Presentation
Right iliac fossa pain for 2 days, but now easing. LMP four weeks ago, irregular cycles. bHCG negative.
Patient Data
The uterus is retroverted, and normal in appearance.
There is anechoic free fluid in the pelvis.
The right ovary is enlarged and diffusely edematous with a volume of 53 cc.
It contains at least 30 follicles, and possibly a corpus luteum. There is quite prominent arterial and venous flow however the uterine tube and the vessels demonstrate a corkscrew appearance typical of a whirlpool sign secondary to a twisted ovarian pedicle.
The left ovary is normal with a volume of 9 cc, normal vascularity and contains 22 follicles.
There has been interval resolution of the right ovarian edema. The right ovary is still enlarged with a volume of 22cc but considerably smaller (previously 53cc), and comparable to the left (which has a volume of 17cc), with >30 follicles seen in each ovary.
A small amount of pelvic free fluid is present, but considerably reduced from the prior scan.
Case Discussion
Typical features of ovarian torsion are present on the initial scan - diffuse ovarian edema and a "whirlpool" appearance of the adnexal vessels. There is however definite and quite pronounced ovarian vascularity. In the context of patient's symptoms concurrently improving this may well represent a degree of hyperemia following de-torsion.
As the patient's symptoms had resolved, no laparoscopy was performed despite the scan findings. Scan performed two weeks later demonstrates a striking resolution of ovarian edema, supporting the suspicion of spontaneous de-torsion.
Incidentally, note the presence of multiple small peripherally arranged follicles in both ovaries, with bilateral ovarian volume >10cc. The appearance fits the ultrasound criteria for polycystic ovarian morphology. However the patient is 20 years old, and therefore only on the cusp of the age category where PCOS ultrasound criteria may be applied. It would be best therefore to avoid overstating the significance of these findings in the clinical report.
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