Review Question - QID 218778

This patient with a history of a moderately-sized benign ovarian cyst presenting with sudden severe pelvic pain, nausea, vomiting, a low-grade fever, and ultrasound showing a diffusely enlarged left ovary has ovarian torsion.

Ovarian torsion is caused by twisting of the ovary around the suspensory ligament of the ovary, leading to impaired venous outflow and arterial inflow. This leads to engorgement of the ovary, which can be seen on ultrasound. The main risk factor for ovarian torsion is the presence of an ovarian cyst or mass, especially those over 5 cm in diameter. Patients with ovarian torsion present with sudden-onset, severe pelvic pain, nausea, vomiting, and low-grade fever. The diagnosis can be made with a Doppler ultrasound of the pelvis showing an enlarged ovary with no Doppler flow. Ovarian torsion is a surgical emergency and should be treated with emergent surgical detorsion to maintain ovarian viability.

Asfour et al. studied the risk factors for ovarian torsion. The authors found that ovarian cysts were 3 times more likely to be present in patients with ovarian torsion than those without. They recommended that a high index of suspicion for torsion be maintained for patients with an ovarian cyst presenting with pelvic pain.

Incorrect Answers:
Answer 1: Ectopic pregnancy presents with unilateral pelvic pain and an adnexal mass. The pain is related to the size of the ectopic pregnancy, which is implanted within the fallopian tube in most cases. In patients with ectopic pregnancy, a urine beta-hCG test is positive and a quantitative beta-hCG is used to track the results of treatment. Ectopic pregnancy is treated with methotrexate or surgery, consisting of salpingectomy or salpingostomy.

Answer 2: Endometriomas present with abdominal or pelvic pain, dyspareunia, and dysmenorrhea. On ultrasound, a cystic mass with an internal "ground glass" appearance is seen rather than an engorged ovary. Endometriomas can be treated with observation for asymptomatic patients or cystectomy for symptomatic patients.

Answer 3: Ovarian cyst rupture should be considered in the differential diagnosis of ovarian torsion in patients with an ovarian cyst. Patients with ovarian cyst rupture would also present with severe pelvic pain, nausea, and vomiting. However, ultrasound would show a ruptured cyst rather than a diffusely enlarged ovary. Abdominal free fluid may also be seen with cyst rupture. Management is centered on pain control.

Answer 5: Tubo-ovarian abscess presents with an adnexal mass, fever, chills, and unilateral pelvic pain. On ultrasound, tubo-ovarian abscesses appear as a complex, multilocular mass rather than diffuse ovarian engorgement. Treatment involves broad-spectrum antibiotics and surgical drainage for larger abscesses.

Bullet Summary:
Ovarian torsion is a surgical emergency that presents with sudden severe pelvic pain, nausea, vomiting, and an engorged ovary without Doppler flow on ultrasound.