Isolated fallopian tube torsion (IFTT) is a rare form of adnexal torsion. A 2024 review described fewer than 150 cases over several decades. The clinical presentation of IFTT is highly variable and nonspecific, which may result in delayed diagnosis. Most patients present with acute unilateral abdominal pain with nausea and/or vomiting, while other patients may present with more gradual symptoms. Risk factors for IFTT include adnexal lesions, hydrosalpinx, previous pelvic surgery, and pelvic inflammatory disease. Ultrasound is particularly useful in identifying the imaging signs of IFTT, which include normal ovarian size and flow, a distended cylindrical structure that tapers to a "beak" adjacent to the ovary, thickened endosalpingeal folds resulting in a "cogwheel" appearance, and, lastly, a twisted vascular pedicle. We present an imaging-focused case in which the diagnosis of IFTT using ultrasound, following equivocal CT, resulted in prompt and confirmatory surgical management. Our goal is to raise awareness of IFTT as a possibility in females with abdominal pain and to discuss ultrasound characteristics that may increase clinical suspicion and diagnostic confidence. Prompt recognition and surgical management may prevent tubal necrosis and loss of fertility.

Endometriosis may rarely present with atypical manifestations that closely mimic intra-abdominal malignancy or severe pelvic sepsis, resulting in significant diagnostic uncertainty. We present two contrasting cases of presumed severe endometriosis with uncommon clinical and radiological presentations. In the first case, a woman in her 30s presented with acute abdominal pain, progressive abdominal distension, and respiratory compromise associated with massive haemorrhagic ascites and markedly elevated cancer antigen 125 levels. Cross-sectional imaging demonstrated extensive deep infiltrative endometriosis with haemoperitoneum and multiple extra-pelvic endometriotic deposits. In the second case, a woman in her 30s presented with a complex adnexal mass, para-aortic lymphadenopathy and inflammatory features initially concerning for tubo-ovarian abscess or underlying malignancy. Following prolonged antibiotic therapy, complete radiological resolution of the adnexal lesion was observed, with subsequent imaging findings considered highly suggestive of an infected endometrioma. These cases emphasise the diverse spectrum of endometriosis presentations, the limitations of non-histological diagnosis and the importance of multidisciplinary assessment, radiological expertise and longitudinal follow-up in complex presentations.

Uterine leiomyosarcoma (uLMS) is a rare and aggressive mesenchymal malignancy associated with a high risk of recurrence and metastatic spread. Although recurrent disease commonly presents with infiltrative or bulky pelvic masses, atypical patterns of dissemination may create diagnostic challenges. We present the case of a 49-year-old woman with a history of FIGO stage IB uterine leiomyosarcoma who underwent total abdominal hysterectomy with bilateral salpingo-oophorectomy in 2023 and subsequently received treatment for recurrent metastatic disease. She presented with acute lower abdominal pain, persistent vomiting, and progressive obstipation. Computed tomography demonstrated a large heterogeneous pelvic mass measuring approximately 14 cm, together with features of a closed-loop small bowel obstruction and mesenteric vessel twisting suggestive of volvulus. Following clinical deterioration despite conservative management, emergency exploratory laparotomy was performed, revealing a 360-degree small bowel volvulus around the superior mesenteric artery pedicle, which was successfully reduced. A large fixed pelvic mass involving adjacent bowel and mesentery was identified, along with numerous smooth, firm, pedunculated nodules distributed throughout the mesentery, bowel serosa, and parietal peritoneum. These nodules had a gross appearance resembling benign parasitic leiomyomas or disseminated peritoneal leiomyomatosis rather than metastatic sarcoma. Segmental small bowel resection with double-barrelled ileostomy was undertaken due to bowel compromise and extensive serosal injury. Histopathological examination of the resected nodules demonstrated atypical spindle cells arranged in intersecting fascicles with moderate nuclear atypia and a mitotic rate of 5-10 mitoses per 10 high-power fields. Immunohistochemical analysis showed diffuse positivity for smooth muscle actin, desmin, and h-caldesmon, with abnormal mutant-pattern p53 expression, confirming multifocal metastatic uterine leiomyosarcoma. This case demonstrates an unusual pattern of metastatic uLMS presenting with a benign-appearing peritoneal distribution and complicated by acute small bowel volvulus and obstruction. The findings highlight the importance of histopathological and immunohistochemical assessment in distinguishing metastatic smooth muscle malignancy from benign-appearing lesions and emphasise the need for multidisciplinary management in complex recurrent disease.

