Diagnostic Dilemma in a 75-Year-Old Woman Presenting with Acute Pain in Her Abdomen

Abstract

Background:

Ovarian torsion is a gynecologic emergency rarely reported in women age 75. Appropriate diagnosis helps avoid a delay in treatment. This reports on a rare case of ovarian torsion in a-75-year-old woman, a case that caused diagnostic confusion.

Case:

A 75-year-old hysterectomized woman presented with lower abdominal pain, difficulty with and painful micturition, and an ill-defined tender mass occupying her suprapubic and right iliac fossa. There was no guarding or rigidity. Ultrasonography (USG) revealed a complex solid cystic mass in her pelvis with vascularity. Contrast magnetic resonance imaging (MRI) showed a well-defined, complex, solid cystic lesion in the midline of the pelvis, with peripheral enhancement, suggestive of chronic collection with a hemorrhagic residua or abscess.

Results:

An emergency laparotomy revealed a left ovarian cyst with thrice torsion. Cut section revealed hemorrhagic fluid. A histopathology report revealed that this was a simple serous cyst with changes secondary to torsion.

Conclusion:

This case had typical USG and MRI findings of ovarian torsion is central avascular stroma and multiple, small, peripherally placed uniform follicles. This phenomenon might not be seen in postmenopausal women, due to depletion of ovarian follicles. A twisted vascular pedicle sign might not be seen prominently in hysterectomized old-age women, due to loss of a dual blood supply and atrophy of the pelvic ligaments and vessels. Although a typical feature of infarction in ovarian torsion seen on MRI is heterogeneous minimal or absent enhancement, some cases of torsion can present with peripheral enhancement causing this condition to be confused with a pelvic abscess. Although central afollicular stroma, peripherally displaced follicles, and twisted vascular pedicle signs are more common and specific findings in reproductive-age and perimenopausal women, these phenomena might not be seen in postmenopausal women. Ovarian torsion should be considered in women of any age who present with acute lower-abdominal pain.