The Case

A 28-year-old female presents with severe lower right quadrant pain. Her intermittent pain started three days ago. She has had several episodes of non-bloody emesis, which usually occurs when the pain worsens, but she denies vaginal bleeding, vaginal discharge, urinary symptoms, fever, diarrhea, back pain, or other symptoms. She is significantly tender in the right lower quadrant, but a pelvic exam is unrevealing.

Abdominal and pelvic pain are common presentations in the emergency department, ranging from benign to serious. One important and dangerous condition not to miss is ovarian torsion.

Ovarian torsion occurs when the ovary completely or partially rotates on the ligamentous supports, resulting in necrosis and infertility if missed.^1–5 Here are five myths that can mislead the emergency physician.

Myth #1: Only Women of Reproductive Age Experience Ovarian Torsion

While ovarian torsion most commonly affects women of reproductive age, typically around 30 years old, the risk factor most strongly associated with torsion is an adnexal mass >5 cm, occurring in up to 80 percent of patients with torsion; underlying risks include polycystic ovarian syndrome, undergoing fertility therapies, history of previous torsion, and history of tubal ligation.^3–16

Approximately 15 percent of ovarian torsion cases occur in pediatric patients, which is thought to occur due to an elongated utero-ovarian ligament.^{3–5,11–13} Unlike other patient populations, more than half of pediatric patients with ovarian torsion have normal ovaries.^3–5,9–16 Postmenopausal patients account for another 15 percent of cases, although almost all of these patients have an enlarged ovary or mass within the pelvis. Pregnant patients are also at risk, accounting for 10 to 25 percent of all cases.^5,9,16–20 In fact, pregnancy is a significant risk factor for torsion, primarily due to progesterone increasing the risk of ovarian cyst formation.^16–20 Most patients with torsion during pregnancy experience it in the first 17 weeks (81 percent), and 73 percent of these patients have undergone fertility therapy.^4,18–20 Fertility treatments can result in ovarian hyperstimulation, further increasing the risk of ovarian cyst formation.5,15

Key Point: Consider ovarian torsion in female patients of all ages.

Myth #2: All Patients with Ovarian Torsion Present with Acute Severe Pain and Vomiting

Symptoms of ovarian torsion occur due to occlusion of vascular flow from torsion of the vascular pedicle. We classically associate this with abrupt, severe pain in the lower abdomen that radiates to the flank or inguinal area as well as nausea and vomiting.^{4–7,10,21,22} However, sudden, severe pain only occurs in 50 percent of patients.^4–7,22 Some form of pain is present in up to 90 percent of patients, but the description of the pain varies.^4–7,22 Symptoms can be vague, lasting for days to months, and be constant or episodic due to intermittent torsion and detorsion of the ovary.23,24 Pain may resemble that of appendicitis, urolithiasis, ectopic pregnancy, and other conditions. Nausea and vomiting occurs in up to 70 percent of patients, and fever may also occur in 2 to 20 percent of patients, further complicating the diagnosis.^{4,6,7,12,23,24} Diagnosing torsion in infants is extremely difficult, as these patients may present with irritability, fussiness, vomiting, or feeding intolerance.^5,11–13 Pediatric females can present with diffuse pain and fever, typically resulting in delayed diagnosis.^5,25,26

Importantly, the critical ischemia time for the ovaries that results in necrosis is unknown. Patients may have symptoms for hours to days, and there is no specific time cutoff that reliably predicts irreversible necrosis.^4,5,27–29

Key Point: Patients with ovarian torsion may present with constant, severe, abrupt, intermittent, or mild pain.