What is the diagnosis for a patient with a right adnexal (adnexa of the uterus) septated, cystic lesion measuring up to 5.4 centimeters, presenting with right flank pain?

From the Guidelines

For right flank pain with a 5.4 cm right adnexal septated cystic lesion, a pelvic ultrasound is strongly recommended as soon as possible for proper characterization of the lesion, as emphasized by the O-RADS US risk stratification and management system 1. This approach is crucial because the septations within the cyst require further evaluation to determine if the cyst is benign or potentially concerning. The O-RADS US system provides a means to offer consistent interpretations and decrease ambiguity in ultrasound reports, assigning a risk of malignancy based on the characteristics of the adnexal lesion 1.

While waiting for the ultrasound, managing pain with over-the-counter medications like ibuprofen (400-600mg every 6 hours with food) or acetaminophen (650mg every 6 hours) can be beneficial. Applying a heating pad to the painful area for 15-20 minutes several times daily can also provide additional relief. It's essential to monitor for worsening symptoms such as severe pain, fever, vomiting, or dizziness, which would warrant immediate medical attention as they could indicate complications like cyst rupture or torsion.

The relationship between the flank pain and the adnexal cyst is not immediately clear, as the location of the pain (flank) doesn't perfectly align with typical ovarian pain patterns, making the ultrasound crucial to establish this relationship and guide appropriate treatment. The use of a standardized lexicon and definitions, as proposed by the O-RADS US system, facilitates the application of lexicon terms to the risk stratification system, ensuring a more accurate assessment of the lesion's risk of malignancy 1.

Key considerations for the management of adnexal lesions include:

• The size and characteristics of the lesion, such as the presence of septations
• The patient's symptoms, including the severity and location of pain
• The risk of malignancy, as determined by the O-RADS US system or other validated models
• The need for prompt evaluation and treatment to prevent potential complications.

From the Research

Characterization of Adnexal Lesions

• The patient presents with a right adnexal septated, cystic lesion measuring up to 5.4 cm, accompanied by right flank pain, which necessitates further characterization to determine its benign or malignant potential 2, 3.
• Ultrasound is the first-line imaging modality for evaluating adnexal lesions, and it may be sufficient for management recommendations in cases of classic simple cysts, hemorrhagic cysts, endometriomas, dermoids, and obviously malignant lesions 2.

Imaging Evaluation

• Transvaginal ultrasonography is the imaging test of choice for evaluating adnexal masses for size and complexity, and it can help identify high-risk features such as solid components or high color flow on Doppler ultrasonography 3.
• In cases where the ultrasound is nondiagnostic, referral to CT or MRI should be considered, especially in pregnant patients or when there is concern for disease outside the ovary 3, 4.
• The ADNEx MR score can be used to increase the specificity for the diagnosis of benignity or malignancy in indeterminate lesions on ultrasound 2.

Management

• Asymptomatic masses that are determined to be benign may be observed and managed expectantly, while symptomatic or emergent cases require consultation with a gynecologist 3.
• Multimodal assessment tools that use ultrasonography and biomarkers, such as the risk of malignancy index, can be useful in the diagnosis and exclusion of malignant causes 3.
• Recent guidelines, including the O-RADS and SRU guidelines, provide a framework for the management of incidental adnexal cysts, emphasizing the importance of limiting unnecessary imaging follow-up and reducing patient anxiety 5.