What should I do if I experience a sharp pain and suspect an ovarian cyst rupture or torsion?

Immediate Management of Suspected Ovarian Cyst Rupture or Torsion

If you experience sharp pelvic pain with suspected ovarian cyst rupture or torsion, seek immediate emergency evaluation with ultrasound as the first-line imaging, and proceed urgently to laparoscopy if torsion is suspected, as delayed diagnosis significantly increases the risk of ovarian necrosis and infertility. 1, 2

Emergency Assessment Algorithm

Immediate Actions

• Go to the emergency department immediately if you experience sudden-onset severe, constant pelvic pain that may fluctuate in intensity but does not completely resolve, as this is the classic presentation of ovarian torsion 1, 2
• Seek urgent care even if the pain is intermittent, as torsion can be partial or intermittent and still cause permanent damage 1

Critical Warning Signs Requiring Immediate ED Evaluation

• Sudden onset of severe colicky unilateral pain radiating from groin to loin 3
• Pain accompanied by nausea and vomiting 3
• Inability to find a comfortable position or pain relief with position changes 1

Diagnostic Pathway

First-Line Imaging: Ultrasound

Transvaginal ultrasound combined with transabdominal views is the initial diagnostic test of choice and should be performed urgently in the emergency department 4, 1

Key ultrasound findings that confirm torsion include:

• Unilaterally enlarged ovary (>4 cm or volume >20 cm³) 1, 2
• Peripheral follicles (present in up to 74% of cases) 1
• Abnormal or absent venous flow on Doppler (100% sensitivity, 97% specificity) 1
• "Whirlpool sign" showing twisted vascular pedicle (90% sensitivity in confirmed cases) 1, 2

Critical pitfall to avoid: Normal arterial blood flow on ultrasound does NOT rule out ovarian torsion, as torsion can be intermittent or partial, and venous flow abnormalities are more sensitive 1, 2

Second-Line Imaging When Ultrasound Is Inconclusive

If ultrasound findings are equivocal but clinical suspicion remains high:

• MRI provides 80-85% sensitivity for torsion with findings of enlarged ovary, stromal edema, and absent/diminished enhancement 1, 2
• CT abdomen/pelvis with IV contrast may show asymmetrically enlarged ovary, twisted pedicle, abnormal/absent ovarian enhancement, and deviation of the uterus to the side of the twist 4, 1
• CT has 74-95% sensitivity and 80-90% specificity for diagnosing adnexal torsion 4

Surgical Management

For Suspected Torsion

Immediate laparoscopic surgery with detorsion is the standard of care to preserve ovarian function, regardless of how the ovary appears macroscopically 2

• Surgery should be performed urgently without delay, as early intervention is essential to prevent adnexal necrosis and infertility 1, 2
• Oophorectomy (ovary removal) should only be considered in cases of definitive necrosis with no signs of recovery after detorsion, large malignant masses, or in postmenopausal women 2

For Ruptured Cysts

Most ruptured ovarian cysts, particularly functional cysts, are self-limiting and managed conservatively with observation and pain control 5

Laparoscopy is necessary only when:

• The diagnosis is uncertain 5
• There is hemodynamic compromise (unstable vital signs from bleeding) 5
• Pain persists despite conservative management 5

Special Considerations by Age

Reproductive Age Women

• Functional cysts <5 cm typically resolve spontaneously without intervention 3, 6
• Simple cysts ≥5 cm are less likely to resolve and need annual ultrasound assessment 3

Postmenopausal Women

Ovarian torsion in postmenopausal women carries higher morbidity due to increased malignancy risk 7

• Any postmenopausal woman with symptomatic cysts, cysts ≥5 cm, or elevated CA-125 levels should be referred to gynecologic oncology 3, 6
• Delayed diagnosis is more common in this age group, increasing associated morbidity 7
• Despite lower prevalence, torsion must remain in the differential diagnosis for acute lower abdominal pain 7

Diagnostic Mimics to Consider

Ovarian torsion can mimic several other conditions, leading to diagnostic delays 2:

• Appendicitis - similar pain pattern 1
• Urinary tract infection - can cause dysuria due to anatomical proximity and inflammation affecting nearby structures 1
• Ureteric colic - pain radiates loin to groin (opposite direction from torsion) 3

Prevention of Recurrence

For recurrent cyst rupture or hemorrhage:

• Suppression of ovulation with combined oral contraceptives is recommended 5
• For recurrent torsion, ovarian fixation by various surgical techniques should be considered 5