What is the next step in managing a 29-year-old female with hematuria, right flank pain, and a 30 mm right ovarian cyst?

Management of Hematuria with Right Flank Pain and Ovarian Cyst

The patient with gross hematuria and right flank pain requires urgent urologic referral for comprehensive evaluation, regardless of the presence of the 30mm ovarian cyst. 1

Evaluation of Hematuria

Initial Assessment

• Gross hematuria with clots, especially when accompanied by flank pain, requires urgent evaluation as it carries a high risk of malignancy (>10%) 1, 2
• The presence of flank pain suggests possible upper urinary tract pathology such as nephrolithiasis, but urologic malignancy must still be excluded 1, 3
• The 30mm ovarian cyst is likely an incidental finding and falls into the "almost certainly benign" category (O-RADS 2) 1

Diagnostic Approach

• The combination of hematuria and flank pain requires evaluation of both the urinary tract and the incidentally found ovarian cyst 1
• CT scan without contrast already performed was appropriate as initial imaging for flank pain and hematuria 1
• The 30mm ovarian cyst is likely benign as it falls below the 3-5cm threshold for increased concern in premenopausal women 1

Management Plan

Urologic Evaluation (Priority)

• Urgent urologic referral is mandatory for all patients with gross hematuria, even if self-limited 1, 3
• The urologist will likely perform:
  • Cystoscopy to evaluate the bladder for malignancy 1
  • Possible upper tract imaging if not already adequately assessed by the non-contrast CT 1, 3
• Do not delay urologic referral while managing the ovarian cyst 1, 3

Ovarian Cyst Management

• The 30mm ovarian cyst in a premenopausal woman is likely physiologic or a benign finding 1
• For premenopausal women, simple cysts or classic benign lesions <3cm require no follow-up 1
• If the cyst has concerning features on imaging (which is not indicated in this case), follow-up ultrasound in 8-12 weeks may be appropriate 1
• The cyst is unlikely to be the cause of the hematuria, as ovarian pathology rarely causes urinary bleeding unless there is direct invasion into the bladder 4, 5

Laboratory Evaluation

• Complete urinalysis with microscopic examination to assess for:
  • Dysmorphic RBCs or RBC casts (suggesting glomerular source) 1, 3
  • WBCs or bacteria (suggesting infection) 1, 3
• Serum creatinine to assess renal function 1, 3
• Urine culture to rule out infection 1, 3

Important Considerations

• Do not assume the ovarian cyst is the cause of hematuria and flank pain without excluding urologic pathology 1, 3
• Do not delay urologic evaluation even if symptoms resolve spontaneously 1, 3
• The presence of clots in the urine suggests a lower urinary tract source rather than glomerular bleeding 1, 3
• If the patient is taking antiplatelet or anticoagulant medications, evaluation should still proceed as these medications do not cause hematuria but may unmask underlying pathology 1, 3

Potential Causes of Symptoms

• Urinary tract: urolithiasis, malignancy, infection, trauma 1
• Ovarian: hemorrhagic cyst (though unlikely to cause urinary bleeding) 6, 7
• Renal: glomerulonephritis, interstitial nephritis (less likely with gross hematuria and clots) 1, 3