Unusually painful: Ovarian torsion

Case presentation

A 13-year-old female presents with acute onset of right lower quadrant pain for the past 4 hours. She states that she has been in her usual, normal state of health and was “just walking down the street” when she experienced the pain, which was accompanied by nausea and she has had three episodes of nonbilious/nonbloody emesis. She states that after the emesis, she feels “a little better” but the pain has persisted. She denies fever, diarrhea, or trauma. She denies being sexually active and there is no history of vaginal bleeding or discharge. She began her menses 2 years ago and has had occasional cramping with her menstrual cycle; her last menstrual period was 2 weeks ago.

Physical examination reveals a slightly uncomfortable-appearing patient, complaining of abdominal pain, mostly in the right lower quadrant. She is afebrile, and aside from mild tachycardia (a heart rate of 120 beats per minute), the vital signs are unremarkable. She has mild tenderness to palpation of the right lower quadrant and suprapubic areas; there is no rebound or guarding. She has no palpable abdominal masses and there is no abdominal distention; a urine pregnancy test is negative.

Imaging considerations

Prior to imaging, a pregnancy test must be obtained, since this can assist the clinician in considering an appropriate imaging modality selection to evaluate nongynecologic and gynecologic causes of abdominal pain and to avoid fetal exposure to ionizing radiation. The American College of Radiology (ACR) has Appropriateness Criteria® (AC) useful for selecting among various imaging modalities for the evaluation of female acute pelvic pain in the reproductive age group, based on gynecologic and nongynecologic suspected etiologies and whether the patient is pregnant or not. As the patient had a negative serum pregnancy test, Variant 2 of the AC for “gynecological etiology suspected, serum β-hCG negative” applies ( Table 23.1 ). The ACR Appropriateness Criteria® content is updated regularly and users should go to the website ( https://www.acr.org/Clinical-Resources/ACR-Appropriateness-Criteria® ) to access the most current and complete version of the AC.

Table 23.1

American College of Radiology (ACR) Appropriateness Criteria®.

Clinical Condition: Acute Pelvic Pain in the Reproductive Age Group

Variant 2: Gynecological etiology suspected, serum β-hCG negative.

From https://acsearch.acr.org/docs/69503/Narrative/ . The ACR Appropriateness Criteria® content is updated regularly and users should go to the website ( https://www.acr.org/Clinical-Resources/ACR-Appropriateness-Criteria® ) to access the most current and complete version of the AC.

Radiologic Procedure	Rating	Comments	RRL*
US pelvis transvaginal	9	Both transvaginal and transabdominal US should be performed if possible
US pelvis transabdominal	9	Both transvaginal and transabdominal US should be performed if possible
US duplex Doppler pelvis	8
MRI pelvis without and with IV contrast	6	This procedure can be performed if US is inconclusive or nondiagnostic. See the Summary of Literature Review and ACR Manual on Contrast Media for the use of contrast media.
MRI abdomen and pelvis without and with IV contrast	6	This procedure can be performed if US is inconclusive or nondiagnostic. See the Summary of Literature Review and ACR Manual on Contrast Media for the use of contrast media.
MRI pelvis without IV contrast	4	This procedure can be performed if US is inconclusive or nondiagnostic. See the Summary of Literature Review and ACR Manual on Contrast Media for the use of contrast media.
MRI abdomen and pelvis without IV contrast	4	This procedure can be performed if US is inconclusive or nondiagnostic. See the Summary of Literature Review and ACR Manual on Contrast Media for the use of contrast media.
CT abdomen and pelvis with IV contrast	4	This procedure can be performed if US is inconclusive or nondiagnostic and MRI is not available. See the Summary of Literature Review for the use of contrast media.
CT pelvis with IV contrast	4	This procedure can be performed if US is inconclusive or nondiagnostic and MRI is not available. In young women undergoing repeat imaging, the cumulative radiation dose should be considered. See the Summary of Literature Review for the use of contrast media.
CT pelvis without IV contrast	2	This procedure can be performed if US is inconclusive or nondiagnostic and MRI is not available. In young women undergoing repeat imaging, the cumulative radiation dose should be considered.
CT pelvis without and with IV contrast	2
CT abdomen and pelvis without IV contrast	2
CT abdomen and pelvis without and with IV contrast	2
Rating Scale: 1, 2, 3 Usually not appropriate; 4, 5, 6 May be appropriate; 7, 8, 9 Usually appropriate			*Relative Radiation Level

CT , Computed tomography; hCG , human chorionic gonadotropin; IV , intravenous; MRI , magnetic resonance imaging; US , ultrasound.