Ovarian torsion is the ﬁfth most common gynecologic emergency.(1)

CasE

A 14-year-old female presented to the Pediatric Emergency Department (PED) with one week of intermittent right lower quadrant (RLQ) abdominal pain. The pain was sudden, sharp, and moderate to severe in intensity, but it spontaneously resolved and was not present at the time of evaluation. She reported no urinary symptoms, and the pain was not associated with bowel movements or food intake.

She had no history of surgeries, including appendectomy, and no chronic health conditions. She took no medications, and her family history was negative for inﬂammatory bowel disease (IBD). Her menstrual cycles were regular, with 28-day intervals, and she experienced no menorrhagia or dysmenorrhea.

In the PED, the patient appeared comfortable and in no distress. Her vital signs were stable, she was afebrile, and she was not tachycardic. She was breathing room air comfortably without any signs of respiratory distress. On physical exam, she had mild RLQ tenderness without rebound tenderness, pain on percussion, or pain at McBurney’s point.

A trans-abdominal ultrasound was performed, which visualized the appendix and showed no signs of inﬂammation, enlargement, or free ﬂuid suggestive of appendicitis. However, a 5-cm ovarian cyst was noted on the right ovary. Despite this, blood ﬂow was visualized in the ovary, and no whirlpool sign (indicating torsion) was seen during the ultrasound.

A urine beta-HCG test was negative for pregnancy, and there was no evidence of a urinary tract infection.

Due to the size of the ovarian cyst and the intermittent, severe nature of the patient’s pain, there was concern for recurrent intermittent ovarian torsion despite the negative ultrasound ﬁndings. She was evaluated by Pediatric Surgery and admitted for further management.

DiagnosiS

Right lower quadrant abdominal pain with concern for intermittent ovarian torsion

Discussion

From Textbook of Pediatric Emergency Medicine

Abdominal pain is a common presenting symptom in Pediatric Emergency Departments. While most cases are due to self-limited conditions like gastroenteritis, the emergency physician's role is to identify those patients whose pain might be the ﬁrst or only sign of a serious condition. (5) This includes surgical pathologies such as appendicitis or intussusception, as well as extra abdominal conditions like pneumonia. Ovarian torsion, in particular, is a diﬃcult diagnosis to make, as its clinical presentation overlaps with many more common causes of abdominal pain. (2,5)

Ovarian torsion is the ﬁfth most common gynecologic emergency.(1) In female patients, especially those of reproductive age, who present with severe and sudden onset unilateral pelvic pain, ovarian torsion should always be considered in the diﬀerential diagnosis.

Ovarian torsion is a challenging diagnosis due to the lack of speciﬁc historical or physical exam ﬁndings. (2) Risk factors for ovarian torsion include the presence of an ovarian mass and a prior history of torsion. (2,3) However, normal ovaries can also undergo torsion, so a lack of risk factors does not rule out the diagnosis. (2) In fact, in the adolescent and pediatric population, torsion without an associated mass or cyst occurs in as many as 46% of cases. (1)

The most common types of ovarian masses in adolescents with ovarian torsion are benign functional ovarian cysts and benign teratomas. (1,2,3) Anatomically, an ovarian mass predisposes the ovary to rotate along the axis of the suspensory and ovarian ligaments, which can cause the ovary to become twisted in this position. (3) Over 85% of patients with ovarian torsion have an ovarian mass, and the risk of torsion increases when the mass is greater than 5 cm. (3)

The most common ﬁnding on ultrasound is an enlarged ovary. (2) However, due to the dual blood supply of the ovary, visualization of blood ﬂow cannot rule out ovarian torsion. (1,3) Even if ultrasound does reveal blood ﬂow, if clinical suspicion remains high for this diagnosis., it is appropriate to consult the appropriate specialists at your institution.

Clinical Presentation of ovarian torsion

The acute onset of moderate to severe pelvic pain can be diﬀuse or unilateral, non-radiating, and often associated with nausea and vomiting. (1,3) The pain is typically sharp and stabbing, but it can also be dull or crampy. Most patients present within 1-3 days of symptom onset. (1,2,3) Precipitating factors, such as recent vigorous activity or abdominal pressure, may be associated with torsion, but the most important aspect of diagnosis is considering torsion as a possibility from the start.

Physical examination ﬁndings are often non-speciﬁc, so imaging studies are used to aid in the diagnosis. Typically, the aﬀected ovary appears enlarged compared to the contralateral ovary. (2) Doppler ﬂow in a twisted ovary may be normal, decreased, or absent. However, normal Doppler ﬂow does not exclude the diagnosis, as incomplete occlusion, intermittent torsion, or collateral blood supply can still maintain some ﬂow and the presence or absence of ﬂow alone should not guide clinical decision making. (1,2)

Takeaways

Consider ovarian torsion in the diﬀerential for any patient with ovaries who presents with severe lower abdominal pain, even if the pain has resolved before arrival.
As emergency providers, we don’t always have a deﬁnitive diagnosis at discharge or admission, but it's crucial to rule out emergent surgical and medical conditions.
The most common ultrasound ﬁnding in ovarian torsion is an enlarged ovary.
Visualization of blood ﬂow on Doppler does not rule out torsion due to the ovary's dual blood supply.
Ovarian torsion is ultimately a surgical diagnosis and may require consultation with pediatric surgery or gynecology.

Author: Derek Scott, MD, is a third-year emergency medicine resident at Brown Emergency Medicine Residency.

Faculty Reviewer: Meghan Beucher, MD, is an attending physician at Hasboro Children’s Hospital and an Assistant Professor and Clinican Educator of Emergency Medicine & Pediatrics

References

1. Adnexal Torsion in Adolescents: ACOG Committee Opinion No, 783 Summary. Obstet Gynecol. 2019 Aug;134(2):435-436. doi: 10.1097/AOG.0000000000003376. PMID: 31348223.

2. Gala PK, Akers AY. Gynecology Emergencies. In: Shaw KN, Bachur RG, Chamberlain JM, et al. eds. Fleisher & Ludwig's Textbook of Pediatric Emergency Medicine, 8e.

3. Laufer MR. Ovarian and Fallopian Tube Torsion. In: UpToDate, Sharp HT (Ed), Wolters Kluwer, (Accessed September 10, 2024.)

4. Lippincott Williams & Wilkins, a Wolters Kluwer business; 2021. Accessed September 08, 2024. https://emergency.lwwhealthlibrary.com/content.aspx? bookid=2984&sectionid=249284493

5. Maniaci V, Neuman MI. Pain: Abdomen. In: Shaw KN, Bachur RG, Chamberlain JM, et al. eds. Fleisher & Ludwig's Textbook of Pediatric Emergency Medicine, 8e. Lippincott Williams & Wilkins, a Wolters Kluwer business; 2021. Accessed September 08, 2024. https:// emergency.lwwhealthlibrary.com/content.aspx?bookid=2984&sectionid=249280368

6. Teachmeanatomy.info. Published 2015. Accessed September 17, 2024. https:// teachmeanatomy.info/wp-content/uploads/Ovarian-ligaments-Ligament-of-Ovary-Suspensory ligament.jpg

Tummy Troubles & Twists: Exploring Pediatric Abdominal Pain and Ovarian Torsion