What is the best management approach for a female patient of reproductive age with chronic back and hip pain, a complex ovarian cyst, and a history of mesenteric adenitis?

Management of Chronic Back and Hip Pain with Complex Ovarian Cyst and History of Mesenteric Adenitis

This patient requires immediate comprehensive imaging with transvaginal ultrasound to characterize the ovarian cyst, followed by MRI of the pelvis if the cyst shows complex features, and concurrent MRI of the hip without IV contrast to evaluate the chronic musculoskeletal pain. 1

Immediate Diagnostic Priorities

Ovarian Cyst Evaluation

• Transvaginal ultrasound is the essential first-line imaging modality to characterize the complex ovarian cyst and determine malignancy risk using the O-RADS classification system 1, 2, 3
• The term "complex" indicates this is NOT a simple cyst—it likely has thick walls, septations, solid components, or internal debris that require urgent characterization 4
• Complex cysts in reproductive-age women mandate gynecology referral for further evaluation, as they cannot be managed with simple observation protocols 2
• If ultrasound shows solid components, thick septations, nodularity, or concerning vascularity on Doppler, MRI pelvis with IV contrast becomes the next appropriate test to distinguish benign from malignant features 1

Hip and Back Pain Evaluation

• Plain radiographs of the pelvis and hip should be obtained first to screen for common pathology such as arthritis, fractures, or bone lesions 1
• If radiographs are negative or equivocal and chronic hip pain persists with concurrent back pain, MRI hip without IV contrast (rated 9/9 "usually appropriate") is the definitive next step to exclude hip pathology as the pain source 1
• The combination of hip and back pain requires evaluation to determine if the hip is the primary source or if pain is referred from lumbar spine or sacroiliac pathology 1

Critical Clinical Correlation Needed

History of Mesenteric Adenitis

• While mesenteric adenitis typically represents self-limited lymph node inflammation, the history raises the possibility that the "complex ovarian cyst" could actually be a mesenteric cyst misidentified on prior imaging 5, 6, 7
• Mesenteric cysts are rare (1 per 100,000-250,000 admissions) and are frequently misdiagnosed as ovarian cysts preoperatively, particularly when located in the pelvis 6, 7
• Definitive imaging with MRI or high-quality ultrasound by a specialist is essential to determine the true organ of origin before any intervention 1

Pain Pattern Assessment

• Document whether the back/hip pain is mechanical (worse with activity, better with rest) versus inflammatory (worse at night, morning stiffness) 1
• Assess for radicular symptoms, motor/sensory changes, or autonomic dysfunction that would suggest neurologic involvement 1
• Determine if pelvic pain correlates with the musculoskeletal symptoms or represents a separate process 1

Management Algorithm Based on Imaging Results

If Cyst is O-RADS 2 (Simple Features, <10cm)

• Follow-up ultrasound in 8-12 weeks during proliferative phase after menstruation to allow functional cysts to resolve 2, 3
• Continue conservative management of musculoskeletal pain with physical therapy and NSAIDs 1

If Cyst is O-RADS 3 (1-10% Malignancy Risk)

• Immediate gynecology referral with ultrasound specialist consultation or MRI 4
• Consider CA-125 testing, though it may be falsely negative in borderline or low-grade malignancies 1
• Proceed with hip/back workup in parallel

If Cyst is O-RADS 4 or Higher (≥10% Malignancy Risk)

• Gynecologic oncology consultation prior to any surgical intervention 4
• Obtain CA-125, and if not elevated, consider CEA and CA19.9 4
• Never perform fine-needle aspiration—this is contraindicated due to risk of spreading malignant cells 3, 4

If Cyst is ≥10cm or Causing Mass Effect

• Surgical management is indicated regardless of imaging characteristics 3, 4
• Large cysts require both transvaginal and transabdominal ultrasound for complete evaluation 3

Musculoskeletal Pain Management

Conservative Multimodal Approach

• Physical or restorative therapy (physiotherapy, exercise therapy) should be initiated for chronic back and hip pain, with evidence supporting effectiveness for 2-18 months 1
• NSAIDs are appropriate for back pain as part of the pharmacologic strategy 1
• Cognitive behavioral therapy, biofeedback, or relaxation training should be performed for chronic pain conditions with evidence of benefit up to 2 years 1

If MRI Hip Shows Specific Pathology

• Intra-articular pathology (labral tears, cartilage defects): Consider MR arthrography or CT arthrography for detailed assessment 1
• Extra-articular soft tissue abnormalities (tendonitis, bursitis): Ultrasound-guided corticosteroid injection may be appropriate 1
• Image-guided diagnostic hip injection (rated 8/9) can definitively determine if hip is the pain source when concurrent back/pelvic pathology exists 1

Critical Pitfalls to Avoid

• Do not apply simple cyst management protocols to complex cysts—the "watch and wait" approach only applies to thin-walled, anechoic, unilocular cysts without internal elements 4
• Do not delay gynecology referral for complex cysts in reproductive-age women—even with normal CA-125, complex features require specialist evaluation 4
• Do not assume the ovarian cyst is causing the back/hip pain—these are likely separate processes requiring parallel workup 1, 8
• Do not overlook the possibility of mesenteric cyst given the history—ensure imaging definitively establishes organ of origin 5, 6, 7
• Do not order CT pelvis as first-line imaging for adnexal masses—it has poor soft-tissue discrimination and unnecessary radiation exposure in reproductive-age women 1

Monitoring Strategy

• Establish a monitoring plan for medication side effects and compliance before initiating long-term pharmacologic therapy for chronic pain 1
• Document functional status, quality of life impacts, and psychosocial factors (anxiety, depression, coping mechanisms) that affect chronic pain 1
• If conservative management fails after 3-6 months, reassess with repeat imaging and consider interventional pain management or surgical consultation 1