The female pelvic cavity contains the upper female reproductive tract (ovaries, fallopian tubes, uterus, and cervix). The ovaries, fallopian tubes, and surrounding connective tissues (eg, uterine broad ligament) are referred to as the adnexa. The pelvic cavity also contains the intestines, lower ureters, and bladder. A pelvic mass may originate from any of these structures.
A pelvic mass may be symptomatic or asymptomatic and may be detected during pelvic examination or with an imaging study. A pelvic mass may be benign. low-malignant potential, or malignant.
The etiology, diagnosis, and treatment of a female pelvic mass vary by reproductive phase or status: premenarche, reproductive age, pregnancy, or menopause. Pelvic masses in children and premenarchal adolescents are discussed here.
Etiology of Female Pelvic Mass in Children
In children, the most common type of mass in the female reproductive tract varies by age group (1).
Neonates and infants may have follicular ovarian cysts if maternal hormones stimulate cyst development in utero or during the first few months of life. A cyst in a fetus may be detected on obstetric ultrasound (2).
In prepubertal girls, pelvic masses are uncommon. Ovarian masses may be follicular ovarian cysts or, rarely, benign or malignant tumors. Germ cell tumors, including gonadoblastoma and mature teratomas, are the most common type of ovarian neoplasm in children, and benign epithelial tumors (eg, serous and mucinous cystadenoma) may also occur (3). Malignant tumors include immature teratoma, germinoma, granulosa cell tumor, and Sertoli-Leydig cell tumor. Some tumors are hormonally active and can cause precocious puberty, such as benign sex cord stromal tumors (thecoma-fibroma). Other causes of pelvic mass before puberty are paratubal cysts (eg, mesonephric cysts or cysts of the broad ligament) or paraovarian cysts.
At puberty, if congenital reproductive tract anomalies block the flow of menses, hematocolpos (blood expands the vagina) or hematometra (blood expands the uterus) may develop.
Pelvic inflammatory disease is rare in prepubertal girls but can occur and may be complicated by a tubo-ovarian abscess or hydrosalpinx.
Etiology references
1. American College of Obstetricians and Gynecologists’ Committee on Practice Bulletins—Gynecology. Practice Bulletin No. 174: Evaluation and Management of Adnexal Masses. Obstet Gynecol. 2016 (reaffirmed 2021);128(5):e210-e226. doi:10.1097/AOG.0000000000001768
2. Zampieri N, Borruto F, Zamboni C, Camoglio FS: Foetal and neonatal ovarian cysts: a 5-year experience. Arch Gynecol Obstet. 2008;277(4):303-306. doi:10.1007/s00404-007-0483-5
3. Birbas E, Kanavos T, Gkrozou F, Skentou C, Daniilidis A, Vatopoulou A: Ovarian Masses in Children and Adolescents: A Review of the Literature with Emphasis on the Diagnostic Approach. Children (Basel). 2023;10(7):1114. Published 2023 Jun 27. doi:10.3390/children10071114
Evaluation of Female Pelvic Mass in Children
History
General medical history is obtained, and for infants, birth history and mother's obstetric history are included. Family history of cancer, especially ovarian cancer, is important. The medical history is obtained from the parent (or caregiver) and the child, if age appropriate.
History of present illness includes whether there are symptoms associated with the mass (eg, pain, pressure, vaginal bleeding, fever).
Review of systems should seek symptoms of possible causes, including the following:
Pelvic pain, nausea, vomiting: Adnexal torsion
Pubertal development within typical age range, vaginal or suprapubic pain, without vaginal bleeding: Possible congenital reproductive tract anomaly with hematocolpos or hematometra
Precocious puberty: A feminizing ovarian tumor
Vaginal discharge, fever, and pelvic pain: Pelvic infection, with possible tubo-ovarian abscess
Physical examination
A general physical examination is done. The abdomen is evaluated for abdominal distention, mass, ascites, tenderness, and peritoneal signs.
If a pelvic examination in a child is required, the parent and child should be educated regarding the examination so they know what to expect and to build trust between the child and clinician. The goal of the examination should be to obtain necessary information without causing fear or unnecessary discomfort to the child.
Examination of the external genitals and perineal and groin area should note any bleeding, discharge, bruising, or injury.
Red flags
The following findings are of particular concern:
Adnexal mass with ultrasonographic features of malignancy in a patient with an elevated tumor marker: Possible malignant tumor
Vaginal discharge, fever, chills, lower abdominal tenderness, and/or signs of genital injury: Possible pelvic infection, with possible tubo-ovarian abscess and/or sexual abuse
Interpretation of findings
Severe pain suggests an etiology that requires urgent treatment. Adnexal torsion is an etiology that requires prompt surgical treatment.
A pelvic mass in a girl with precocious puberty raises concern for a hormone-producing tumor.
Testing
In children, the pelvic examination is typically limited, and imaging is done to evaluate for a pelvic mass. Transabdominal ultrasound is preferred over transvaginal ultrasound in young children and prepubertal adolescents. If ultrasound does not clearly delineate size, location, and consistency of the mass, another imaging test (typically, MRI) may be needed.
A complete blood count is done if the signs and symptoms are consistent with a pelvic infection. A sample of vaginal discharge can be collected without a speculum examination, using methods appropriate for children. The sample is cultured for common vaginal bacterial infections or candidiasis. If sexual abuse is suspected, nucleic acid amplification tests (NAATs) are done; NAATs can detect both gonorrhea and chlamydia.
Signs of precocious puberty require an endocrinologic evaluation. In patients with an ovarian mass and a suspected nonepithelial neoplasm, tumor markers (eg, alpha-fetoprotein, lactate dehydrogenase, inhibin) are measured.
Treatment of Female Pelvic Mass in Children
A pelvic mass in infants or children is managed based on the etiology.
Some adnexal masses may be safely monitored and may resolve spontaneously (eg, follicular ovarian cysts).
Surgery is required if a benign or malignant neoplasm is suspected based on imaging or tumor markers, or if adnexal torsion is likely (1). Fertility-preserving surgery is preferred whenever possible (2).
Surgery may also be required for a congenital reproductive tract abnormality to allow menstrual flow.
Treatment references
1. Adnexal Torsion in Adolescents: American College of Obstetricians and Gynecologists (ACOG) Committee Opinion No, 783. Obstet Gynecol. 2019;134(2):e56-e63. doi:10.1097/AOG.0000000000003373
2. Delehaye F, Sarnacki S, Orbach D, et al: Lessons from a large nationwide cohort of 350 children with ovarian mature teratoma: A study in favor of ovarian-sparing surgery. Pediatr Blood Cancer. 2022;69(3):e29421. doi:10.1002/pbc.29421
Key Points
The most common type of pelvic mass in children varies by age group.
A pelvic mass may be symptomatic or asymptomatic and may be benign or malignant.
Neonates and infants (or even fetuses) may develop follicular ovarian cysts due to stimulation by maternal hormones.
Germ cell tumors, particularly mature teratomas, are the most common type of ovarian neoplasm in children.
Evaluate a child with a suspected pelvic mass with imaging; transabdominal ultrasound is preferred to transvaginal ultrasound in young children or prepubertal adolescents.
