Should ovarian torsion be considered and promptly ruled out in a 12‑year‑old female presenting with severe left lower‑quadrant abdominal pain radiating to the left flank?

Ovarian Torsion Must Be Urgently Ruled Out in This Patient

Yes, ovarian torsion is a critical gynecologic emergency that must be immediately considered and excluded in any 12-year-old female presenting with severe left lower quadrant abdominal pain and flank pain. 1

Why This Is a Gynecologic Emergency

Ovarian torsion accounts for 20-30% of ovarian surgeries in pediatric patients and represents the fifth most common gynecologic emergency in this age group. 2 The clinical presentation in your patient—severe, acute-onset left lower quadrant pain—is the hallmark symptom of ovarian torsion. 3, 4

Key clinical features that heighten concern:

• Severe, constant pain is characteristic of ovarian torsion, though it may fluctuate in intensity without completely resolving. 1
• Left flank radiation can occur due to anatomical proximity and referred pain patterns. 1
• Pediatric patients are at particular risk, and torsion can affect females of all ages, including premenarchal girls. 3, 4

Critical Diagnostic Pitfalls to Avoid

Do not be falsely reassured by:

• Normal vital signs or absence of fever – fever is not typically associated with ovarian torsion but rather suggests tubo-ovarian abscess. 1
• Sterile pyuria on urinalysis – approximately 50% of pediatric ovarian torsion cases demonstrate pyuria without bacteruria, as inflammation from torsion affects nearby urinary structures. 1, 4
• Normal arterial flow on Doppler ultrasound – this does NOT rule out torsion, as torsion can be intermittent or partial, and venous flow abnormalities are more sensitive (100% sensitivity, 97% specificity). 1

Immediate Diagnostic Approach

First-line imaging: Combined transabdominal and transvaginal pelvic ultrasound with color and spectral Doppler 1

The ultrasound must systematically document:

• Ovarian size (>4 cm or volume >20 cm³ suggests torsion) 1
• Peripheral follicle pattern (present in 74% of torsion cases) 1
• Whirlpool sign (twisted vascular pedicle with 90% sensitivity for confirmed torsion) 1
• Both arterial AND venous flow characteristics (absent venous flow has 100% sensitivity) 1

If ultrasound is inconclusive but clinical suspicion remains high:

• CT abdomen/pelvis with IV contrast shows asymmetrically enlarged ovary, twisted pedicle, abnormal/absent ovarian enhancement, and deviation of uterus to the affected side (74-95% sensitivity, 80-90% specificity). 1
• MRI provides 80-85% sensitivity with findings of enlarged ovary, stromal edema, and absent/diminished enhancement. 1

Urgent Management Algorithm

1. Obtain immediate pelvic ultrasound with Doppler in the Emergency Department 1
2. Urgent gynecologic consultation regardless of imaging findings if clinical suspicion is high 1
3. Proceed to diagnostic laparoscopy if imaging suggests torsion or remains inconclusive with persistent severe pain 1, 4

Surgical management is time-critical: Immediate laparoscopic detorsion with ovarian preservation is the standard of care, even when the ovary appears necrotic, as intraoperative visual assessment is highly inaccurate (only 18-20% of ovaries that appear necrotic are actually necrotic on pathology). 1

Differential Considerations in This Age Group

While ovarian torsion is paramount, also consider:

• Ovarian cyst (can cause intermittent pain from incomplete torsion or cyst enlargement) 5
• Appendicitis (though typically presents with periumbilical pain migrating to right lower quadrant, not sudden severe left-sided pain) 1, 4
• Nephrolithiasis or UTI (renal pathology can refer pain to lower abdomen) 5

However, the sudden onset of severe left lower quadrant pain in a 12-year-old female makes ovarian torsion the most concerning diagnosis that cannot be missed. 1, 4

Bottom line: This patient requires immediate ultrasound evaluation and urgent gynecologic consultation to prevent ovarian loss and preserve future fertility. 1, 2