{"paper_id":"8225ea50-ee31-405a-b5c0-ccb2a409909b","body_text":"Case reports \nPeritubal Endometriosis Discovered During Surgery for Ovarian        \nTorsion in an Adolescent Without Dysmenorrhea: A Case Report          \nSamar Kaddoura1\n, Latha Ganti, MD, MS, MBA, FACEP, FAAN2\n1 Montverde Academy, 2 The Warren Alpert Medical School of Brown University \nKeywords: adolescent endometriosis, ovarian torsion, paratubal cyst, laparoscopy \nhttps://doi.org/10.62186/001c.172338 \nAcademic Medicine & Surgery \nEndometriosis is often investigated in adolescents because of dysmenorrhea or chronic \npelvic pain. We report a 15-year-old girl with previously painless menstruation who \npresented with abrupt severe right lower-quadrant pain and nausea. Ultrasonography \nsuggested marked right ovarian enlargement and an 8.4-cm adnexal cyst; Doppler flow \nwas present but showed elevated resistance. Urgent laparoscopy confirmed right ovarian \ntorsion. The ovary was detorsed and preserved, and a cyst arising from the right fallopian \ntube/peritubal region was excised. Histopathology identified endometriosis with vascular \ncongestion. Postoperative recovery was uncomplicated. A right-sided cyst was \ndocumented on subsequent imaging; later ovarian measurements decreased. This case \nunderscores that endometriosis may be discovered during an acute adnexal emergency \nwithout preceding menstrual symptoms and that ultrasonography may not establish the \nprecise origin of a large adnexal lesion. \n1. CASE PRESENTATION \nA 15-year-old postmenarchal girl presented to the Emer-\ngency Department in June 2025 with sudden severe right \nlower-quadrant pain and nausea. Before this episode, she \nreported predominantly painless menses lasting 4–5 days \nand denied chronic pelvic pain, significant dysmenorrhea, \nor similar prior episodes. She had no other past medical or \nsurgical history. \nPelvic ultrasonography reported a markedly enlarged \nright ovary measuring 9.2 × 10.3 × 8.0 cm (estimated vol-\nume, 396 mL) and an apparent ovarian cyst measuring 2.1 \n× 8.4 × 6.2 cm. Doppler flow was detectable but showed in-\ncreased vascular resistance. A small amount of cul-de-sac \nfree fluid was noted. The uterus and left ovary had no re-\nported significant abnormality. Despite detectable flow, the \nclinical and sonographic findings raised concern for torsion \n(Figure 1). \nUrgent laparoscopy confirmed right ovarian torsion. The \nright ovary was detorsed and preserved, with a satisfactory \nappearance after detorsion. The large cystic lesion, initially \nthought to be ovarian on ultrasound, was identified intra-\noperatively as originating in the right fallopian tube/per-\nitubal region. The cyst was excised; no additional gross le-\nsions suggestive of endometriosis were seen. The specimen \nwas submitted as a right peritubal cyst. Final histopatho-\nlogic examination showed endometriosis with vascular con-\ngestion and no malignancy. \nAt approximately 2-week follow-up, the patient reported \nno ongoing abdominal pain, nausea, vomiting, or fever; her \nlaparoscopic incisions were healing appropriately. Pathol-\nogy was discussed with the patient and her mother, and \ngynecologic follow-up was arranged. In October 2025, ul-\ntrasound documented a right ovarian cyst measuring 49.1 \n× 37.7 × 44.5 mm. The February and June 2026 imaging \nrecords documented right ovarian volumes of approxi-\nmately 9.2 and 3.9 cm³, respectively; however, it was un-\nclear whether the October cyst had resolved or represented \na new or persistent lesion. The chronology is summarized \nin Figure 2. This case report was prepared in accordance \nwith the Consensus-based Clinical Case Reporting Guide-\nline Development (CARE) guidelines.1 \n2. DISCUSSION \nAdolescent endometriosis is commonly considered in pa-\ntients with dysmenorrhea or chronic pelvic pain.2,3 In a sys-\ntematic review, endometriosis was identified in 648 of 1,011 \n(64%) adolescents who underwent laparoscopy for pelvic \npain; that figure reflects a selected symptomatic group, not \nthe prevalence in all adolescents.3 The current case illus-\ntrates a different diagnostic pathway: endometriosis was \nfound histologically in a peritubal cyst removed during an \nacute surgical emergency, although the patient reported no \npreceding