Rovsing’s sign: what is it, and how it helps your clinical diagnosis?

1. What is Rovsing’s sign?

Rovsing’s sign (a.k.a. indirect tenderness) is a right lower quadrant pain elicited by pressure applied on the left lower quadrant. The phenomenon is generally named after the Danish surgeon Niels Thorkild Rovsing. However, the very similar phenomenon – differences see below – was first described by the Swedish surgeon Emil Samuel Perman. The sign is sometimes called Perman-Rovsing’s sign or Perman’s sign.

The prime suspect pathology behind Rovsing’s sign is generally appendicitis. However, other pathology relating to the bladder, ascending colon, uterus and the adnexa can result in a “positive” Rovsing’s sign.

2. The history and diagnosis of Rovsing’s sign

It is commonly taught that the pressure applied on the right lower quadrant elicits peritoneal irritation, and thus pain, if inflammation is present. This would fit in Perman’s description of the phenomenon.

“Furthermore, I have always found another symptom evident, namely a pain located to the ileocaecal tract with pressure to the left part of the abdomen”
Perman E.S., 1904

However, Rovsing’s original intention – and thus the maneuver – was slightly different, and he described a more detailed pathophysiological explanation. He described the maneuver as an attempt to push the content of the intestine “backward”, in an antiperistaltic direction, to increase the pressure within the colon, including the caecum and appendix. 

“I press with my right hand onto the fingers of the left hand that is lying flat against the colon descendens [descending colon] and then let the hand glide up toward the splenic flexure…The entire method is based upon the isolated rise of pressure within the colon.” Rovsing 1907

It is interesting to see that medical literature often simplifies the maneuver as a “pressure applied” without the “glide-up” movement, that resembles Perman’s description, while naming the sign after Rovsing.

3. The background and importance of Rovsing’s sign

Inflammation of the mucosa is generally not the cause of the pain. Pain in the gastrointestinal tract is mainly limited to the distention of the organ or a full-thickness inflammation of the intestinal wall that stimulates the visceral peritoneum, inciting the release of inflammatory mediators that elicit pain. This also means that if the patient’s inflammatory system is compromised in the elderly or due to treatment such as steroids, they will experience little or no pain, which can even mask a significant intra-abdominal disease.

In the case of appendicitis, the appendix is clogged and distended. In time, a full-thickness inflammation of the wall will develop that will irritate the peritoneum.

The purpose of applying pressure in the left lower quadrant is double. This maneuver pushes intestinal content from the left lower abdomen in an antiperistaltic fashion, increasing pressure in the colon and thus the appendix, and further irritating the peritoneum eliciting tenderness at the site of inflammation.

The pressure is far away from the expected location of the pain, and the indirect tenderness suggests a less biased (more objective) localization of the pain.

The predictive power of Rovsing’s sign (indirect tenderness) is much greater than that of the even more generally known McBurney’s point tenderness (a.k.a. direct tenderness), 2.47 and 1.29, respectively.

4. How do we approach a patient with a positive Rovsing’s sign?

From the signs of tenderness, Rovsing’s sign has the largest likelihood ratio for appendicitis, and it also has one of the largest likelihood ratio for peritonitis in all H&P.

However, one should carefully assess the peritoneal signs of acute abdomen and the additional signs of McBurney’s point tenderness, the psoas sign, the obturator sign, and direct rectal examination, to further improve the combined likelihood ratio and the evidence-based diagnosis. These techniques also help assess valuable information in the diagnosis of acute appendicitis in children.

Further lab tests should include a complete blood count, CRP for all patients and a pregnancy test in women of reproductive age.
A definitive diagnosis of appendicitis can be made with abdominal CT in adult patients or with abdominal ultrasound in pediatric and female patients.

Sources:

  1. Lynn S. Bickley: Bates’ Guide to Physical Examination and History Taking Twelfth, North American Edition
  2. Mike Cadogan: Rovsing sign, Life in the Fastlane
  3. Steven McGee: Evidence-Based Physical Diagnosis, Third Edition
  4. A.E. De la Torre-Quiroga, F.J. Bosques-Padilla, L.A. Morales-Garza: How do we approach an adult patient with suspected acute appendicitis? Medicina Universitaria. 2016; 18(71): 125—129, DOI: 10.1016/j.rmu.2016.05.001
  5. Bradley P. Fuhrman and Jerry J. Zimmerman : Pediatric Critical Care, Fourth Edition

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