What is the recommended evaluation and management for a patient presenting with ovarian pain?

Evaluation and Management of Ovarian Pain

For a patient presenting with ovarian pain, immediately perform transvaginal ultrasound combined with transabdominal ultrasound as the first-line diagnostic imaging to rule out ovarian torsion and other acute gynecologic emergencies. 1, 2

Initial Clinical Assessment

Critical Red Flags Requiring Urgent Evaluation

• Sudden onset of severe, constant pain that fluctuates in intensity suggests ovarian torsion, which is a gynecological emergency requiring immediate ultrasound and surgical consultation 2
• Acute pain with peritoneal signs (guarding, rebound tenderness) indicates potential rupture of hemorrhagic cyst, ectopic pregnancy, or tubo-ovarian abscess 3, 4
• Pain with vaginal bleeding in reproductive-age women mandates immediate β-hCG testing to exclude ectopic pregnancy before any imaging decisions 5

Key History and Physical Examination Elements

• Pain characteristics: Sudden severe pain favors torsion; colicky pain radiating to pelvis suggests ureteral calculi; periumbilical pain migrating to right lower quadrant suggests appendicitis 2, 5
• Fever presence: Typically absent in ovarian torsion but present with tubo-ovarian abscess or pelvic inflammatory disease 2
• Pregnancy status: Obtain urine or serum β-hCG in all reproductive-age women, as a negative test essentially rules out pregnancy-related causes 2, 5

Diagnostic Imaging Algorithm

First-Line: Pelvic Ultrasound (Usually Appropriate)

Combined transvaginal and transabdominal ultrasound provides the most comprehensive assessment and should be performed together whenever possible. 1, 2

Key Ultrasound Findings by Diagnosis:

Ovarian Torsion:

• Unilaterally enlarged ovary (>4 cm or volume >20 cm³) with peripheral follicles (74% of cases) 2
• Whirlpool sign (twisted vascular pedicle) has 90% sensitivity in confirmed cases 2
• Abnormal or absent venous flow on Doppler (100% sensitivity, 97% specificity) 2
• Critical pitfall: Normal arterial flow does NOT rule out torsion, as torsion can be intermittent or partial; venous flow abnormalities are more sensitive 2

Doppler ultrasound performance: 80% sensitivity and 88% specificity for ovarian torsion; grayscale alone has 79% sensitivity and 76% specificity 2

Other Gynecologic Pathology:

• Hemorrhagic or ruptured ovarian cysts: Complex cystic masses with internal echoes and free pelvic fluid 3, 4
• Pelvic inflammatory disease: Tubal wall thickening, pyosalpinx, or tubo-ovarian abscess 5
• Hydrosalpinx: Fluid-distended fallopian tubes visible on ultrasound 1

Second-Line: CT Abdomen and Pelvis with IV Contrast

Use CT when ultrasound is inconclusive but clinical suspicion remains high, or when non-gynecologic causes (appendicitis, diverticulitis) are being considered. 2, 5

CT Findings:

Ovarian Torsion:

• Asymmetrically enlarged ovary with twisted pedicle 2
• Abnormal/absent ovarian enhancement 2
• Deviation of uterus to the affected side 2
• Engorged vessels on the twisted side 2
• CT sensitivity: 74-95%; specificity: 80-90% 2

Non-Gynecologic Causes:

• Appendicitis: CT has 95% sensitivity and 94% specificity 5
• Right colonic diverticulitis: Accounts for 8% of right lower quadrant pain 5
• Ureteral calculi: Best evaluated with non-contrast CT 1

Third-Line: MRI Pelvis

Consider MRI when ultrasound is equivocal but clinical suspicion remains high, particularly in young patients or pregnant women to avoid radiation. 2

• MRI sensitivity for ovarian torsion: 80-85% 2
• Findings include enlarged ovary with stromal edema, surrounding fluid, and absent/diminished enhancement 2

Management Based on Diagnosis

Ovarian Torsion (Surgical Emergency)

Immediate laparoscopic detorsion with ovarian preservation is the standard of care, even when the ovary appears necrotic. 2

• Intraoperative visual assessment of ovarian viability is highly inaccurate: only 18-20% of ovaries appearing necrotic are actually necrotic on pathological examination 2
• Early detection is essential to prevent adnexal necrosis and infertility 2

Chronic/Subacute Pelvic Pain in Postmenopausal Women

For postmenopausal women with subacute or chronic ovarian pain (lasting ≥6 months), the differential narrows significantly 1:

Deep Pelvic Pain Etiologies:

• Pelvic venous disorders (pelvic congestion syndrome): Engorged periuterine/periovarian veins (≥8 mm), low-velocity flow, retrograde ovarian vein flow on Doppler 1
• Chronic pelvic inflammatory disease: Pelvic fluid, hydrosalpinx, inflammatory adnexal masses 1
• Adhesive disease: Real-time dynamic ultrasound may document abnormal adherence, though diagnosis remains difficult 1

Important Note: Vaginal bleeding or suspected adnexal mass in postmenopausal women should take precedence over general pelvic pain complaints due to prevalence of endometrial and ovarian neoplasia 1

Common Pitfalls to Avoid

• Do not rely on normal arterial Doppler flow to exclude ovarian torsion—venous flow assessment is critical 2
• Do not assume fever rules out torsion or confirms infection—torsion typically presents without fever 2
• Do not skip pregnancy testing in reproductive-age women—ectopic pregnancy can mimic ovarian pathology 5
• Do not delay surgical consultation for suspected torsion—time to intervention directly impacts ovarian salvage 2
• Do not assume pyuria confirms UTI—ovarian torsion can cause dysuria and pyuria due to anatomical proximity and inflammation 2