Case #040

Sudden, severe, one-sided pelvic pain with vomiting and an adnexal mass is ovarian torsion until proven otherwise, and the first job is to remove the diagnosis that kills fastest: a negative pregnancy test takes ectopic off the table. The rest of the immediate differential falls away on the same page, since an entirely clean dipstick argues against renal colic and urinary infection, and the absence of cervical motion tenderness argues against pelvic inflammatory disease. What sets this up is the cyst. An ovary carrying a lesion above about 5 cm has a lead point, enough weight to let it twist on its pedicle, and torsion in a completely normal ovary is uncommon in adults. The ultrasound findings follow directly from the mechanics: venous and lymphatic drainage is choked off before arterial inflow, so the ovary becomes engorged and oedematous, swelling from a normal 3 cm to 8 cm, and the expanding stroma shoves the follicles out to the rim. The whirlpool sign of the coiled pedicle is the most specific finding of all. The trap worth remembering is the Doppler: the ovary has a dual blood supply from both the ovarian and uterine arteries, and torsion is often intermittent, so flow is frequently still present. Preserved Doppler flow does not exclude torsion, and a reassuring scan must never delay theatre when the clinical picture reads like this one. Theatre is where this is both confirmed and treated: the ovary is untwisted laparoscopically and kept. The instinct to remove a dusky, blue-black ovary should be resisted, because colour on the table predicts later function very poorly and the great majority recover once perfusion returns; oophorectomy is for an ovary that is frankly necrotic, or for postmenopausal women. The 6 cm cyst that started this comes out at the same operation or at an interval, so it cannot do it again, and ovariopexy is considered where torsion recurs. Time is the variable that really matters, since prolonged ischaemia, not the twist itself, is what turns a salvageable ovary into a lost one.