menstrual or chronic pelvic symptoms. The lack \nof additional visible implants does not exclude microscopic \ndisease elsewhere. \nAcute unilateral pain with nausea is typical of adnexal \ntorsion. The presence of Doppler flow does not exclude tor-\nsion, and prompt laparoscopy with detorsion and adnexal \npreservation is recommended when the clinical suspicion is \nhigh.4‑6 The surgical findings in this patient confirmed tor-\nsion despite preserved flow on ultrasound. In addition, the \nlesion interpreted preoperatively as ovarian was found to be \nperitubal. Large adnexal lesions can obscure their anatomic \norigin on ultrasonography, and operative inspection may \nKaddoura S, Ganti L. Peritubal Endometriosis Discovered During Surgery for Ovarian\nTorsion in an Adolescent Without Dysmenorrhea: A Case Report. Academic Medicine &\nSurgery. Published online October 15, 2026. doi:10.62186/001c.172338\n\nFigure 1. Pelvic ultrasound composite created from patient report.        \nFigure 2. Clinical course and imaging findings.      \nclarify the relationship of a cyst to the ovary and fallopian \ntube.7,8 \nThe pathologic finding supports endometriosis involving \nthe excised peritubal specimen, but it does not, by itself, \nprove that endometriosis caused the torsion. The available \ngross and final pathologic descriptions also do not establish \nwhether the lesion meets a more specific histologic def-\ninition of an endometrioma. The distinction matters be-\ncause peritubal cysts of other causes may also be associated \nwith torsion.7 Wenger and colleagues reported a tubal en-\ndometrioma associated with torsion of the fallopian tube in \nan 18-year-old; in contrast, the present operative account \ndocuments ovarian torsion and a separately excised per-\nitubal lesion.9 The conclusion supported here is therefore \nan association between ovarian torsion and an excised per-\nitubal cyst containing endometriosis, rather than a demon-\nstrated causal mechanism. \nPeritubal Endometriosis Discovered During Surgery for Ovarian Torsion in an Adolescent Without Dysmen…\nAcademic Medicine & Surgery 2\n\nFollow-up interpretation requires similar caution. The \nOctober 2025 scan documented a right ovarian cyst several \nmonths after excision, whereas subsequent scans reported \nmuch smaller ovarian dimensions. Because the identity and \ncourse of the cyst were incompletely characterized in the \navailable follow-up records, normal ovarian volume cannot \nbe equated with proven cyst resolution or absence of recur-\nrent endometriosis. Continued gynecologic assessment is \nimportant to establish the nature of any recurrent adnexal \nlesion and address symptoms if they arise.10 \nThe principal limitations are the incomplete availability \nof initial vital signs and laboratory data, the lack of full \nsubsequent sonographic descriptions, and the absence of \ndetailed microscopic pathology findings in the source ma-\nterial. These constraints limit inferences about recurrence, \nstaging, and causation, but do not diminish the docu-\nmented concurrence of torsion and histologically identified \nperitubal endometriosis. \n3. CONCLUSION \nEndometriosis may be discovered unexpectedly in adoles-\ncents undergoing surgery for acute adnexal pathology, even \nwhen dysmenorrhea and chronic pelvic pain are absent. \nThis case also reinforces two practical points: preserved \nDoppler flow does not rule out ovarian torsion, and ultra-\nsonography may not precisely locate a large adnexal cyst. \nHistopathology was essential to identifying endometriosis \nin the excised peritubal tissue. \n4. PATIENT PERSPECTIVE \nBefore this event, the patient had never considered her \nmenstrual cycles abnormal and had experienced no sig-\nnificant menstrual or pelvic pain. The abrupt transition \nfrom routinely painless periods to severe abdominal pain \nrequiring emergency surgery made the later diagnosis of \nendometriosis particularly unexpected. Learning that en-\ndometriosis had been present despite an absence of the \nsymptoms commonly associated with the condition sub-\nstantially changed her understanding of how the disease \ncan present in adolescents. \nSUPPLEMENTARY MATERIALS \nSupplementary Appendix 1: CARE Checklist (PDF) \nCompleted CARE guidelines checklist for clinical case