Severe Lower Left Abdominal Pain

43-year-old female with no significant medical or surgical history presents with acute onset, severe left lower abdominal pain.

Figure 1: Primary concern was for ovarian torsion. TVUS showed a normal sized left ovary, with Doppler and Spectral blood flow, essentially ruling out ovarian torsion. A mass was partially visualized likely a fibroid (arrow).

Figure 2: A contrast-enhanced CT was subsequently performed which showed a large fibroid uterus, in addition to a hypoattenuating and somewhat heterogeneous soft tissue density within the left adnexa measuring 5.6x4.8x6.0 cm.

Figure 3: Intraoperatively, the left adnexal mass was found to be a large pedunculated fibroid, torsed on its pedicle. Given the concern for necrosis & repeat torsion, patient underwent myomectomy.

Patient presented to emergency department with pain that began the night before after she ate some questionable fish. She subsequently had a moderately loose non-bloody bowel movement with no relief.

Physical exam was notable for a palpable and tender left lower quadrant/adnexal mass.

A limited transvaginal ultrasound was performed but had to be terminated early secondary to patient discomfort. The partial exam demonstrated a normal sized left ovary, with demonstrable Doppler and Spectral blood flow, essentially ruling out ovarian torsion.

Intraoperatively, it was discovered that left adnexal mass was a large pedunculated fibroid, torsed on its pedicle.

Uterine leiomyomas (fibroids) are the most common gynecologic tumors, estimated to be in 20-40% of women of reproductive age.

Initial imaging workup should begin with a transabdominal and transvaginal ultrasound which can help identify a lesion lateral to the uterus; however, a definitive diagnosis cannot always be made as the torsed pedicle may be too thin for identification with this imaging technique.

Utilizing imaging early in the workup can certainly help exclude other differential pathologies.