From the Guidelines
Ovarian torsion typically presents with sudden, severe, unilateral lower abdominal or pelvic pain, often accompanied by nausea, vomiting, and tenderness in the lower abdomen, particularly on the affected side, as reported in the 2024 study by the Journal of the American College of Radiology 1. The pain associated with ovarian torsion can be constant or intermittent, developing over minutes to hours, and may radiate to the back, flank, or groin. Associated symptoms include:
- Nausea and vomiting, occurring in about 70% of cases
- Fever, though less common
- Abnormal vaginal bleeding or urinary symptoms in some patients On physical examination, there is usually tenderness in the lower abdomen, particularly on the affected side, and a palpable adnexal mass may be present in some cases. Movement of the cervix during examination often worsens the pain. The diagnosis of ovarian torsion is typically made using ultrasound, with a sensitivity of 79% and specificity of 76% for transvaginal ultrasound (TVUS) in detecting adnexal torsion, as reported in a meta-analysis of 12 studies including 1,187 patients 1. Other signs indicating torsion include:
- Ovarian tissue edema
- Absence of intraovarian vascularity
- Absence of arterial flow
- Absence or abnormal venous flow
- A unilaterally enlarged ovary with central afollicular stroma and multiple uniform 8 to 12 mm peripheral follicles It is essential to note that ovarian torsion is a gynecological emergency requiring prompt diagnosis and surgical intervention, as delayed treatment can lead to ovarian necrosis and loss of the ovary, as highlighted in the 2024 study by the Journal of the American College of Radiology 1.
From the Research
Ovarian Torsion Symptoms
- Abdominal or pelvic pain is a common symptom of ovarian torsion, although it may not always be sudden in onset or severe 2
- Nausea and vomiting occur in approximately 70% of cases 2
- Other symptoms may include adnexal mass or ovarian enlargement 3
- Abnormal ovarian blood flow, and an elevated neutrophil to lymphocyte ratio may also be indicative of ovarian torsion 3
- A 'whirlpool' sign, 'follicular ring' sign, enlarged/edematous ovary, and absent Doppler flow to the ovary are highly suggestive of adnexal torsion on imaging 3
Clinical Presentation
- The most common presenting symptom is abdominal pain, with most localizing to the right lower quadrant, followed by nausea and vomiting 4
- Almost all patients require opioids for pain management 4
- Ovarian torsion can occur in females of all ages, including infants, reproductive-aged women, pregnant women, and postmenopausal women 2, 5, 6
- The diagnosis becomes more challenging as torsion can occur in female patients of all ages, and symptoms may mimic other disorders such as appendicitis, pyelonephritis, and nephrolithiasis 5
Diagnostic Findings
- Ultrasound can assist with diagnosis, but a normal ultrasound examination cannot exclude the diagnosis 2
- Computed tomography with intravenous contrast can also assist with diagnosis 2
- Pelvic ultrasonography can provide information on ovarian cysts, and is the first-line imaging modality 3, 6
- A high index of clinical suspicion is necessary for diagnosis, as imaging findings may not always be conclusive 5, 4