What is the appropriate evaluation and management for a patient with a history of ovarian cysts presenting with symptoms of nausea, abdominal pain radiating to the lower back, and temperature instability?

Evaluation and Management of Lower Abdominal Pain with History of Ovarian Cysts

This patient requires immediate clinical assessment with pelvic ultrasound (transabdominal and transvaginal) as the first-line imaging modality to evaluate for ovarian cyst complications including hemorrhage, torsion, or rupture, given her constellation of symptoms suggesting acute gynecologic pathology. 1

Immediate Clinical Assessment

Key symptoms to evaluate:

• Sudden onset severe colicky unilateral pain radiating from groin to loin suggests ovarian torsion, which is a surgical emergency most commonly occurring with pre-existing ovarian cysts, particularly dermoid cysts 2, 3
• Nausea, vomiting, and temperature instability (feeling hot/cold/clammy) are consistent with acute ovarian pathology including torsion or hemorrhagic cyst complications 2, 3
• Pain radiating to lower back may indicate peritoneal irritation or retroperitoneal involvement 4

Critical examination findings to assess:

• Presence of involuntary abdominal guarding, which indicates peritonitis and requires immediate surgical evaluation 4
• Unilateral adnexal tenderness and palpable mass 2
• Hemodynamic stability (blood pressure, heart rate) as unstable patients require immediate surgical intervention 4

Diagnostic Workup

First-line imaging:

• Pelvic ultrasound (combined transabdominal and transvaginal) is the standard initial imaging modality for suspected gynecologic causes of acute pelvic pain 1
• Color Doppler should be performed simultaneously to assess for ovarian torsion, which shows 70-95% sensitivity 1
• Transvaginal ultrasound provides superior visualization of ovarian structures due to probe proximity, though 26.8% of patients report pain during the procedure 1

Alternative imaging if ultrasound is non-diagnostic:

• CT abdomen and pelvis with IV contrast is equally appropriate as initial imaging and is the modality of choice when ultrasound is inconclusive 1
• CT has higher sensitivity for detecting intra-abdominal pathology beyond gynecologic sources 1

Laboratory studies:

• Serum beta-hCG to exclude pregnancy-related causes (ectopic pregnancy) 1
• Complete blood count with differential to assess for leukocytosis suggesting infection or inflammation 1, 4
• CA-125 if malignancy is suspected (particularly in women over 50 or with complex cysts) 2, 5

Management Algorithm Based on Findings

If ovarian torsion is diagnosed:

• Immediate surgical intervention (laparoscopy or laparotomy) is required as this is a surgical emergency 3
• Ovarian-preserving detorsion should be attempted when possible, particularly in reproductive-age women 3

If hemorrhagic cyst is identified:

• Cysts ≤5 cm in premenopausal women require no further management 1
• Cysts >5 cm but <10 cm require follow-up ultrasound in 8-12 weeks 1
• If cyst persists, enlarges, or patient remains symptomatic, refer to gynecologist or consider MRI 1

If simple ovarian cyst without complications:

• Premenopausal women with simple cysts <5 cm can be managed expectantly 2, 5
• Cysts ≥5 cm require annual ultrasound surveillance at minimum 2
• Symptomatic patients should be referred regardless of cyst size 6

If peritonitis with diffuse guarding is present:

• Hemodynamically unstable patients proceed directly to laparotomy 4
• Hemodynamically stable patients should undergo CT with IV contrast before surgical decision 4
• Antimicrobial therapy effective against aerobic gram-negative organisms and anaerobes should be initiated once intra-abdominal infection is diagnosed 1, 4

Resuscitation and Supportive Care

Immediate interventions:

• Rapid restoration of intravascular volume should begin immediately when hypotension is identified 1
• For patients without volume depletion, IV fluid therapy should begin when intra-abdominal infection is first suspected 1
• Antimicrobial therapy should be initiated once intra-abdominal infection is considered likely, and immediately in septic shock 1

Critical Pitfalls to Avoid

Delayed diagnosis increases morbidity and mortality:

• Serial examinations are essential in patients managed non-operatively, as clinical findings may evolve and initial imaging may be falsely negative 4
• Do not rely solely on imaging when clinical suspicion is high - diagnostic laparoscopy has higher sensitivity and specificity than radiological assessment and should not be delayed 4
• Ovarian torsion can be missed if only relying on Doppler flow, as presence of flow does not exclude torsion due to dual blood supply 1
• Abdominal guarding may be masked by distracting injuries or altered mental status, requiring heightened clinical suspicion 4

Work Certification

The patient requires medical evaluation before work clearance can be provided, as her symptoms suggest potentially serious acute pathology requiring urgent assessment and possible intervention 2, 3. Work clearance should only be issued after appropriate diagnostic workup excludes surgical emergencies and symptoms are adequately controlled.