Simple Paratubal Cyst Resulting in Contralateral Ovarian Torson: A Case Report

Purpose: To report a rare case of simple cyst progression to contralateral ovarian torsion in a previously healthy adolescent. Methods: Case Report. Introduction: Paratubal cysts are typically benign and asymptomatic, often discovered incidentally during imaging or surgery. However, their potential to cause significant complications, including adnexal torsion, especially in pediatric populations, is less commonly reported. Adnexal torsion is the fifth most common gynecologic emergency.1 This case presents an unusual scenario of a simple right-sided paratubal cyst leading to torsion of the contralateral (left) ovary and fallopian tube in a premenarchal adolescent girl. The case emphasizes the importance of timely surgical evaluation in the setting of persistent abdominal pain and demonstrates how even benign-appearing lesions on imaging may result in complex intra-abdominal pathology. Results: We present the case of a 12-year-old premenarchal, virginal female with no significant medical or surgical history who presented to a rural medical clinic with severe lower abdominal pain. The patient endorsed roughly two weeks of pain that was initially attributed to constipation; however, over the past week, the pain had significantly progressed, despite more regular bowel movements. She endorsed pain so severe that she was unable to tolerate any food intake. A pelvic ultrasound revealed a uterus measuring 4.42 x 2.3 x 1.54 cm with an endometrial thickness of 3.91 mm. The left ovary appeared normal, while the right ovary contained a 5.8 x 5.5 x 7.3 cm unilocular, anechoic cyst with a smooth inner wall, consistent with ORADS-2. No free fluid was seen. Due to persistent pain and the size of the adnexal mass, the patient underwent diagnostic laparoscopy. Inspection revealed torsion of the left ovary and fallopian tube with appropriate coloration. Manipulation of the left ovary showed a large, dark cystic mass within the cul-de-sac The mass appeared adherent with the left adnexa and contiguous to the right ovary. The uterus was mobile and not involved. Due to the complexity and extent of the mass, Pediatric Surgery was consulted intraoperatively. They performed lysis of adhesions and identified the mass as a large, right-sided, paratubal cyst. The mass was carefully dissected from surrounding structures, including shelling it out from the left fallopian tube before removal. The fimbriae were involved and could not be preserved. The left ovary was de-torsed and noted to have good perfusion. Due to its size of the mass in the bag, the specimen bag was brought towards the anterior abdominal surface, and the cyst was then ruptured. The dark brown fluid was aspirated with a suction irrigator – taking care to ensure no spillage. The cyst wall was then removed in its entirety and sent to pathology. The final intraoperative assessment showed that the remaining left ovary and fallopian tube appeared viable with good color. Pathology revealed a 5.8 x 5.3 x 3.5 cm disrupted cyst with a markedly dusky outer surface and a cobblestone, trabeculated inner lining containing an adherent blood clot. The cyst wall measured 0.2–0.5 cm in thickness and lacked distinct anatomic features, consistent with a paratubal cyst. The patient recovered well postoperatively and was discharged in stable condition. Follow-up will focus on monitoring the return of ovarian function and future pubertal development. Conclusion(s): This case highlights the importance of maintaining a broad differential diagnosis when evaluating premenarchal patients with persistent lower abdominal pain, particularly in rural or resource-limited settings where access to specialty care may be delayed. Although initial imaging suggested a benign ovarian cyst, the patient’s escalating symptoms warranted surgical evaluation, ultimately revealing a large paratubal cyst with adnexal torsion. Prompt surgical intervention facilitated ovarian preservation and resolution of symptoms. This case underscores the value of timely referral, multidisciplinary intraoperative collaboration, and the need for careful post-operative follow-up to ensure normal pubertal progression and reproductive health in pediatric patients.