Clinical Summary

• Left adnexal well-defined simple cystic lesion 5.0 × 4.8 cm, no septations or solid components
• Left ovary mildly enlarged (13 cc), abutting the cyst
• No free fluid in pelvis
• Uterus normal; endometrial thickness 4.4 mm
• Right ovary normal
• Appendix not visualized; TVS not performed

• Left adnexal cyst — likely functional/benign
• Mild left ovarian enlargement
• Early or intermittent ovarian torsion cannot be excluded
• MRI pelvis recommended

Differential Diagnosis (in order of urgency)

Ovarian torsion is a surgical emergency. It is the twisting of the ovary on its vascular pedicle, causing initial venous obstruction → edema → eventual arterial thrombosis and necrosis. In adolescents, torsion commonly occurs even without a large cyst due to elongated pelvic ligaments. Pain may be intermittent early on; nausea/vomiting is present in 70% of cases. — Tintinalli's Emergency Medicine, Chapter 97

Investigations to Order NOW (Emergency)

1. Urine/Serum β-hCG — mandatory to rule out ectopic pregnancy
2. CBC — leukocytosis may suggest torsion or appendicitis
3. CRP / ESR
4. LFT, RFT, Electrolytes
5. Urine routine/microscopy
6. Repeat Doppler USG by a senior radiologist (assess venous flow — arterial flow can be normal even in torsion in up to 60% of cases; absent venous flow is an early warning sign)
7. MRI Pelvis (as suggested by radiologist) — better tissue characterization, confirms torsion features (whirl sign, uterine deviation), and rules out complex cyst

Management Plan

Immediate (Emergency Room)

• IV access + fluid resuscitation
• NPO (nil per oral) — treat as a surgical candidate until torsion excluded
• IV antiemetics (ondansetron 4 mg IV)
• Adequate analgesia (IV paracetamol ± opioid titrated carefully)
• Urgent gynaecology consultation — this is mandatory given the radiologist's warning

If Ovarian Torsion is Confirmed / Strongly Suspected

Conservative management with laparoscopic detorsion and oophoropexy is the treatment of choice. Salpingo-oophorectomy is reserved only for clearly necrotic, non-viable ovaries. — Schwartz's Principles of Surgery, 11th Ed.

• Laparoscopic detorsion: Untwist the adnexa; viability is assessed intraoperatively (even a hemorrhagic-appearing ovary may be salvageable — do not rush to remove)
• Oophoropexy: Suture the ovary to prevent recurrence, especially in adolescents
• Cystectomy: If a cyst is confirmed as the precipitant, concurrent laparoscopic cystectomy is performed while preserving ovarian tissue
• Note: TVS was not performed in this patient due to age/pain — Doppler + MRI findings will guide urgency of operative intervention

If Torsion is Excluded (MRI/Doppler normal)

• Functional cyst (<6 cm, simple): Conservative management
  • Analgesia (NSAIDs — mefenamic acid / ibuprofen)
  • Follow-up USG at 6–8 weeks to confirm resolution
  • Oral contraceptive pills (OCP) may be considered to suppress further cyst formation after acute phase
  • No hormonal treatment needed to make the cyst regress (it will resolve spontaneously in most cases)
• Discharge with strict return precautions: worsening pain, fever, vomiting, inability to tolerate orals

Key Clinical Caution

There is no radiologic or clinical finding that can completely exclude torsion. Clinical suspicion based on history and physical examination must guide gynaecologic consultation even when US appears normal. — Tintinalli's Emergency Medicine

1. Re-use the previous USG report (Ms. Shilpa, 15F) — I'll provide the same analysis as above
2. Attach a new/different report or image — please share it and I'll analyze fresh

• Specific surgical steps for detorsion/oophoropexy?
• MRI findings to expect in ovarian torsion?
• Differentiating torsion from a ruptured cyst?
• Postoperative management?

Patient: Ms. Shilpa, 15F — LIF Pain + Vomiting × 2 days

USG Key Findings

• Left adnexal simple cyst 5.0 × 4.8 cm
• Left ovary mildly enlarged (13 cc), abutting the cyst
• No free fluid, no septations, no solid components
• Right ovary normal
• Appendix not visualized
• Radiologist flags: early/intermittent ovarian torsion cannot be excluded

Top Diagnosis: Probable Intermittent Ovarian Torsion

Immediate Management

Definitive Management

• If torsion confirmed → Emergency laparoscopy
  • Detorsion + assess viability
  • Oophoropexy (suture ovary to prevent recurrence)
  • Concurrent cystectomy if cyst is precipitant
  • Salpingo-oophorectomy only if ovary is clearly necrotic
• If torsion excluded → Conservative
  • NSAIDs for pain
  • Follow-up USG at 6–8 weeks
  • Consider OCP to suppress further cyst formation

Critical Point