Patients present in various manners, making this a challenge to diagnose in an emergency setting. The most classic presentation is a sudden onset of sharp / stabbing pain in either the right or left lower quadrant that only lasts a few seconds to a few minutes and then resolves to a dull ache, only to recur at various intervals with sharp / stabbing pains for a short amount of time. This presentation is associated more with partial or intermittent torsion. Patients also commonly present with a gradual onset of more colicky, unimpressive-type pain. Often patients will also complain of nausea / vomiting when pain occurs.
Abdominal examination may reveal positive rebound and guarding or may be more benign if the ovary is not acutely torsed at time of examination.
Risk factors include ovarian cyst with size greater than 4-6 cm or with solid components, history of prior torsion, pregnancy, and history of pelvic surgery. Patients may not have had a history of ovarian cysts prior.
N83.519 – Torsion of ovary and ovarian pedicle, unspecified side
13595002 – Torsion of ovary
Differential Diagnosis & Pitfalls
- Ectopic pregnancy – persistent pain, positive blood human chorionic gonadotropin (hCG) test, missed menses, other pregnancy-related symptoms (nausea, breast tenderness, fatigue)
- Appendicitis – pain usually not intermittent, other pertinent clinical history
- Ruptured ovarian cyst – usually pain is progressively worse over time, not intermittent; pain relieved with medication
- Fallopian tube torsion – can have similar presentation and clinical examination / imaging findings; treatment is the same
- Bowel issues, including obstruction (large, small) – suspected based on clinical history
- Kidney stone – pain usually not intermittent, blood on urine dip
- Pelvic inflammatory disease – will often have pain with intercourse, vaginal discharge, other complaints
- Cystitis or pyelonephritis