Obgyn · Year 3 · from Obgyn
Case 2: Ovarian Torsion
Patient Demographics
- Age: 19 years
- Sex: Female
- Occupation: College student
Chief Complaint
"I woke up with sudden severe pain on my right side and I keep throwing up."
History of Present Illness
The patient presents to the emergency department at 3 AM with sudden onset of severe right lower quadrant pain that woke her from sleep approximately 4 hours ago. She describes the pain as sharp and stabbing, rated 10 out of 10, constant but with intermittent worsening episodes. She has vomited four times since the pain started. She denies any recent trauma or strenuous activity. She recalls having similar but milder episodes of right-sided pain twice in the past 2 months that resolved spontaneously after a few hours. She denies vaginal bleeding, discharge, or dysuria. Her last menstrual period was 2 weeks ago and was normal. She is sexually active with one male partner and uses condoms inconsistently. She has no history of sexually transmitted infections.
Past Medical History
- Previously healthy
- No prior surgeries
- Menarche age 12, regular cycles
- G0
Physical Examination Findings
- Vital Signs: BP 142/88 mmHg, HR 108 bpm, RR 20, Temperature 37.2 degrees Celsius
- General: Young woman in severe distress, lying very still, intermittently writhing with pain
- Abdomen: Soft but tender in the right lower quadrant extending to the right flank, voluntary guarding, mild rebound tenderness on the right, no distension, hypoactive bowel sounds
- Pelvic Examination: External genitalia normal, no vaginal discharge, cervix appears normal, uterus normal size and non-tender, right adnexal tenderness with palpable fullness, left adnexa non-tender
Diagnostic Workup
- Urine Pregnancy Test: Negative
- Complete Blood Count: WBC 13,400/microL (mildly elevated), Hemoglobin 13.2 g/dL, Platelets 268,000/microL
- Urinalysis: Negative for infection, no hematuria
- Transvaginal Ultrasound:
- Right ovary markedly enlarged at 8.5 x 6.2 x 5.8 cm (normal <3 cm3)
- Right ovary contains a 4-cm simple cyst
- Peripheral follicles displaced by central stromal edema
- Color Doppler: Diminished arterial flow to the right ovary compared to left
- Left ovary normal (2.8 cm3), normal arterial flow
- Small amount of free fluid in the cul-de-sac
- Uterus normal
Diagnosis
Right Ovarian Torsion with associated ovarian cyst
- Clinical presentation strongly suggestive: sudden severe unilateral pain with nausea/vomiting
- Ultrasound findings supportive: enlarged edematous ovary with diminished Doppler flow
- Prior intermittent episodes consistent with intermittent torsion/detorsion
Key Teaching Point
Normal Doppler flow does NOT exclude ovarian torsion. Clinical suspicion alone warrants surgical exploration. This patient has diminished but present flow - some patients with torsion have preserved flow due to dual blood supply or intermittent torsion.
Management
Decision for Emergent Surgery:
- Clinical presentation and ultrasound findings highly suspicious for torsion
- Time-sensitive emergency - delays lead to irreversible ovarian necrosis
- Proceed to operating room without further imaging
Procedure: Emergent diagnostic laparoscopy with right ovarian detorsion and cystectomy
Operative Findings:
- Right ovary torsed 720 degrees (two complete twists) on its pedicle
- Right ovary enlarged, edematous, and dusky blue-purple in color
- 4-cm simple ovarian cyst present
- Left ovary and both fallopian tubes normal
- No endometriosis or adhesions
Surgical Procedure:
- Detorsion: The ovary was untwisted counterclockwise
- Observation period: Warm saline irrigation applied; ovary observed for 10-15 minutes
- Color return: Ovary gradually regained pink coloration indicating return of arterial perfusion
- Cystectomy: Simple cyst enucleated to reduce risk of recurrent torsion
- Oophoropexy: Ovary sutured to the pelvic sidewall using permanent suture to prevent recurrence
- Decision NOT to remove ovary: Despite initial dusky appearance, the ovary was preserved because:
- Young patient with desire for future fertility
- Evidence of reperfusion after detorsion
- Studies show ovarian function often recovers even when ovary appears necrotic
Why Preserve the Ovary?
- Multiple studies demonstrate that ovaries appearing "nonviable" at surgery often regain function
- Oophorectomy should be reserved for clearly necrotic ovaries (black, no reperfusion)
- Fertility preservation is paramount in young patients
- Follow-up ultrasound can assess ovarian function
Postoperative Course
Day 0 (POD #0):
- Pain controlled with oral analgesics
- Tolerating clear liquids
- Ambulating
Day 1 (POD #1):
- Discharged home on oral ibuprofen and acetaminophen
- Instructions provided for wound care and activity restrictions
Discharge Instructions:
- Pelvic rest for 2 weeks
- No heavy lifting for 4 weeks
- Report fever, worsening pain, or unusual vaginal discharge
- Follow-up in 2 weeks for wound check
- Follow-up ultrasound in 6-8 weeks to assess ovarian viability
6-Week Follow-up:
- Healing well, no complications
- Follow-up Ultrasound:
- Right ovary now measures 4.2 x 3.1 x 2.8 cm (normal size)
- Normal follicular development visualized
- Doppler flow normal and symmetric bilaterally
- Left ovary unchanged, normal
- Conclusion: Right ovary has recovered function
Pathology of Cyst:
- Simple serous cystadenoma (benign)
Clinical Image
Image Description: Panel A shows transvaginal ultrasound of an enlarged right ovary with peripheral follicles displaced by central stromal edema, characteristic of ovarian torsion. Panel B shows the corresponding laparoscopic view of the torsed ovary with dusky discoloration prior to detorsion. Panel C shows the same ovary after detorsion with return of pink coloration indicating restored perfusion.
Attribution: Ovarian torsion ultrasound images available on Wikimedia Commons, Category: Ultrasound images of ovarian torsion (https://commons.wikimedia.org/wiki/Category:Ultrasound_images_of_ovarian_torsion).