What is the management plan for a patient with right adnexal mass, abdominal pain radiating to the back, and urinalysis showing blood and leukocytes?

Management of Right Adnexal Mass with Abdominal Pain and Urinalysis Abnormalities

Immediate Diagnostic Approach

Obtain CT abdomen and pelvis with IV contrast immediately to evaluate both the adnexal mass and exclude urologic pathology, as this patient's presentation suggests overlapping gynecologic and urologic etiologies that require comprehensive cross-sectional imaging. 1, 2

The presence of hematuria and leukocytes with right-sided pain radiating to the back raises concern for concurrent urologic pathology (nephrolithiasis, pyelonephritis) that may be contributing to or mimicking adnexal pathology. 2 While ultrasound has already characterized the adnexal mass, CT is essential to:

• Evaluate the urinary tract for stones, hydronephrosis, or infection that could explain the urinalysis findings and back pain 1, 2
• Assess for complications of the ovarian mass including torsion (despite normal Doppler), rupture, or hemorrhage 1
• Identify alternative diagnoses such as appendicitis, diverticulitis, or bowel pathology, which CT detects in approximately 50% of right lower quadrant pain cases 2

Risk Stratification of the Adnexal Mass

The ultrasound findings suggest a complex ovarian mass requiring further characterization, though several features are reassuring:

Favorable features (lower malignancy risk):

• Normal blood flow pattern (reduces torsion and malignancy concern) 1
• Predominantly cystic with anechoic (simple fluid) content 1
• Patient appears to be reproductive age (based on clinical context)

Concerning features requiring attention:

• Size >10 cm (8.3 cm largest dimension approaches this threshold) 3, 4, 5
• Multiple large cysts with largest measuring 3.8 cm 1
• Difficulty distinguishing ovary from adnexa suggests complex architecture 1

Additional Imaging Considerations

If CT demonstrates the adnexal mass has indeterminate features or solid components not well-characterized on ultrasound, obtain MRI pelvis with and without IV contrast to further characterize malignancy risk. 1 MRI achieves superior soft tissue characterization and can identify specific benign entities (endometriomas, dermoids, fibromas) with high accuracy. 1, 6

Do not repeat pelvic ultrasound—the initial study adequately characterized the mass, and additional ultrasound will not change management. 7

Laboratory Evaluation

Obtain the following labs immediately:

• Beta-hCG in all women of reproductive age to exclude ectopic pregnancy, which can present with adnexal mass and abdominal pain 2, 4
• Complete blood count to assess for leukocytosis suggesting infection or inflammation 2
• Urine culture given hematuria and leukocytes to diagnose urinary tract infection or pyelonephritis 2
• CA-125 if malignancy risk stratification is needed after imaging, though this should not delay definitive imaging 4, 5

Management Algorithm Based on CT Findings

Scenario 1: CT identifies urologic pathology (stone, pyelonephritis)

• Treat urologic condition appropriately
• Manage adnexal mass based on characteristics (see below)
• Pain may resolve with urologic treatment

Scenario 2: CT shows simple/minimally complex adnexal cyst without urologic pathology

• If <10 cm and asymptomatic after pain control: observe with repeat ultrasound in 6-12 weeks 1, 3
• If >10 cm or symptomatic: gynecology referral for surgical evaluation 3, 4, 5

Scenario 3: CT/MRI demonstrates high-risk features for malignancy

• Solid components, thick septations (>2-3 mm), ascites, or peritoneal implants warrant immediate gynecologic oncology referral 1, 3, 4, 5
• Do not delay referral—initial management by gynecologic oncologist is the second most important prognostic factor after stage 1

Scenario 4: Acute surgical abdomen (torsion, rupture, hemorrhage)

• Emergency gynecology consultation regardless of imaging findings 4, 5
• Torsion can occur despite normal Doppler flow in early stages 1

Specific Referral Criteria

Immediate gynecologic oncology referral if any of the following:

• Solid components with vascularity on Doppler 1, 3, 4
• Thick septations >2-3 mm 3
• Ascites or peritoneal disease 1, 3, 5
• Bilateral masses 3
• CA-125 elevation with complex mass features 4, 5

Routine gynecology referral if:

• Mass >10 cm (this patient approaches this threshold at 8.3 cm) 3, 4, 5
• Persistent mass >12 weeks 3
• Symptomatic mass requiring intervention 4, 5

Critical Pitfalls to Avoid

• Do not assume pain is solely from the adnexal mass—the urinalysis abnormalities and back radiation strongly suggest concurrent urologic pathology requiring evaluation 2
• Do not delay CT for oral contrast—IV contrast alone is sufficient and avoids treatment delays 2
• Do not discharge without clear return precautions for worsening pain, fever, or vomiting suggesting torsion or rupture 2, 4
• Do not overlook torsion risk—masses 5-10 cm have highest torsion risk, and normal Doppler does not exclude early torsion 1, 4
• Do not order plain radiography—it provides no useful diagnostic information for adnexal masses 2

Pain Management

Provide appropriate analgesia while diagnostic workup proceeds, but avoid masking peritoneal signs that might indicate surgical emergency. 2