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Key Terms

  1. Adnexal: refers to tube and ovary and adjacent area in the female pelvis.

  2. Cystic mass: refers to a mass containing fluid and having a thin, regular wall.

  3. Complex mass: contains both cystic and solid components.

  4. Solid mass: has solid central consistency.

  5. Torsion: twisting of adnexa and its vascularity, usually resulting in compromised blood flow and acute or recurrent pelvic pain.


Sonography is the diagnostic modality of choice for the initial evaluation of most patients with a pelvic mass. This is particularly true for pelvic masses thought, on a clinical basis, to be benign. Although the sonographic features of a pelvic mass frequently do not permit a specific histopathologic diagnosis, sonography usually provides clinically important parameters for the pelvic mass.1 These include the following:

  1. Confirmation of the presence or absence of a pelvic mass

  2. Delineation of its size, internal consistency, and contour

  3. Establishment of the origin and anatomic relationship of the mass to other pelvic structures

  4. A survey to establish the presence or absence of abnormalities associated with malignant disease, such as ascites or metastatic lesions

  5. Guidance for aspiration or biopsy of selected pelvic masses, such as tubo-ovarian abscesses

Each of these parameters will be discussed, as well as specific types of pelvic masses. This chapter is structured to emphasize the way sonographic evaluation of pelvic masses proceeds from evaluation of clinically pertinent parameters to consideration of specific lesions. It includes recently published guidelines for distinguishing benign versus malignant pelvic masses by the International Ovarian Tumor Analysis (IOTA) and guidelines for the follow-up of adnexal lesions by the Society of Radiologists in Ultrasound (SRU).2,3

Information gained by sonography is useful in guiding the gynecologic surgeon through decisions regarding surgical intervention. In general, masses that are over 5 cm in average dimension, contain irregular solid components, or are associated with significant amounts (over 20 mL) of intraperitoneal fluid require surgical treatment.4 Similarly, pelvic masses that are associated with acute pelvic pain may require immediate surgical intervention because they may be associated with adnexal torsion.5,6 In contrast, masses that are completely cystic and smaller than 4 to 5 cm may be observed over a few months with repeat sonograms to document any change in size. If the cystic mass is unilocular (<10 cm) it also can often be observed.7 Although small (<5 cm) unilocular cystic adnexal masses can be detected in postmenopuasal women, only a minority will represent a malignant neoplasm.4 However, since the postmenopausal ovary should not be larger than approximately 2 cm these small cystic masses that are greater than 1 cm do require follow-up ultrasound evaluation if surgical exploration is not performed. In patients with recurrent ovarian carcinoma, sonography has been found to be highly accurate in the detection of ascites, but it is a poor predictor of the presence ...

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