The diagnosis and the type of ruptured cyst are ascertained by blood tests and transvaginal ultrasound. Pregnancy test, complete blood count, and, if orthostasis is present, type and screening should be ordered. Leukocytosis is uncommon. The hematocrit is decreased if active bleeding is present. If ultrasound is not available, a culdocentesis will reveal the nature of the intraperitoneal ﬂuid. If orthostasis is absent and the peripheral hematocrit is relatively normal, clinically significant hemoperitoneum is unlikely. This conclusion is supported by culdocentesis findings of clear or blood-tinged ﬂuid with a ﬂuid hematocrit under 16% or transvaginal ultrasound revealing only a small amount of free intraperitoneal ﬂuid.
Culdocentesis is very helpful in determining the cause of peritonitis: fresh blood suggests a corpus luteum; chocolate “old” blood, an endometrioma; oily sebaceous ﬂuid, a benign teratoma; purulent ﬂuid, pelvic inﬂammatory disease (PID) or tubo-ovarian abscess. A skillful reading of transvaginal ultrasound images can help to characterize a cystic structure in the pelvis as a dermoid, endometrioma, corpus luteum, or pelvic abscess and quantify the amount of intraperitoneal ﬂuid.
Orthostasis, significant anemia, hematocrit of the culdocentesis ﬂuid of greater than 16%, or a large amount of free peritoneal ﬂuid on ultrasound suggests significant hemoperitoneum and usually requires surgical management by laparoscopy or laparotomy. Patients who are not orthostatic or febrile, who are not pregnant or anemic, and who have only a small amount of ﬂuid in the cul-de-sac can often be observed in the hospital, without surgical intervention, or even discharged home from the emergency room after observation.
Adnexal Torsion Torsion (twisting) of the vascular pedicle of an ovary, ovary with cyst, fallopian tube, paratubal cyst, or rarely a pedunculated uterine myoma results in ischemia of the structures distal to the twisted pedicle and acute onset of pain. A benign cystic teratoma is the most common neoplasm to undergo torsion. Because of adhesions, ovarian carcinoma and inﬂammatory masses such as endometriomas or abscesses rarely undergo torsion. It is unusual for a normal tube and ovary to torque, although a polycystic ovary can undergo torsion. Diagnosis of adnexal torsion is challenging. The clinician must base the diagnosis on history, clinical examination, and additional investigations such as pelvic ultrasound (14). There is no specific size criteria for ovarian torsion, but one study found that 83% of torsion occurred in ovaries that were 5 cm or larger (15).
The pain of torsion is usually severe and constant or, if the torsion is partial and intermit, the pain can wax and wane. The onset of the torsion and subsequent abdominal pain frequently coincides with activity such as lifting, exercise, or intercourse. Autonomic reﬂex responses (e.g., nausea, emesis, tachycardia, and apprehension) are usually present.
Mild temperature elevation, tachycardia, and leukocytosis may accompany the necrosis of tissue. Pregnancy test is negative unless there is a co-existent pregnancy. The diagnosis must be suspected in any woman with acute pain and unilateral adnexal mass.
On examination, the localized direct and rebound tenderness can be noted in the lower quadrant(s). Another important sign is the presence of a large pelvic mass on bimanual examination.