Adnexal Mass · Surveillance vs Surgery + Approach

Step-by-step decision

Choose step by step as prompted; reaching an endpoint gives the management recommendation. You can go back a step or restart anytime.

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Full pathway

1. [Decision] Emergency? + risk stratification + menopausal status
   Emergency? + risk stratification (IOTA/O-RADS/RMI) + menopausal status? (Risk stratification: IOTA simple rules/ADNEX model, ACR O-RADS US, or RMI = U × M × CA125.)
   • Torsion/rupture with bleeding (acute abdomen) → Torsion/rupture → emergency surgery
   • Low-risk (simple cyst/IOTA benign/O-RADS 2-3) → Low-risk · surveillance vs surgery
   • Intermediate-high risk (O-RADS 4-5/ADNEX high/raised CA125/solid/ascites) → Intermediate-high → gyne-onc staging surgery
2. [End] Torsion/rupture → emergency surgery
   Ovarian torsion/cyst rupture with bleeding → emergency surgery (laparoscopic preferred): preserve the ovary where possible (detorsion/cystectomy), perform adnexectomy only for clear necrosis.
3. [Decision] Low-risk · surveillance vs surgery
   Low-risk: surveillance or surgery?
   • Asymptomatic simple cyst (premenopausal ≤5 cm / postmenopausal small, normal CA125) → Surveillance
   • Symptomatic/enlarging/persistent/patient prefers surgery → Laparoscopic cystectomy/adnexectomy
4. [End] Surveillance
   Surveillance — premenopausal simple cysts usually resolve spontaneously, serial ultrasound; postmenopausal small simple cysts with normal CA125 can also be followed.
5. [End] Laparoscopic cystectomy/adnexectomy
   Benign-appearing surgical case → laparoscopic ovarian cystectomy (preserve ovary/fertility) or adnexectomy (postmenopausal/larger/not suitable for preservation); avoid intraoperative cyst rupture and spillage.
6. [End] Intermediate-high → gyne-onc staging surgery
   Intermediate-high risk/suspected malignancy → refer to gynecologic oncology; open staging surgery (total hysterectomy + bilateral salpingo-oophorectomy + omentum + peritoneal staging), avoid puncture/rupture and spillage; not suitable for simple laparoscopic cystectomy. Preoperative CA125/HE4 ± imaging.

Source guidelines & references

• Adnexal mass evaluation and management (ACOG 174; IOTA ADNEX/simple rules; ACR O-RADS US)

This pathway is our own synthesis of the decision logic in the guidelines above (not the guideline verbatim); thresholds and workflows change as guidelines update — in practice follow the latest guideline, your institution's protocol and the individual patient.

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