Is ovarian torsion pain intermittent?

Ovarian Torsion Pain Characteristics

Ovarian torsion pain typically presents as severe, constant pain that may fluctuate in intensity but rarely completely resolves without intervention. 1, 2

Clinical Presentation of Ovarian Torsion

• Ovarian torsion classically presents with sudden onset of unilateral lower abdominal pain that is severe and sharp in nature 3, 2
• The pain is typically constant but may have fluctuating intensity, giving the false impression that it comes and goes 2, 4
• Pain is frequently accompanied by nausea and vomiting (common associated symptoms) 3, 4
• Patients may report symptoms lasting for several hours or even days, contrary to the misconception that torsion always presents with very acute symptoms 2

Diagnostic Challenges

• Ovarian torsion is often misdiagnosed initially due to its nonspecific clinical features that can mimic other conditions such as appendicitis, pyelonephritis, or renal colic 3, 2
• The diagnosis is particularly challenging in postmenopausal women, where it's less commonly considered in the differential diagnosis 5
• Patients may present with varying degrees of pain, which can lead to diagnostic confusion when pain temporarily seems to improve 2
• Normal arterial blood flow on ultrasound does not rule out ovarian torsion, as torsion can be intermittent or partial 2

Imaging Findings

• Ultrasound is the first-line imaging modality for suspected ovarian torsion 1
• Key ultrasound findings include:
  • Unilaterally enlarged ovary (>4 cm or volume >20 cm³) 1
  • Peripheral follicles (found in up to 74% of cases) 1
  • Abnormal or absent venous flow (100% sensitivity, 97% specificity) 1
  • Whirlpool sign (twisting of the vascular pedicle) 1
• CT findings include enlarged, featureless, hypoenhancing ovary with swirling of vascular pedicle 1
• MRI has 80-85% sensitivity for ovarian torsion with findings of enlarged ovary, stromal edema, and absent/diminished enhancement 1

Common Pitfalls

• Assuming pain must be constant and unremitting - the pain may fluctuate in intensity, giving a false impression of intermittent pain 2
• Ruling out torsion based on normal arterial flow on Doppler ultrasound - venous flow abnormalities are more sensitive 1
• Delaying diagnosis due to atypical presentation or patient age - torsion can occur in all age groups from infants to elderly 2
• Dismissing the diagnosis when symptoms have been present for several days - ovarian salvage may still be possible even with prolonged symptoms 2

Management Considerations

• Surgical intervention is the definitive treatment for ovarian torsion 2, 4
• Early diagnosis and prompt intervention are crucial to preserve ovarian function 3, 4
• Even with prolonged symptoms, detorsion should be attempted as the ovary may still be viable 2
• In postmenopausal women, there is a higher risk of malignancy with ovarian masses causing torsion, requiring complete evaluation 5

Remember that the fluctuating intensity of pain in ovarian torsion can mislead both patients and clinicians into thinking the condition is resolving when it is not. Any woman with acute onset of severe lower abdominal pain should be evaluated for possible ovarian torsion, even if the pain seems to temporarily improve.