What is the management plan for a patient with abdominal pain, a 1.5 cm left adrenal adenoma, a simple-appearing right renal cyst, renal (kidney) vascular calcifications, and possible small nonobstructing kidney stones found on a computed tomography (CT) scan of the abdomen?

Management of Incidental CT Findings in a Patient with Abdominal Pain

The primary focus should be determining whether the abdominal pain is related to the small nonobstructing kidney stones versus other causes, while the 1.5 cm adrenal adenoma and simple renal cyst are likely incidental findings requiring minimal intervention.

Immediate Assessment Priorities

Address the Abdominal Pain

• Evaluate for renal colic characteristics: flank pain radiating to groin, hematuria, or urinary symptoms that would suggest the small nonobstructing stones are symptomatic 1, 2
• Check for urological emergencies: fever with obstruction, signs of sepsis (hypotension, leukocytosis), or intractable pain unresponsive to analgesia 2, 3
• Perform urinalysis to assess for hematuria (supports stone-related pain) and signs of infection 2
• Measure serum creatinine to assess renal function, particularly important given bilateral kidney involvement 1, 3

Rule Out Alternative Causes

• The CT has already excluded most acute surgical causes of abdominal pain including appendicitis, diverticulitis, cholecystitis, and bowel obstruction 4
• Consider whether pain characteristics fit the incidental findings or suggest another etiology entirely

Management of Small Nonobstructing Kidney Stones

If Stones Are Causing Symptoms

• Provide NSAIDs as first-line analgesia (diclofenac, ibuprofen) which are superior to opioids for renal colic 1, 2
• Offer medical expulsive therapy with alpha-blockers for stones >5mm in the distal ureter if conservative management is appropriate 1
• Conservative management duration: maximum 4-6 weeks from presentation; intervention indicated if stone doesn't pass within 28 days or symptoms worsen 1, 3

If Stones Are Truly Asymptomatic and Nonobstructing

• Conservative management with observation is appropriate for small, asymptomatic, nonobstructing stones 1
• Preventive measures: ensure fluid intake achieving urine volume ≥2.5 liters daily 1
• Follow-up imaging with ultrasound combined with KUB radiography for routine surveillance to reduce radiation exposure 1, 3

Management of 1.5 cm Left Adrenal Adenoma

This lesion requires hormonal evaluation but likely represents a benign, non-functional incidentaloma.

Hormonal Assessment Required

• The majority of adrenal cysts and small adenomas are benign and non-functional 5, 6
• Perform hormonal evaluation to exclude functional adenoma, though this size lesion is typically benign 6
• Most adrenal cysts are asymptomatic and detected incidentally between ages 40-60 with slight female predominance 5

Imaging Characteristics to Confirm Benign Nature

• Benign adrenal adenomas typically appear well-demarcated, rounded, with homogenous internal structure and low attenuation (<20 Hounsfield Units) on CT 5
• If imaging characteristics are consistent with benign adenoma and hormonal workup is negative, conservative management with observation is recommended 5, 6

Follow-Up Strategy

• Small, asymptomatic, non-functional lesions with benign characteristics may be treated conservatively with regular follow-up by CT or ultrasound and hormonal evaluation 6
• When uncertainty exists regarding benign nature, additional work-up or follow-up imaging is needed 5

Management of Simple-Appearing Right Renal Cyst

Simple renal cysts are extremely common incidental findings requiring no intervention.

• Simple renal cysts are benign and do not require treatment or follow-up unless they become symptomatic (rare) or demonstrate complex features 4
• The CT has already characterized this as simple-appearing, which excludes complex features requiring further evaluation 4
• No further action needed for this finding

Management of Renovascular Calcifications

These represent chronic vascular changes and are not acutely relevant to the current presentation.

• Renovascular calcifications indicate chronic vascular disease but do not require specific urological intervention 4
• Address cardiovascular risk factors as part of routine medical care, but this is not the focus of the acute presentation

Common Pitfalls to Avoid

• Do not assume all small stones will pass spontaneously: presence of moderate-to-severe hydronephrosis indicates higher risk of passage failure even with small stones 2, 3
• Do not delay drainage if infection is present with obstruction: this constitutes a urological emergency requiring percutaneous nephrostomy within hours 2, 3
• Do not over-investigate the simple renal cyst: simple cysts are benign and common, requiring no follow-up 4
• Do not ignore the adrenal adenoma entirely: hormonal evaluation is necessary to exclude functional lesions, though most are benign 5, 6

Recommended Management Algorithm

1. Determine if abdominal pain is stone-related through clinical assessment and urinalysis 1, 2
2. If symptomatic stones: provide NSAIDs, consider medical expulsive therapy, plan follow-up imaging in 4-6 weeks 1, 2
3. If asymptomatic stones: conservative management with hydration and surveillance imaging 1
4. Adrenal adenoma: obtain hormonal workup; if non-functional and <4cm, observe with follow-up imaging 5, 6
5. Simple renal cyst: no action needed 4
6. If pain persists or worsens: reassess for alternative diagnoses and consider urology referral 2, 3