts for women under the age of 30. It forms due to a totipotential germ cell (a primary oocyte). A totipotential germ cell is a cell that can form all orders of cells that are required to form mature tissues. Dermoid cysts contain bone, skin, hair and sometimes even other tissues (e.g. teeth).
- Cyst adenomas: Cyst adenomas are more common to postmenopausal women. Such ovarian cysts develop from cells which cover the outer part of the ovaries. Since they are not inside the ovary they have potential to grow considerably large.
It is also known as endometriosis of ovaries and is caused when a tiny patch of endometrium grows inside the ovaries. During each menstrual cycle the endometrium grows, thickens and sheds. Normally, this blood leaves through the vaginal opening. But when this patch grows in the ovaries the blood has nowhere to go, which results in a buildup of blood and a brownish color.
Ovarian cancer is a rare type of cancer that affects less than 1 million people in India every year, but it accounts for more casualties than any other female reproductive organ cancer. This type of cancer is hard to detect in its early stages. It is usually detected when it has spread within the abdomen and pelvis, but it is very difficult to treat the cancer at this late stage. Therefore, the best time to treat it is during its early stages.
The risk factors of ovarian cancer are, age obesity pregnancy history estrogen therapy family history, smoking, PCOS (polycystic ovary syndrome), smoking, fertility treatment and IUDS (intrauterine devices). The symptoms include problems related to excretion, abdomen area and menstrual cycle. The earlier such type of cancer is detected the better it is for treatment. Diagnosis can be done by pelvic examination, special blood tests, radio imaging techniques and biopsies. The treatment for ovarian cancer depends on how far the cancer has spread and patient’s general health. Treatment usually involves a combination of surgery and chemotherapy
Other types of adnexal masses
The other types of adnexal masses from gynecological sources include tubo-ovarian abscesses and paraovarian cysts. Tubo-ovarian abscesses are caused by pelvic inflammatory disease (PID), since it is one of the late complications of PID. It can be a life threatening condition if the abscess ruptures. Paraovarian cyst is a closed sac like structure which contains fluid and is found near the ovary but not attached to it.
Adnexal masses, in many cases are asymptomatic – i.e. the patient does not experience any major symptoms. In such cases, the mass may be diagnosed during a routine pelvic examination. In other cases the symptoms include:
- Unusual abdominal bloating
- Pressure in the abdomen or pelvis
- Abdominal pain
- Back pain
- Weakness and lack of energy
- Torsion (Twisting of the mass)
Other symptoms related to the root cause
Although different masses can be diagnosed with different techniques, a transvaginal ultrasound can be very useful in many cases.The other techniques for diagnosis of adnexal masses are as follows:
- Cervical Culture
- USG + Doppler
- MRI (if indicated)
- Tumor Markers – CA 125, Beta hCG, AFP, CEA
But there is no combination of diagnostic tests /algorithm that will absolutely differentiate between malignant and benign adnexal masses. Only histology can provide the absolute diagnosis
Laparoscopy (with consent for laparotomy taken) is the dominant procedure for management of adnexal masses that are benign. It presents several advantages over laparotomy such as:
: Laparoscopy is a minimally invasive surgery and the incisions made are of the size of 5-15mm.
: The hospital stay if any, due to laparoscopy is relatively much shorter than the stay required due to laparotomy.
: Since the incisions are smaller the pain is also considerably lesser.
: The high magnification provided laparoscopy allows for very accurate identification of adhesions and also allows for very accurate correction of these with restoration of normal anatomy