What is the next best step in managing a patient with a history of endometriosis, increased abdominal pain, and complex ovarian cysts on CT?

Management of Complex Ovarian Cysts in a Patient with Endometriosis and Abdominal Pain

The next best step in managing this patient with a history of endometriosis, increased abdominal pain, and complex ovarian cysts on CT is to perform a pelvic ultrasound with Doppler imaging. 1

Rationale for Pelvic Ultrasound

Ultrasound is the preferred imaging modality for further evaluation of ovarian cysts for several important reasons:

• It allows for detailed characterization using the O-RADS risk stratification system
• It can differentiate between endometriomas and infected/complicated cysts
• It provides real-time assessment without radiation exposure
• It can evaluate for signs of torsion or rupture that may require urgent intervention 1

CT scans have limitations in characterizing adnexal masses compared to ultrasound, and the findings in this case (enhancement and edema) raise concern for potential infection that requires further evaluation.

Interpretation of Current Findings

The CT findings in this patient are concerning for several reasons:

• Two complex right ovarian cysts (2.6 cm and 2 cm)
• Peripheral enhancement and adjacent edema
• Worsening abdominal pain
• Possible superimposed infection

While these cysts may represent endometriomas given the patient's history, the enhancement pattern and clinical symptoms suggest potential complications that require immediate characterization.

Management Algorithm

1. Immediate pelvic ultrasound with Doppler

   • Assess for signs of infection (increased vascularity, complex internal echoes)
   • Evaluate for torsion (absent blood flow)
   • Characterize cysts using O-RADS classification

2. Based on ultrasound findings:

   • If infected endometriomas confirmed:

     • Gynecology consultation
     • Antibiotic therapy
     • Possible surgical intervention 1

   • If typical endometriomas without infection:

     • Pain management
     • Follow-up imaging in 8-12 weeks 1

   • If higher O-RADS classification (3 or above):

     • Gynecologic oncology referral 1

Important Considerations

• Superimposed infection in endometriomas requires prompt treatment to prevent abscess formation or sepsis 1
• The size of these cysts (2-2.6 cm) is relatively small, which may influence management decisions - larger cysts (>4 cm) typically warrant more aggressive management due to risk of rupture or torsion 2
• Delaying evaluation of potentially infected cysts can lead to serious complications 1
• While surgical treatment is often considered for symptomatic endometriomas, the immediate concern is ruling out infection or other acute complications 3

Potential Pitfalls

• Relying solely on CT findings without ultrasound confirmation may lead to misdiagnosis
• Assuming symptoms are solely due to endometriosis without ruling out infection or other complications
• Delaying gynecology consultation if infection is confirmed
• Failing to consider that other pathologies can coexist with endometriomas 1

The patient's history of endometriosis increases the likelihood of endometriomas, but the current presentation with worsening pain and concerning imaging findings necessitates prompt ultrasound evaluation to guide appropriate management.