A 13-year-old girl folds forward on the stretcher, one hand pressed over her right lower abdomen, while the room fills with the sharp smell of vomit. Her mother says the pain began suddenly during school and intensified over two hours; she has vomited twice and cannot get comfortable. She denies dysuria, vaginal bleeding, or fever, and her last menstrual period was “about three weeks ago.” The ultrasound technician is not yet in the department, and the next decision is still yours.

— What’s your move? Read on.

Before you read
  • How do pregnancy testing, torsion, trauma, and infection alter the pathway?
  • Which apparently minor finding should make you consider abuse or a foreign body?

When to Think of It

Think broadly with acute pelvic or lower abdominal pain, vomiting, adnexal tenderness, a palpable mass, vaginal bleeding, urinary retention, genital swelling, unexplained discharge, or genital trauma. Sudden unilateral pain with nausea/vomiting is torsion until excluded; neonatal or prepubertal bleeding requires careful inspection for trauma, foreign body, infection, prolapse, or estrogenized tissue.

Sick or Not Sick

Sick vs. not sick: the key call is whether this is a threatened organ or life—especially torsion, hemorrhage/ectopic pregnancy, incarcerated hernia, or sepsis. Peritonitis, shock, severe uncontrolled pain, pregnancy with pain/bleeding, or a dusky/necrotic-appearing genital structure mandates immediate specialist escalation rather than waiting for a perfect scan.

The First Fifteen Minutes

  • ABCs, monitor, IV access, NPO, and early pediatric gynecology/urology consultation for suspected torsion, ectopic pregnancy, incarcerated hernia, or major trauma.
  • Severe pain → fentanyl 1 mcg/kg IV (or 1–2 mcg/kg intranasally if no IV; reassess and repeat cautiously), because μ-opioid analgesia rapidly reduces sympathetic stress without delaying diagnosis.
  • Moderate pain in a child ≥2 years with adequate renal function and no bleeding risk → ketorolac 0.5 mg/kg IV/IM, maximum 15 mg/dose, because prostaglandin blockade treats inflammatory pain; avoid with renal disease, dehydration, ulcer disease, or significant bleeding.
  • Vomiting → ondansetron 0.15 mg/kg IV/PO, maximum 8 mg, because 5-HT3 blockade improves tolerance of examination and imaging; check QT-risk history.
  • Possible pregnancy → obtain urine/serum β-hCG before radiologic or medication decisions, but do not delay operative consultation for a clearly threatened ovary.
  • Hemodynamic instability or major bleeding → lactated Ringer’s or normal saline 20 mL/kg IV bolus, reassessing perfusion after each bolus, because restoring circulating volume supports organ perfusion.
  • Do not manually manipulate a suspected torsed adnexa or obstructed genital tract; analgesia is appropriate while arranging definitive evaluation.

Definitive Care & Disposition

Ovarian torsion requires urgent operative detorsion; Doppler flow does not reliably exclude it, and preservation is preferred when feasible. Ectopic pregnancy requires gynecology involvement, serial examination/β-hCG and ultrasound when stable, and operative or methotrexate management according to location, stability, and specialist criteria. Imperforate hymen with urinary retention or severe cyclic pain requires gynecologic drainage; labial adhesions are usually outpatient unless retention or infection is present. Foreign body, unexplained genital injury, or concerning history requires a trauma-informed examination and child-protection pathway. Stable vulvovaginitis, dermatitis, and minor injuries may be discharged with follow-up; torsion, ectopic pregnancy, significant trauma, sepsis, or inability to control pain requires admission or transfer.

How This One Kills

The classic failure is treating sudden unilateral pain as gastroenteritis or a UTI, obtaining a “normal-flow” Doppler study, and losing the ovary while waiting. Another lethal miss is assuming a postmenarchal child cannot be pregnant.
The Differential — What Else Looks Like This
  • Appendicitis — progressive migratory pain, anorexia, and focal peritoneal findings; confusing it with torsion delays abdominal surgery, while confusing torsion with appendicitis loses ovarian viability.
  • Ectopic pregnancy — positive β-hCG with pain/bleeding and possible syncope; missing it risks catastrophic hemorrhage.
  • UTI/pyelonephritis — dysuria, pyuria, fever, and flank pain; anchoring on infection can delay torsion.
  • Sexual abuse or foreign body — inconsistent history, discharge, bruising, or recurrent bleeding; treating empirically without safeguarding can miss ongoing harm.

The Second-Day Story

In younger children, torsion may appear as vague abdominal pain, lethargy, or vomiting without localizing pelvic findings; adolescents may describe only nausea or urinary discomfort. A partially infarcted ovary may produce intermittent pain, and Doppler flow may remain present through dual ovarian blood supply or intermittent torsion. Repeated examination, pregnancy testing when biologically possible, focused ultrasound, and consultation based on clinical suspicion—not a single imaging result—preserve safety.
Back to Our Patient
Back to the 13-year-old with sudden right-sided pain and vomiting: the trigger presentation makes ovarian torsion the leading concern, even without fever or urinary symptoms. She is hemodynamically stable but has focal right adnexal tenderness and persistent vomiting, so she receives IV fentanyl and ondansetron, remains NPO, has β-hCG and urgent pelvic ultrasound ordered, and gynecology is called before imaging is definitive. The ultrasound shows an enlarged right ovary with peripheral follicles and reduced venous flow; she proceeds urgently to operative detorsion and is admitted under gynecology.
Patient Presentation to Attending
How you’d present this patient on the floor — tight, pertinent positives and negatives, no rambling
“This is a previously healthy 13-year-old girl with two hours of sudden right lower-quadrant and pelvic pain with two episodes of vomiting. She has no fever, dysuria, vaginal bleeding, or diarrhea, and her last menstrual period was three weeks ago. She is hemodynamically stable but uncomfortable, with focal right lower-quadrant/adnexal tenderness without diffuse peritonitis. β-hCG is pending, and ultrasound shows an enlarged right ovary with peripheral follicles and reduced venous flow. My leading diagnosis is right ovarian torsion, with ectopic pregnancy, appendicitis, and UTI as alternatives. She is NPO, has IV access and analgesia, and I have called gynecology for urgent operative evaluation.”

Study Directive

  • Draw the pediatric acute pelvic-pain pathway from memory: torsion, ectopic pregnancy, appendicitis, UTI, trauma, and foreign body.
  • Review one pediatric pelvic ultrasound case and identify which findings support torsion without relying on Doppler flow alone.
  • Practice a trauma-informed genital history and documentation script.
  • Memorize weight-based fentanyl, ketorolac, ondansetron, and fluid-bolus dosing; verify institutional pediatric sedation limits in Lexicomp or your local protocol.

Recent Literature

  • Review or guideline Pediatric Genitourinary Infections and Other Considerations
    Stephanos K, Bragg AF · Emerg Med Clin North Am, 2019 · PMID 31563205 · cited 2×
    Provides an emergency-focused framework for recognizing, evaluating, and treating pediatric genitourinary infections and related acute GU presentations.