What could be causing left ovarian pain during urination in a female of reproductive age?

Left Ovarian Pain During Urination: Differential Diagnosis and Evaluation

You need urgent transvaginal ultrasound to evaluate for ovarian torsion, which is a gynecologic emergency that can present with pain during urination due to anatomical proximity of the ovary to the bladder and urinary tract. 1

Most Likely Diagnoses to Consider

Ovarian Torsion (Most Urgent)

• Ovarian torsion is the most critical diagnosis to exclude because it requires emergency surgical intervention within hours to prevent ovarian necrosis and potential infertility 1
• Pain from torsion is typically severe and constant but can fluctuate in intensity, and importantly, can cause urinary symptoms including dysuria (burning with urination) due to inflammation affecting nearby bladder structures 1
• The anatomical proximity of the ovaries to the bladder means that ovarian pathology frequently mimics urinary tract symptoms 1, 2

Ovarian Cyst with Complications

• Ovarian cysts are common in reproductive-age women and can cause unilateral pelvic pain, pressure symptoms, and discomfort 3
• Hemorrhagic cysts or cyst rupture can cause sudden-onset pain that may worsen with bladder filling during urination 4
• Functional cysts are particularly associated with pain and menstrual disturbances 3

Pelvic Inflammatory Disease (PID)

• PID can present with unilateral adnexal pain and urinary symptoms including urgency and frequency 4
• Tubo-ovarian abscess is a complication that causes severe pain and requires urgent treatment 4

Endometriosis

• Endometriosis can cause chronic or acute pelvic pain that may be unilateral and can involve the bladder, causing pain with urination 4

Urinary Tract Pathology

• While urinary tract infection or ureteral calculi should be considered, the specific localization to the left ovary makes gynecologic pathology more likely 4
• Interstitial cystitis can cause chronic pelvic pain with urinary symptoms but typically presents bilaterally 2

Immediate Diagnostic Approach

First-Line Imaging: Transvaginal Ultrasound

Transvaginal ultrasound combined with transabdominal ultrasound is the essential first-line imaging study and should be performed urgently 4, 1

Key ultrasound findings to identify:

For Ovarian Torsion:

• Unilaterally enlarged left ovary (>4 cm or volume >20 cm³) 4, 1
• Peripheral follicles in a "string of pearls" pattern (present in 74% of torsion cases) 4
• Absent or abnormal venous flow on Doppler (100% sensitivity, 97% specificity) 4, 1
• Whirlpool sign showing twisted vascular pedicle (90% of patients with this sign have confirmed torsion) 1
• Critical pitfall: Normal arterial flow does NOT rule out torsion, as venous flow abnormalities are more sensitive 1

For Ovarian Cyst:

• Cyst size, complexity, and presence of hemorrhage or rupture 4
• Simple cysts <5 cm often resolve spontaneously 3

For PID/Tubo-ovarian Abscess:

• Tubal wall thickness >5 mm, cogwheel sign, incomplete septa 4
• Complex adnexal mass with thick walls and internal debris suggests abscess 4

Laboratory Evaluation

• Obtain urine β-hCG immediately to exclude ectopic pregnancy in all reproductive-age women before making imaging decisions 5
• Urinalysis to evaluate for urinary tract infection, but recognize that pyuria has low positive predictive value and can occur with ovarian pathology 1
• Consider CBC and inflammatory markers if infection is suspected 4

Second-Line Imaging if Ultrasound Inconclusive

If ultrasound is non-diagnostic but clinical suspicion for torsion remains high, obtain CT abdomen/pelvis with IV contrast or MRI 4, 1

CT findings of torsion include:

• Asymmetrically enlarged left ovary with twisted pedicle 4, 1
• Abnormal or absent ovarian enhancement 4
• Deviation of uterus to the left side 4
• CT has 74-95% sensitivity and 80-90% specificity for torsion 4

MRI findings (80-85% sensitivity):

• Enlarged ovary with stromal edema 1
• Absent or diminished enhancement 1

Management Algorithm

1. If ovarian torsion is suspected: Immediate gynecologic consultation for urgent surgical exploration, as this is a time-sensitive emergency 1

2. If large or complex ovarian cyst (≥5 cm): Gynecology referral for further evaluation and management 3

3. If PID/tubo-ovarian abscess: Initiate broad-spectrum antibiotics and obtain gynecology consultation 4

4. If simple functional cyst <5 cm: Consider observation with repeat ultrasound in 6-8 weeks, as these often resolve spontaneously 3

Critical Pitfalls to Avoid

• Do not assume urinary symptoms mean urinary tract infection – ovarian pathology frequently causes dysuria and urgency due to anatomical proximity 1, 2
• Do not rely on presence of arterial flow to exclude torsion – venous compromise occurs first, and torsion can be intermittent 1
• Do not delay imaging for urinalysis results – if torsion is suspected, ultrasound should be performed immediately 1
• Do not dismiss pain that fluctuates – intermittent torsion can cause pain that comes and goes but still requires urgent evaluation 1