Posthysterectomy Bilateral Simultaneous Ovarian Torsion in the Absence of Adnexal Masses: A Rare Case Report

Background Ovarian torsion (OT) is a common and serious gynecological emergency that accounts for 2%–3% of acute pelvic pain presentations to the emergency department (ED). OT most commonly occurs in the setting of a reproductive-aged woman with an existing ovarian mass; however, OT can occur in a variety of ages with or without ovarian masses. Despite the variability in presentation, nearly all OT cases occur unilaterally. Asynchronous bilateral OT (ABOT) is a rare occurrence where both ovaries torse at different times. Case This is the case of a 36-year-old female patient with a history of prior hysterectomy who presented to the ED with vague abdominal pain and was found to have bilateral OT in the absence of existing ovarian masses.

ABOT is a rare variant of OT that has seldom been described in literature since the first case was described nearly 90 years ago. ABOT can cause sterility and premature menopause, and future research should identify the factors that may contribute to this condition. 1. Introduction Ovarian torsion (OT) is a serious and relatively common gynecologic emergency defined as the interruption of ovarian arterial, venous, and lymphatic flow caused by the partial or complete twisting of the adnexa [1]. This twisting can strangulate the organ and ultimately result in ischemia, necrosis, and loss of the ovary and other affected structures [2]. Although OT most commonly occurs in reproductive-aged women, cases have been reported across a wide age range, from prepubescent to postmenopausal patients. This surgical emergency accounts for ~2%–3% of acute pelvic pain presentations and is the fifth most common cause of pelvic pain among women of reproductive age [3]. Common risk factors for OT include pregnancy, ovulation induction or fertility treatments, and adnexal mass effects, with the highest risk associated with ovarian cysts greater than 5 cm in size [2]. However, the absence of ovarian cysts should not exclude torsion from the differential diagnosis, as nearly half of torsion cases occur without an associated ovarian mass [4]. Despite its relative frequency, OT is overwhelmingly unilateral [5]. Bilateral OT is exceedingly rare. While asynchronous bilateral OT (ABOT)—defined as torsion of each ovary occurring at separate, distinct time points—was first described in 1934, only a limited number of cases have been reported [6]. True asynchronous torsion requires documentation of two temporally distinct torsion events [7]. In contrast, simultaneous bilateral OT, in which both ovaries are found torsed during a single operative event, represents a distinct and even rarer clinical entity. Both presentations carry the potential for devastating consequences, including loss of fertility and premature surgical menopause if not promptly recognized and treated [8]. We present a rare case of simultaneous bilateral OT in a patient with a prior hysterectomy and no adnexal masses, a presentation that has not been previously described in the literature to our knowledge. 2. Case Presentation A 36-year-old G4P2022 presented to the emergency department (ED) with a chief complaint of acute onset right lower quadrant pain with radiation to the right flank and lower back for 1 day. It was described as a sharp pain that was intermittent in nature and associated with intermittent nausea and vomiting. The patient reported that this pain initially began a week prior on the left side; however, the pain subsided within the day, and the patient did not seek care at this time. The patient has a significant past medical history of nephrolithiasis, with prior percutaneous nephrolithotomy, and assumed her pain was due to kidney stones, given the similar presentation as her prior stones. The patient denied fever, chills, hematuria, and urinary frequency at presentation. In 2018, the patient had an uncomplicated laparoscopic hysterectomy for adenomyosis. On arrival, the patient was afebrile and had stable vital signs. A laboratory work-up was initiated, including a complete blood count (CBC), basic metabolic panel (BMP), urine pregnancy test (UPT), and a urinalysis. UPT was negative. The rest of the labs were largely unremarkable, with a normal white blood cell count of 8.8 and a normal urinalysis, including negative RBCs. The patient subsequently underwent a transvaginal ultrasound (TVUS) and a computed tomography (CT) of the abdomen and pelvis without contrast. TVUS revealed a surgically absent uterus and bilateral enlargement of the ovaries without cysts. The right ovary measured 4.9 cm × 2.8 cm × 4.4 cm (volume 30 mL) and the left ovary measured 5.8 cm × 3.1 cm × 4.3 cm (volume 39 mL). An arterial waveform was identified in the left ovary; however, not clearly identified in the right ovary. CT scan showed a 2 mm nonobstructing left kidney stone in the absence of hydronephrosis, hydroureter, and ureteral calculus. Other than a surgically absent uterus and present ovaries, described as “prominent,” no further comments were made on CT. Obstetrics and gynecology were consulted for a suspected right OT. After an evaluation by the team, OT remained highest on the differential and the patient was counseled on medical management vs. surgical management. A shared decision-making process was exercised, and the patient ultimately opted for surgical management. At this time, the patient was counseled on the potential complications of the surgery and consented to the potential removal of one or both ovaries if necessary. Furthermore, the patient was made aware of the rare possibility that if both ovaries would need to be removed, immediate hormone replacement therapy would be initiated. Consents were signed, and the patient underwent a diagnostic laparoscopy. Laparoscopy revealed a grossly enlarged right ovary that was twisted around the infundibulopelvic (IP) ligament at least twice (Figure 1). The right ovary appeared necrotic and dusky. The inspection also revealed an enlarged left ovary that was twisted twice around the left IP (Figure 2). The left ovary was similarly dusky and dark with a greenish tint—concerning for necrosis. Given the necrotic appearance of both ovaries, a bilateral salpingo-oophorectomy was performed. There were no intraoperative or postoperative complications. After surgery, the patient was informed of the results and given instructions to follow up outpatient with a plan of beginning immediate hormone replacement therapy. The patient was subsequently discharged in stable condition. 