The double bladder sign: Challenges in early sonographic diagnosis of ovarian torsion

Ovarian torsion is an emergency whereby challenges in diagnosis may lead to delayed management. The morbidity associated with delayed diagnosis can be severe and includes loss of ovarian function. We present a case of a 24-year-old female who presented to the hospital with left lower quadrant abdominal pain with unremarkable physical examination. A transabdominal and transvaginal ultrasound were acquired and demonstrated a mildly enlarged left ovary and fallopian tube without other significant findings. However due to worsening pain and up trending inflammatory markers, diagnostic laparoscopy was performed and demonstrated a 12cm ovarian cyst, a necrotic left adnexal mass and a torsed left tubo-ovarian pedicle. These findings were not appreciated on the initial Doppler ultrasound acquired but retrospective analysis demonstrated a double bladder sign. Our case report aims to aid sonographers and physicians to promptly diagnose ovarian torsion through the "double bladder sign" and other salient ultrasonographic and clinical features.