Acute Abdominal Pain in Adolescent Females – Focus on Ovarian Torsion

Diagnostic Work‑up

• Obtain a urine or serum β‑hCG test immediately to exclude pregnancy‑related emergencies; a negative result effectively rules out ectopic pregnancy. 1
• Perform both transvaginal and transabdominal pelvic ultrasound with Doppler as the first‑line imaging study in the emergency department. 3
• Avoid initiating CT imaging in reproductive‑aged females because it adds unnecessary radiation when gynecologic causes are most likely. 3
• Severe, constant abdominal pain that may fluctuate but rarely resolves without intervention is characteristic of ovarian torsion. 1
• Fever in this setting points more toward a tubo‑ovarian abscess rather than torsion. 1
• Menstruation can trigger acute angioedema episodes; therefore, severe abdominal pain during menses warrants evaluation beyond “cramps.” 4

Key Ultrasound Findings for Ovarian Torsion

These sonographic criteria together provide high diagnostic confidence for ovarian torsion.* 1

Management Algorithm When Ovarian Torsion Is Suspected

• Call an urgent gynecologic team for immediate laparoscopic detorsion. 1
• Proceed to surgery even if the ovary appears necrotic; intra‑operative visual assessment is inaccurate—only 18‑20 % of ovaries that look necrotic are truly necrotic on pathology. 1
• Early detection is critical to prevent adnexal necrosis and future infertility. 1

Imaging Alternatives When Ultrasound Is Inconclusive

• MRI of the pelvis (with and without IV contrast) – sensitivity 80‑85 % for torsion; shows enlarged ovary with stromal edema and absent/diminished enhancement. 3
• CT abdomen/pelvis with IV contrast (second‑line) – sensitivity 74‑95 %, specificity 80‑90 %; demonstrates asymmetrically enlarged ovary, twisted pedicle, and abnormal/absent ovarian enhancement. 1

Tubo‑Ovarian Abscess Diagnosis

• Pelvic ultrasound detects tubo‑ovarian abscess with 93 % sensitivity and 98 % specificity. 3

Pelvic Inflammatory Disease (PID)

• Start empiric broad‑spectrum antibiotics immediately when minimum criteria (uterine tenderness, adnexal tenderness, cervical motion tenderness) are met, covering N. gonorrhoeae, C. trachomatis, gram‑negative rods, anaerobes, and streptococci. 2
• Do not delay antibiotic therapy while awaiting culture results, as postponement can cause permanent reproductive damage. 2
• Obtain cervical cultures for gonorrhea and chlamydia to guide partner treatment. 2
• Requiring multiple clinical criteria before treating PID reduces sensitivity and may miss cases that threaten future fertility. 2

Critical Pitfalls to Avoid

• Never dismiss severe menstrual‑related pain as “just cramps”; abdominal angioedema can present with a visual analog scale > 5, ascites, or intestinal edema. 4
• Do not use CT as the initial imaging modality; ultrasound offers comparable or superior diagnostic accuracy for gynecologic emergencies without radiation exposure. 3
• Do not rely on normal arterial flow to exclude torsion; venous flow abnormalities are the more sensitive indicator. 1