3. Discussion Simultaneous bilateral OT can significantly impact a patient’s quality of life by threatening fertility and inducing premature surgical menopause [9]. Although OT most commonly occurs in reproductive-aged women with unilateral adnexal masses, a wide spectrum of presentations exists, as demonstrated by this case. To our knowledge, this represents the first reported case of simultaneous bilateral OT occurring in a reproductive-aged patient with a prior hysterectomy and no adnexal masses. The clinical diagnosis of OT remains challenging due to its variable and nonspecific symptomatology. Presenting symptoms may range from localized or diffuse pelvic pain to nausea, vomiting, or fever. Prior studies have demonstrated that acute-onset abdominal pain is the most common presenting symptom in patients ultimately diagnosed with OT [10], which is also one of the most common ED chief complaints with an extensive differential diagnosis [11, 12]. As a result, OT is frequently overlooked during initial evaluation, particularly in patients without classic risk factors. One series of 13 cases reported OT as part of the initial differential diagnosis in only one patient [13]. These factors can contribute to delays in diagnosis and intervention, which may compromise ovarian viability. The absence of adnexal masses in this patient is notable, as ovarian masses are traditionally considered a primary risk factor for torsion [14]. Physical examination may fail to identify adnexal enlargement due to patient discomfort, body habitus, or examiner limitations [15]. TVUS with Doppler evaluation is commonly used in the diagnostic workup of suspected torsion [7]. While decreased or absent arterial flow may increase suspicion, preserved arterial flow does not exclude torsion because of the ovary’s dual blood supply [16]. In this case, Doppler imaging demonstrated arterial flow in one ovary and absent flow in the other, yet intraoperative findings confirmed torsion of both ovaries. This underscores the limitation of imaging modalities and reinforces that OT remains a clinical diagnosis. An additional noteworthy feature of this case is the patient’s history of a laparoscopic hysterectomy. Although hysterectomy itself is not considered a strong independent risk factor for OT [17], some evidence suggests an association between torsion and prior laparoscopic pelvic surgery, possibly due to altered adnexal support and increased ovarian mobility compared to open procedures [18]. Ogawa et al. have similarly described non-neoplastic OT occurring exclusively in patients with prior laparoscopic surgery and no underlying ovarian pathology, supporting the hypothesis that surgical disruption of pelvic anatomy may predispose otherwise normal ovaries to torsion. Surgical intervention remains the definitive treatment for OT. Prompt operative management is critical to preserve ovarian function and prevent complications such as necrosis, hemorrhage, and peritonitis. Detorsion is preferred when ovarian viability appears salvageable [14]. In select cases, oophoropexy may be considered to reduce the risk of recurrence, particularly in patients without adnexal masses or with increased ovarian mobility [16]. When ovarian tissue is nonviable, salpingo-oophorectomy is indicated [7, 14]. Patients undergoing bilateral oophorectomy before natural menopause require counseling regarding surgical menopause and the role of hormone replacement therapy [19]. Without estrogen replacement, patients face increased risks of vasomotor symptoms, osteoporosis, cardiovascular disease, cognitive decline, and dementia [20–23]. Estrogen therapy has been shown to mitigate these risks and alleviate symptoms that are often more severe than those experienced during natural menopause [24]. 4. Discussion Several aspects of this patient’s presentation are exceptionally rare. The majority of OT cases are associated with adnexal masses and occur unilaterally. In contrast, this patient was found to have simultaneous bilateral OT in the absence of ovarian masses following a prior hysterectomy. This case highlights that acute or recurrent unilateral pelvic or abdominal pain—even when occurring at different time points—should prompt consideration of bilateral torsion, though prior symptoms alone should not be assumed to represent asynchronous events. Furthermore, preserved Doppler flow does not exclude torsion, and a history of hysterectomy or other pelvic surgery should not eliminate torsion from the differential diagnosis. Increased awareness of mass-negative and postsurgical torsion mechanisms is essential to improve timely diagnosis and optimize ovarian preservation strategies. Funding This research received no external funding. Disclosure All authors have read and approved the final version of the manuscript. The corresponding author had full access to all of the data in this study and takes complete responsibility for the integrity of the data and the accuracy of the data analysis. Nicole Friedlich affirms that this manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned have been explained. The funding source had no role in the study design; collection, analysis, or interpretation of data; writing of the report; or the decision to submit the manuscript for publication. Consent Written informed consent was obtained from the patient for publication of this case report and accompanying clinical images. Conflicts of Interest The authors declare no conflicts of interest. Data Availability Statement The authors confirm that the data supporting the findings of this study are available within the article and its accompanying clinical images.