re-\nporting. \nETHICS APPROVAL AND CONSENT FOR PUBLICATION \nWritten informed consent was obtained from the patient \nand her parent/legal guardian for the publication of this \ncase report and any accompanying images. Institutional \nReview Board (IRB) approval was not required by Brown \nUniversity, as single-patient case reports describing stan-\ndard clinical care do not meet the federal definition of hu-\nman subject research under 45 CFR 46. This study was \nconducted in accordance with the ethical standards of the \nDeclaration of Helsinki. \nDATA AVAILABILITY STATEMENT \nDe-identified clinical data are available from the corre-\nsponding author upon reasonable request, subject to pa-\ntient privacy constraints. \nCOMPETING INTERESTS \nThe authors declare that they have no known competing fi-\nnancial interests or personal relationships that could have \nappeared to influence the work reported in this paper. \nFUNDING \nThis research received no specific grant from any funding \nagency in the public, commercial, or not-for-profit sectors. \nAUTHORS’ CONTRIBUTIONS \nSK and LG drafted the manuscript together. \nACKNOWLEDGEMENTS \nNone \nSubmitted: October 07, 2026 EDT. Accepted: October 12, 2026 \nEDT. Published: October 15, 2026 EDT. \nThis is an open-access article distributed under the terms of the Creative Commons Attribution 4.0 International License \n(CCBY-4.0). View this license's legal deed at http://creativecommons.org/licenses/by/4.0 and legal code at http://creativecom-\nmons.org/licenses/by/4.0/legalcode for more information. \nPeritubal Endometriosis Discovered During Surgery for Ovarian Torsion in an Adolescent Without Dysmen…\nAcademic Medicine & Surgery 3\n\nREFERENCES \n1. Gagnier JJ, Kienle G, Altman DG, et al. The CARE \nguidelines: consensus-based clinical case reporting \nguideline development. BMJ Case Rep. \n2013;2013:bcr2013200800. doi:10.1136/\nbcr-2013-200800 \n2. Shim JY. Dysmenorrhea and endometriosis in \nadolescents. Obstet Gynecol Clin North Am. \n2024;51(4):651-661. doi:10.1016/j.ogc.2024.08.003 \n3. Hirsch M, Dhillon-Smith R, Cutner AS, Yap M, \nCreighton SM. The prevalence of endometriosis in \nadolescents with pelvic pain: a systematic review. J \nPediatr Adolesc Gynecol. 2020;33(6):623-630. \ndoi:10.1016/j.jpag.2020.07.011 \n4. American College of Obstetricians and \nGynecologists. Adnexal torsion in adolescents: ACOG \nCommittee Opinion No. 783. Obstet Gynecol. \n2019;134(2):e56-e63. doi:10.1097/\nAOG.0000000000003373 \n5. Bronstein ME, Pandya S, Snyder CW, Shi Q, \nMuensterer OJ. A meta-analysis of B-mode \nultrasound, Doppler ultrasound, and computed \ntomography to diagnose pediatric ovarian torsion. \nEur J Pediatr Surg. 2015;25(1):82-86. doi:10.1055/\ns-0034-1387946 \n6. Servaes S, Zurakowski D, Laufer MR, Feins N, Chow \nJS. Sonographic findings of ovarian torsion in \nchildren. Pediatr Radiol. 2007;37(5):446-451. \ndoi:10.1007/s00247-007-0429-x \n7. Lampl BS, King CR, Attaran M, Feldman MK. \nAdolescent endometriosis: clinical insights and \nimaging considerations. Abdom Radiol (NY). \n2025;50(10):4844-4853. doi:10.1007/\ns00261-025-04870-7 \n8. Thakore SS, Chun MJ, Fitzpatrick K. Recurrent \novarian torsion due to paratubal cysts in an \nadolescent female. J Pediatr Adolesc Gynecol. \n2012;25(4):e85-e87. doi:10.1016/j.jpag.2011.10.012 \n9. Wenger JM, Soave I, Lo Monte G, Petignat P, Marci \nR. Tubal endometrioma within a twisted fallopian \ntube: a clinically complex diagnosis. J Pediatr Adolesc \nGynecol. 2013;26(1):e1-e4. doi:10.1016/\nj.jpag.2012.06.005 \n10. Becker CM, Bokor A, Heikinheimo O, et al. ESHRE \nguideline: endometriosis. Hum Reprod Open. \n2022;2022(2):hoac009. doi:10.1093/hropen/hoac009 \nPeritubal Endometriosis Discovered During Surgery for Ovarian Torsion in an Adolescent Without Dysmen…\nAcademic Medicine & Surgery 4\n\nSUPPLEMENTARY MATERIALS \nSupplementary Appendix 1:    CARE Checklist   \nDownload: https://academic-med-surg.scholasticahq.com/article/172338-peritubal-endometriosis-discovered-during-\nsurgery-for-ovarian-torsion-in-an-adolescent-without-dysmenorrhea-a-case-report/attachment/370926.pdf \nPeritubal Endometriosis Discovered During Surgery for Ovarian Torsion in an Adolescent Without Dysmen…\nAcademic Medicine & Surgery 5","source_license":"CC0","license_restricted":false}