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Emergency and Acute Medicine – Ovarian Cyst and Adnexal Torsion
Ovarian cysts are common gynecologic findings and are usually asymptomatic unless complicated by rupture, hemorrhage, infection, or torsion. The most frequent type is the follicular cyst, which can occur from fetal life through menopause. These cysts are typically thin-walled, unilocular, and measure between 3 and 8 cm. Because of their thin walls, they may rupture easily, often causing minimal bleeding and little pain. Midcycle rupture during ovulation is known as mittelschmerz and is generally benign.
Corpus luteal cysts are clinically more significant. They are usually smaller than 10 cm but are prone to intracystic hemorrhage. Rapid bleeding can lead to cyst rupture, most commonly just before the onset of menses, and may result in severe intraperitoneal hemorrhage. In some cases, gradual bleeding into the cyst or ovary causes capsular distension and pain even without rupture. Anticoagulated patients are at particularly high risk for significant bleeding from corpus luteal cysts.
Adnexal torsion is a true gynecologic emergency and represents the fifth most common surgical emergency in gynecology. It occurs when the ovary, fallopian tube, or a paratubal cyst twists around its vascular pedicle, leading to impaired lymphatic and venous drainage followed by arterial compromise. This process causes rapid adnexal enlargement, ischemia, and eventual necrosis if not promptly treated. The greatest risk of torsion is associated with ovarian cysts measuring 8–12 cm. Although torsion can occur at any age, it is most common in reproductive-age women, with approximately 15% of cases occurring in children. During pregnancy, torsion is most likely in the first trimester, especially following ovarian stimulation or in vitro fertilization.
Patients with ovarian cysts typically present with unilateral lower abdominal or pelvic pain that may be sharp or aching and intermittent or constant. Pain may be precipitated by exercise, intercourse, trauma, or pelvic examination. Fever is uncommon and suggests an alternative diagnosis. Menstrual irregularities, infertility, pregnancy status, and prior sexually transmitted infections should be assessed. In contrast, adnexal torsion often presents with sudden-onset, severe, colicky abdominal pain that may localize to one side or radiate to the groin or flank. Nausea and vomiting are common, and symptoms may wax and wane due to intermittent torsion and detorsion. Fever and vaginal bleeding may occur but are not universal.
Physical examination in ovarian cysts may reveal abdominal or adnexal tenderness and, occasionally, a palpable pelvic mass. In cases of hemorrhagic cyst rupture, signs of hypovolemia such as orthostasis, tachycardia, or hypotension may be present. Adnexal torsion similarly causes abdominal and adnexal tenderness and may be associated with a palpable mass. Severe cases can mimic other acute abdominal emergencies.
A pregnancy test is essential in all patients of reproductive age to exclude ectopic pregnancy. Initial laboratory evaluation includes a complete blood count to assess for anemia or infection and urinalysis to evaluate urinary causes of pain. If significant hemorrhage is suspected, type and crossmatching for packed red blood cells should be performed. Cervical cultures may be indicated if pelvic inflammatory disease is a concern.
Transvaginal ultrasound is the imaging modality of choice. It can identify ovarian cysts, adnexal masses, free pelvic fluid, and an enlarged, edematous ovary suggestive of torsion. Doppler flow studies may demonstrate decreased or absent blood flow, but the presence of flow does not exclude torsion, particularly if detorsion has occurred. MRI may be useful in pregnant patients with nondiagnostic ultrasound findings, while CT imaging can help identify alternative diagnoses or provide supportive evidence of torsion when ultrasound is inconclusive. Ultimately, laparoscopy remains the gold standard for diagnosing adnexal torsion and allows for definitive treatment.
The differential diagnosis includes ectopic pregnancy, pelvic inflammatory disease, appendicitis, endometriosis, round ligament pain, ovarian or metastatic neoplasm, and uterine torsion. In postmenopausal women, ovarian cysts are concerning for malignancy until proven otherwise.
Management depends on the diagnosis and clinical stability. Suspected adnexal torsion requires urgent gynecologic consultation and surgical intervention, as early detorsion improves the likelihood of ovarian salvage, particularly in pediatric patients. Ruptured ovarian cysts without significant hemorrhage may be managed conservatively with analgesia and close follow-up. Patients with ongoing pain, hemodynamic instability, or significant hemoperitoneum require admission and possible surgical management.
A key clinical pearl is that adnexal torsion is primarily a clinical diagnosis. Imaging studies may appear reassuring, but normal Doppler flow does not rule out torsion. Therefore, adnexal torsion should always remain high on the differential diagnosis in women and girls presenting with acute abdominal or pelvic pain.
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