Why can ovarian torsion be excluded in a 58‑year‑old postmenopausal woman presenting with left flank pain, fever, chills, dysuria, oliguria, left costovertebral angle tenderness, leukocytosis and a urine culture positive for Escherichia coli?

Why Ovarian Torsion Can Be Ruled Out

Ovarian torsion is effectively excluded in this 58-year-old postmenopausal woman because her clinical presentation is entirely consistent with acute pyelonephritis—with fever, flank pain, dysuria, CVA tenderness, pyuria, and positive urine culture for E. coli—rather than the typical presentation of ovarian torsion. 1, 2

Age and Menopausal Status

• Ovarian torsion is exceedingly rare in postmenopausal women, as it occurs most commonly in reproductive-age women and typically requires an underlying ovarian mass or cyst as a predisposing factor. 1, 3
• In the postmenopausal population, ovarian cysts account for only one-third of gynecologic causes of acute pelvic pain, and isolated torsion without a mass is considered rare in this age group. 1
• The patient's postmenopausal status (age 58, Filipino female) significantly reduces the likelihood of ovarian torsion compared to younger reproductive-age women. 1, 3

Clinical Presentation Inconsistent with Torsion

• Ovarian torsion characteristically presents with severe, constant lower abdominal or pelvic pain that may fluctuate but rarely completely resolves without intervention—not the flank pain pattern seen in this patient. 2, 4
• The patient's symptom progression (suprapubic pain and dysuria for 4 days, then fever, chills, and flank pain) follows the classic timeline of ascending urinary tract infection progressing to pyelonephritis, not the acute onset typical of torsion. 2
• Fever is not typically associated with ovarian torsion but rather suggests infectious etiologies such as tubo-ovarian abscess or, in this case, pyelonephritis. 2

Laboratory and Urinalysis Findings

• The presence of abundant WBCs in urine, moderate bacteria (Gram-negative bacilli), and positive urine culture growing E. coli with specific antibiotic sensitivities definitively establishes the diagnosis of urinary tract infection/pyelonephritis. 2
• While ovarian torsion can mimic UTI symptoms including dysuria due to anatomical proximity and inflammation affecting nearby structures, the positive urine culture with significant bacterial growth confirms true urinary infection rather than referred symptoms. 2
• The leukocytosis (WBC 13.35 with 75.2% neutrophils) combined with fever and positive urine culture supports systemic bacterial infection, not the typical presentation of torsion. 2

Physical Examination Findings

• Left CVA tenderness is the hallmark physical finding of pyelonephritis, directly correlating with the patient's left flank pain and supporting renal/ureteral pathology rather than adnexal pathology. 1
• The absence of a palpable adnexal mass on examination makes ovarian torsion significantly less likely, as torsion typically occurs secondary to an underlying ovarian mass or cyst in postmenopausal women. 1, 5
• The patient's abdomen was described as "flat, soft, normoactive bowel sounds, nontender"—inconsistent with the severe lower abdominal/pelvic tenderness expected with ovarian torsion. 2, 4

Diagnostic Imaging Considerations

• If ovarian torsion were suspected, transvaginal and transabdominal ultrasound with Doppler would be the first-line imaging modality, showing unilateral ovarian enlargement >4 cm, peripheral follicles, whirlpool sign, and abnormal venous flow. 1, 6, 4
• The American College of Radiology guidelines specify that in postmenopausal women with acute pelvic pain, imaging should be directed by clinical presentation—and this patient's presentation clearly points to urinary tract pathology, not gynecologic pathology. 1
• No imaging for ovarian pathology is indicated here because the clinical diagnosis of pyelonephritis is established by history, physical examination, and laboratory confirmation. 1

Key Clinical Pitfalls to Avoid

• Do not confuse dysuria and suprapubic pain with gynecologic pathology when urinalysis and culture confirm UTI—ovarian torsion can mimic UTI symptoms, but positive urine culture with significant bacterial growth establishes the true diagnosis. 2
• While ovarian torsion should be considered in any woman with acute pelvic pain, the constellation of fever, CVA tenderness, pyuria, and positive urine culture makes pyelonephritis the obvious diagnosis. 1, 2
• Emergency physicians must recognize that ovarian torsion rarely presents with fever and typically causes lower abdominal/pelvic pain rather than flank pain with CVA tenderness. 2, 3

Treatment Implications

• This patient requires antibiotic therapy targeting E. coli based on culture sensitivities (susceptible to Amikacin, Gentamicin, Piperacillin-Tazobactam, Ertapenem; resistant to Cefuroxime, Ceftriaxone, Ciprofloxacin), not surgical intervention for ovarian torsion. 2
• If ovarian torsion were the diagnosis, immediate laparoscopic detorsion would be required to preserve ovarian function—but this is not indicated given the clear diagnosis of pyelonephritis. 4