Uterine leiomyomas are not often seen in this age group. Obstructive uterovaginal anomalies occur during adolescence, at the time of menarche, or shortly thereafter. Frequently, the correct diagnosis either is not suspected or is delayed (121). A wide range of anomalies can occur, from imperforate hymen to transverse vaginal septa; from vaginal agenesis with a normal uterus and functional endometrium to vaginal duplications with obstructing longitudinal septa, and obstructed uterine horns (Fig. 14.13). Patients may seek treatment for cyclic pain, amenorrhea, vaginal discharge, or an abdominal, pelvic, or vaginal mass. A hematocolpos, hematometra, or both frequently will be present, and the resulting mass can be quite large (34).
Of all age groups of sexually active women, adolescents have the highest rates of PID (83). Thus, an adolescent who has pelvic pain may have an inﬂammatory mass. Such masses may consist of a tubo-ovarian complex (a mass of matted bowel, tube, and ovary), tubo-ovarian abscess (a mass consisting primarily of an abscess cavity within an anatomically defined structure such as the ovary), pyosalpinx, or, chronically, hydrosalpinx.
The diagnosis of PID is primarily a clinical one based on the presence of lower abdominal, pelvic, and adnexal tenderness; cervical motion tenderness; a mucopurulent discharge; and elevated temperature, white blood cell count, or sedimentation rate (see Chapter 18). The risk of PID is clearly associated with that of acquiring STDs, and methods of contraception may either decrease the risk (male latex condoms) or increase it (the intrauterine device in the interval immediately after insertion) (122,123).
In adolescents, pregnancy should always be considered as a cause of a pelvic mass. In the United States, nearly half of adolescent women have experienced sexual intercourse (124). Most pregnancies in adolescents are unintended; 100% of pregnancies in adolescents younger than age 15, 87% in women aged 15 to 17, and 79% in women aged 18 to 19 are unintended (94). Adolescents may be more likely than adults to deny the possibility of pregnancy because of wishful thinking, anxiety about discovery by parents or peers, or unfamiliarity with menstrual cycles and information about fertility. Ectopic pregnancies may cause pelvic pain and an adnexal mass. The increasing incidence of ectopic pregnancies in the United States is strongly associated with rising rates of PID. With the availability of quantitative measurements of β-hCG, more ectopic pregnancies are being discovered before rupture, allowing conservative management with laparoscopic surgery or medical therapy (see Chapter 20). The risk of ectopic pregnancy varies by method of contraception; users of no contraception have the highest risk, whereas oral contraceptive users have the lowest risk (125). As with older patients, paraovarian cysts and nongynecologic masses can appear as a pelvic or abdominal mass in adolescents (Fig. 14.15).
Management of Pelvic The management of masses in adolescents depends on the suspected diagnosis and the initial
Masses in Adolescents symptom. Figure 14.8 outlines a plan of management for pelvic masses in adolescents. Asymptomatic unilocular cystic masses are best managed conservatively because the likelihood of malignancy is low. If surgical management is required based on symptoms or uncertainty of diagnosis, attention should be directed to minimizing the risks of subsequent
Figure 14.15 A: Paratubal cyst. B: Paratubal cyst, incised.