Suspected ovarian torsion — MRCEM SBA MCQ

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EasyObstetric and gynaecological emergenciesSuspected ovarian torsionMRCEM SBA

A 27-year-old woman presents to the emergency department with six hours of sudden, severe left iliac fossa pain and vomiting. She recalls a brief similar episode last week that resolved spontaneously. Her observations are normal, and a urine pregnancy test is negative. Transvaginal ultrasonography shows a 6 cm left ovarian cyst without significant free fluid. Colour Doppler demonstrates arterial flow in the left ovary. She remains markedly tender despite analgesia. What is the most appropriate next management plan?

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Correct answer: A — Admit under gynaecology for urgent assessment for laparoscopy.

The abrupt unilateral pain, vomiting, persistent tenderness and preceding self-limiting episode raise substantial concern for ovarian torsion, potentially with earlier intermittent torsion. The ovarian cyst provides a plausible anatomical focus. **Preserved arterial Doppler flow does not exclude torsion**: reduced or absent flow has limited sensitivity, so the scan must be interpreted alongside the clinical presentation. Suspected torsion warrants admission through the on-call gynaecology team and urgent assessment for surgical exploration rather than delayed reassessment. ([rms.cornwall.nhs.uk](https://rms.cornwall.nhs.uk/rms/primary_care_clinical_referral_criteria/primary_care_clinical_referral_criteria/gynae/pre_menopausal_asymptomatic_complex_ovarian_cysts)) **B** is tempting because flow is present and she is haemodynamically stable, but repeating Doppler tomorrow risks delaying a time-critical decision; observation would be more appropriate if urgent specialist assessment found torsion unlikely. **C** could be appropriate if an alternative abdominal diagnosis remained the leading concern, but CT should not precede gynaecology referral in this presentation. **D** would fit suspected pelvic infection with supporting infective features, which are absent here. **E** would fit an uncomplicated cyst with settled symptoms, not ongoing severe pain and vomiting. The priority is to act on the clinical suspicion despite the apparently reassuring Doppler result. ([rms.cornwall.nhs.uk](https://rms.cornwall.nhs.uk/rms/primary_care_clinical_referral_criteria/primary_care_clinical_referral_criteria/gynae/pre_menopausal_asymptomatic_complex_ovarian_cysts))

Reference: Pre Menopausal Complex Ovarian Cysts — emergency and red flags (Reviewed 11 October 2024) — https://rms.cornwall.nhs.uk/rms/primary_care_clinical_referral_criteria/primary_care_clinical_referral_criteria/gynae/pre_menopausal_asymptomatic_complex_ovarian_cysts Diagnostic accuracy of ultrasound signs for detecting adnexal torsion: systematic review and meta-analysis (2022) — https://pubmed.ncbi.nlm.nih.gov/35751902/ Imaging in gynecological disease (20): clinical and ultrasound characteristics of adnexal torsion (2020) — https://pubmed.ncbi.nlm.nih.gov/31975482/