Obgyn · Year 3 · from Obgyn
Case 1: Ovarian Torsion
Patient Demographics
- Age: 25 years
- Sex: Female
- Occupation: Graduate student
Chief Complaint
"I woke up with the worst pain in my right side. I'm going to throw up."
History of Present Illness
The patient presents to the emergency department with sudden onset of severe right lower quadrant pain that woke her from sleep 4 hours ago. The pain is constant, rated 10/10, and has not responded to ibuprofen. She has vomited 3 times since the pain started. She denies fever, diarrhea, dysuria, or vaginal bleeding. Her last menstrual period was 2 weeks ago. She has had similar but less severe episodes of right-sided pain twice in the past month that resolved spontaneously.
Gynecologic History
- Menarche: Age 12
- Cycles: Regular, 28 days
- LMP: 14 days ago
- Sexually active: Yes, one partner
- Contraception: Combined oral contraceptive pills
- Prior pregnancies: G0
- No prior surgeries
Past Medical History
- Ovarian cyst found incidentally on ultrasound 3 months ago during evaluation for pelvic pain (5 cm, described as dermoid)
- Recommended observation at that time
Physical Examination
- Vital Signs: BP 118/72, HR 108 (tachycardic), RR 20, Temp 98.6F
- General: Appears in significant distress, diaphoretic, crying in pain
- Abdomen: Soft, severe tenderness to palpation in right lower quadrant, guarding but no rebound, decreased bowel sounds
- Pelvic: Cervix normal, uterus normal size, right adnexa extremely tender with palpable fullness, left adnexa non-tender
Differential Diagnosis
- Ovarian torsion (most likely given known cyst and sudden onset)
- Ruptured ovarian cyst
- Appendicitis
- Ectopic pregnancy
- Tubo-ovarian abscess
Diagnostic Workup
Laboratory Studies:
| Test | Result | Interpretation |
|---|---|---|
| Urine hCG | Negative | Rules out ectopic pregnancy |
| WBC | 12,500 | Mild leukocytosis (stress response) |
| Hemoglobin | 13.2 g/dL | Normal (no significant bleeding) |
Transvaginal Ultrasound:
- Right ovary: Enlarged (8 cm), heterogeneous appearance, edematous stroma
- 6 cm mature cystic teratoma (dermoid) within right ovary
- Follicles displaced to periphery
- Doppler: Absent arterial and venous flow to right ovary
- Left ovary: Normal
- No free fluid
Diagnosis
Right Ovarian Torsion
- Sudden severe pain with nausea/vomiting
- Known ovarian mass (risk factor)
- Enlarged, edematous ovary with absent Doppler flow
- Previous intermittent episodes (likely intermittent torsion)
Emergency Surgical Consultation
Indications for Urgent Surgery:
- Clinical presentation strongly suggestive of torsion
- Absent Doppler flow (though normal flow does not exclude torsion)
- Do not delay for additional imaging
Surgical Management: Laparoscopic Detorsion
Operative Findings:
- Right adnexa twisted 720 degrees (2 complete turns)
- Ovary appears dusky purple/blue
- Dermoid cyst (6 cm) visible within ovary
Procedure:
- Detorsion performed by untwisting counterclockwise
- Observed for reperfusion for 10 minutes
- Ovary gradually regained pink color (viable!)
- Ovarian cystectomy performed to remove dermoid
- Ovary preserved
- Oophoropexy (plication to shorten utero-ovarian ligament) to prevent recurrence
Post-Detorsion Appearance:
- Ovary pink with good perfusion
- Capsule intact
- No necrotic areas
Pathology
- Mature cystic teratoma (dermoid cyst)
- Contains hair, sebaceous material, tooth
- Benign
Postoperative Course
- Pain significantly improved
- Started on PO intake evening of surgery
- Discharged POD 1
Patient Counseling
- Ovary was saved despite dusky appearance
- Most ovaries recover function after detorsion (even if they look "dead")
- Oophoropexy reduces but does not eliminate recurrence risk
- Monitor for any return of symptoms
- Fertility should be preserved
Teaching Points
- Ovarian torsion is a surgical emergency - time to intervention matters
- Risk factors: Ovarian mass 5-8 cm (most significant), pregnancy, ovulation induction
- Classic presentation: Sudden severe unilateral pain with nausea/vomiting
- Intermittent torsion: Waxing and waning pain from twisting and untwisting
- Doppler findings can be normal in early or intermittent torsion
- Clinical suspicion should drive decision to operate
- Always attempt detorsion first - do NOT remove ovary based on appearance alone
- Even dusky/blue ovaries frequently recover after detorsion
Clinical Image
Image Description: Laparoscopic image demonstrating a torsed right ovary with dusky purple discoloration. The adnexa is twisted on its vascular pedicle. After detorsion, the ovary gradually regained normal pink coloration indicating restoration of blood flow.
Attribution: Educational illustration. Used for medical education purposes.