Uterine artery embolization is a minimally invasive, uterus-preserving treatment for symptomatic uterine leiomyomas that is generally considered safe; delayed infectious complications are uncommon and may be difficult to distinguish from postembolization syndrome. This report presents a case of delayed pyometra associated with a necrotizing leiomyoma following uterine artery embolization. A 41-year-old multiparous woman with a history of two cesarean deliveries underwent bilateral uterine artery embolization for a symptomatic large FIGO type 2 submucosal leiomyoma after declining surgical treatment. Although her symptoms initially improved, she presented three months later with high fever and severe pelvic pain despite only mildly elevated inflammatory laboratory findings. Imaging demonstrated a necrotic leiomyoma with pyometra, and endometrial culture yielded Streptococcus agalactiae. Despite uterine drainage and culture-directed antimicrobial therapy, persistent symptoms ultimately required total laparoscopic hysterectomy. Histopathological examination confirmed extensive coagulative necrosis of the leiomyoma with acute inflammatory infiltration. This case highlights that delayed infectious complications may occur several months after uterine artery embolization for large submucosal leiomyomas and may mimic postembolization syndrome despite relatively mild inflammatory laboratory abnormalities. Careful long-term follow-up and prompt evaluation are essential for timely diagnosis and appropriate management.

A 12-year-old premenarchal female patient presented with right iliac fossa pain, perianal pruritus, urticaria, angioedema, arthralgia, peripheral eosinophilia, and an initially undetectable C-reactive protein. Serial ultrasonography demonstrated increasing intra-abdominal free fluid. Diagnostic laparoscopy demonstrated appendiceal serosal injection, turbid pelvic fluid, and mesenteric lymphadenopathy, prompting appendectomy. Histopathology identified Enterobius vermicularis (EV) within the appendiceal lumen, with reactive lymphoid hyperplasia but no acute suppurative inflammation. Symptoms resolved following surgery and mebendazole treatment. A descriptive updated systematic review of appendectomy specimens containing EV was performed. Seventy-six studies comprising 196,138 appendectomy specimens were included. EV was identified in 3,913 specimens, corresponding to a crude proportion among appendectomy specimens of 2.00% (95% CI: 1.93-2.06%). Among 11 newly identified studies reporting histological subclassification, 247 of 694 EV-positive specimens (35.6%) demonstrated histological acute appendicitis, whereas most showed non-suppurative or reactive pathology. This case and review suggest that appendiceal enterobiasis may present as an appendicitis-like illness, particularly when abdominal pain occurs alongside atypical features such as perianal pruritus, eosinophilia, urticaria, or angioedema. Recognition of enterobiasis may guide anthelmintic therapy and consideration of household treatment; however, a causal relationship between EV and systemic hypersensitivity features cannot be established from a single case. Importantly, clinical deterioration should continue to prompt urgent surgical assessment.

The bladder is innervated by a complex network of sensory neurons that detect and transmit mechanical and chemical signals to the central nervous system, regulating both urine storage and voiding, and mediating sensations of bladder fullness and pain. While stretch-sensitive afferents within the bladder wall are known to monitor bladder tension, the contribution of stretch-insensitive afferents that reside within the bladder mucosa to bladder sensation and function remains unclear. Here, we establish a mouse model of selective bladder mucosal afferent denervation using intravesical instillation of resiniferatoxin to define the functional roles of these fibers in health and disease. We assessed the impact of mucosal denervation on sensory nerve activity and bladder function in healthy mice and in a model of urinary tract infection (UTI) induced by acute bacterial challenge with uropathogenic Escherichia coli. We show that mucosa-innervating afferents do not influence bladder distension responses or voiding function under healthy conditions. In contrast, during UTI, these afferents become hypersensitive and serve as important drivers of infection-induced pelvic pain and urinary frequency, responses that contribute to bacterial clearance. Together, these findings identify bladder mucosal afferents as key sensors of pathogenic challenge and reveal a previously unrecognized mechanism that drives behavioral responses to reduce the burden and extent of UTI.

Literature on major urological surgery in heart transplant recipients remains limited because these patients historically had shorter life expectancies, limiting long-term surgical follow-up. However, advances in medical care, immunosuppressive therapy, and patient management have prolonged survival, increasing the incidence of age-related diseases, including prostate cancer. This intersection of cardiac transplantation and urological disease presents unique clinical challenges requiring further study of optimal surgical and postoperative management. Heart transplant patients receiving lifelong tacrolimus-based immunosuppression are particularly prone to impaired wound healing and postoperative complications. The authors report a 71-year-old man who underwent heart transplantation in November 2015 for ischemic cardiomyopathy. His immunosuppressive regimen included tacrolimus (target trough 5-7 µg/L), mycophenolate mofetil, and low-dose steroids. The patient underwent robot-assisted radical prostatectomy (RARP) with bilateral pelvic lymphadenectomy for prostate adenocarcinoma (iPSA 9.3 ng/mL). Histopathology revealed pT3b pN1 (5/30) Gleason 7b (4 + 3, 80% + 20%) disease with negative margins. Recovery was initially uneventful, and he was discharged on postoperative day 5, catheter-free after spontaneous micturition. Fifteen days postoperatively, the patient was readmitted with acute flank pain. Imaging demonstrated left ureteral extravasation. Review of the surgical recording excluded thermal injury during lymphadenectomy, suggesting tacrolimus-associated impaired healing as a possible cause. Management included placement of a double-J stent, antibiotics, and cardiac monitoring. Because urinary drainage remained insufficient, urinary diversion with a Mono-J stent and percutaneous nephrostomy (PCN) was performed, considering the patient's cardiologic risk profile. A cystogram demonstrated minimal secondary urethrovesical anastomotic insufficiency, possibly related to endourological manipulation, although tacrolimus-associated healing impairment could not be excluded. The Mono-J stent and the nephrostomy catheter were removed after 2 and 3 months, respectively, following complete ureteral healing. Secondary percutaneous radiotherapy with androgen deprivation therapy was recommended. This case demonstrates the feasibility of RARP in heart transplant recipients while highlighting the potential impact of immunosuppressive therapy on postoperative healing.

