Ovarian Torsion: The Daily PANCE Blueprint
A 24-year-old woman has sudden severe right lower quadrant pain that began two hours ago while she was at the gym, with nausea and vomiting. The pain comes in waves and radiates to her flank. She is afebrile, and a urine pregnancy test is negative. Her abdomen is tender in the right lower quadrant with a palpable tender adnexal mass. White count is 11,000. Transvaginal ultrasound with Doppler shows an enlarged right ovary with a 6-cm cyst and markedly diminished venous flow. Which of the following is the most appropriate next step in management?
A. Emergent laparoscopy with detorsion
B. Intravenous antibiotics and observation
C. Outpatient follow-up ultrasound in 6 weeks
D. CT of the abdomen and pelvis
E. Methotrexate
Answer and topic summary
The answer is A. Emergent laparoscopy with detorsion
Sudden severe unilateral pelvic pain with nausea, a palpable adnexal mass, and compromised Doppler flow in an enlarged ovary is ovarian torsion — the ovary twisting on its vascular pedicle, usually enabled by a mass 5 cm or larger acting as a fulcrum. It is a surgical emergency, and the answer is emergent laparoscopy with detorsion to restore perfusion and salvage the ovary; in a young woman the goal is conservation, not oophorectomy, and a visibly dusky ovary frequently recovers once untwisted. Two traps deserve attention. First, normal or present Doppler flow does NOT exclude torsion, because the dual ovarian blood supply and intermittent twisting can preserve arterial signal — torsion remains a clinical diagnosis and equivocal imaging should not delay the operating room. Second, waiting for confirmatory imaging such as CT wastes the window; ovarian viability falls sharply after roughly 8 hours of ischemia. Antibiotics would treat tubo-ovarian abscess, which builds over days with fever, and methotrexate treats ectopic pregnancy, excluded here by the negative pregnancy test.
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