A 19-year-old woman presented to the emergency department with a 36-hour history of lower abdominal pain that was sharp and initially intermittent, later becoming constant and severe. The patient also reported feeling nauseated and vomited once in the ER. She did not have diarrhea and had opened her bowels normally 8 hours before admission. She had no symptoms of dysuria. She was afebrile, slightly tachycardic at 95/min, and had a normal blood pressure. Blood results showed mild leukocytosis of 11.6 x 109/L and normal renal and liver function tests. She reported being sexually active with a long-term partner. She was never pregnant, and the urine pregnancy test on admission was negative.
On physical examination there was tenderness in the right iliac fossa with guarding. On vaginal examination a tender mass in the right adnexal region was felt. The patient subsequently underwent a transvaginal ultrasound examination for evaluation of adnexal pathology. The scan showed a markedly enlarged right ovary measuring up to 8 cm in long axis with echogenic stroma and peripherally distributed follicles. There was no internal vascularity when color Doppler was applied. A small amount of free fluid was seen in the pouch of Douglas. The diagnosis of ovarian torsion was made.
Ovarian torsion is the twisting of an ovary on its suspensory ligament, which contains arterial, venous, and lymphatic vessels (forming so-called vascular pedicle), leading to a compromised blood supply. Initially, the venous and lymphatic circulation is compromised, resulting in ovarian edema and enlargement. The arterial flow is maintained longer due to thicker and less compressible arterial walls. Prolonged torsion leads to increased internal ovarian pressure that eventually results in arterial thrombosis, ischemia of the ovarian tissue, and necrosis. If the correct diagnosis and treatment are delayed, the patient may develop generalized sepsis.
The symptoms are nonspecific, making the diagnosis of ovarian torsion challenging. There is often no significant past medical history.
At surgery, the right ovary was hemorrhagic and necrotic with the pedicle twisted 360 degrees. The left ovary was normal in appearance. Right-sided salpingo-oophorectomy was performed, and histopathological examination confirmed completely necrotic ovary without any residual normal ovarian tissue. The patient made a quick recovery after surgical intervention.
Ovarian torsion is encountered in women of all ages, but those of reproductive age have much higher prevalence. Torsion of a normal ovary is uncommon and is seen more frequently in adolescent population, with elongated pelvic ligaments, fallopian tube spasm, or more mobile fallopian tubes or mesosalpinx cited as contributing factors.
A young man developed pain in his right gluteal region, in the posterior aspect of the thigh and around the posterior and lateral aspects of the leg. On further questioning, he reported that the pain also radiated over the lateral part of the foot, particularly around the lateral malleolus.
The areas of pain correspond to dermatomes L4 to S3 nerves.
Over the following weeks, the patient began to develop muscular weakness, predominantly footdrop.
These findings are consistent with loss of the motor function and sensory change in the common fibular nerve, which is a branch of the sciatic nerve in the lower limb.
A computed tomography (CT) scan of the abdomen and pelvis revealed a mass in the posterior aspect of the right side of the pelvis. The mass was anterior to the piriformis muscle and adjacent to the rectum.
On the anterior belly of the piriformis muscle, the sciatic nerve is formed from the roots of L4 to S3 nerves. The mass in the patient’s pelvis compressed this nerve, producing his sensory and motor dysfunction.
During surgery, the mass was found to be a benign nerve tumor and was excised. This patient had no long-standing neurological deficit.