We present the case of a 12-year-old post-menarchal female (bone age: 13 years; 30th percentile for height) who received an initial gonadotropin-releasing hormone (GnRH) analogue injection for height augmentation to maximize adult height potential prior to imminent epiphyseal fusion. Immediately following the injection, she developed acute-onset abdominal pain, emesis, and diarrhea. Refractory to conservative management, her clinical status prompted pelvic ultrasonography and subsequent contrast-enhanced CT imaging, which revealed significant bilateral ovarian enlargement, multiple cystic masses, and congestion of the left vascular pedicle highly indicative of adnexal torsion. Urgent surgical exploration confirmed bilateral ovarian cyst formation and left-sided ovarian torsion. Following an unremarkable post-operative recovery, GnRH analogue therapy was permanently discontinued. This case underscores the critical need to recognize the heightened risk of rapid ovarian hyperstimulation and subsequent torsion when initiating these medications in post-menarchal or late pubertal females, in whom mature follicles are already present. While GnRH analogues generally maintain a favorable safety profile, clinician vigilance regarding this severe ovarian complication in older pediatric cohorts is vital to prevent diagnostic delays and ensure prompt surgical intervention.

Obturator hernia (OH) is a rare but potentially life-threatening pelvic hernia associated with delayed diagnosis, bowel strangulation, and high mortality. We present a rare case of spontaneously reduced right obturator hernia documented by sequential computed tomography (CT) imaging and successfully treated with elective laparoscopic transabdominal preperitoneal (TAPP) mesh repair. A 67-year-old thin woman presented with acute lower abdominal pain associated with medial right thigh pain consistent with a positive Howship-Romberg sign. Initial non-contrast CT performed at a district hospital demonstrated a right obturator hernia with incarcerated bowel protruding through the obturator canal. However, following interhospital transfer, the patient experienced complete spontaneous symptom resolution, and repeat contrast-enhanced CT no longer demonstrated the herniated bowel loop or evidence of bowel obstruction. Despite apparent clinical and radiologic improvement, the previously documented obturator defect was considered at high risk for recurrent incarceration and strangulation. Elective laparoscopic TAPP repair performed three days later confirmed a widened right obturator defect without residual incarcerated bowel, and prosthetic mesh reinforcement was completed successfully without bowel resection or perioperative complications. The postoperative course was uneventful. This case highlights the diagnostic challenge of spontaneously reduced obturator hernia and emphasizes the importance of correlating prior imaging findings with clinical evolution, even when repeat imaging appears normal. Sequential CT imaging uniquely documented the dynamic transition from incarcerated obturator hernia to spontaneous reduction, thereby preventing missed diagnosis through careful correlation of prior and repeat imaging findings despite complete symptom resolution.

Alpha-gal syndrome (AGS) is an immunoglobulin E (IgE) mediated hypersensitivity reaction caused by tick bites. The body's immune response to tick bites can lead to the production of anti-alpha-gal IgE antibodies, disrupting the normal oral tolerance to food allergens. AGS typically results in delayed anaphylaxis after consuming red meat or certain medications and immediate anaphylaxis following tick bites; however, isolated gastrointestinal manifestations are increasingly being reported. We present a case of a 38-year-old female patient with a history of AGS who developed acute sigmoid diverticulitis with associated pelvic abscess, likely related to her AGS. Despite initiation of broad-spectrum intravenous antibiotics, the patient experienced persistent severe abdominal pain requiring diagnostic laparoscopy; however, bowel resection was ultimately avoided. The patient improved with continued intravenous antibiotics and had complete symptom resolution on follow-up. This case highlights the expanding gastrointestinal spectrum of AGS and raises the concern of an association between AGS-related immune dysregulation and inflammatory colonic pathology such as diverticulitis. Recognition of atypical gastrointestinal presentations of AGS is essential to reduce delays in diagnosis and misclassification as other gastrointestinal disorders.