From the Guidelines
The workup for ovarian torsion should begin with a thorough history and physical examination, followed by transvaginal ultrasound (TVUS) as the first-line imaging study, which has a sensitivity of 83.3% for ovarian torsion, as reported in a prospective study 1. The clinical presentation of ovarian torsion typically includes sudden onset of severe, unilateral pelvic pain, which may be accompanied by nausea, vomiting, and fever. When performing TVUS, the following signs should be looked for:
- An enlarged ovary (>4 cm)
- Reduced or absent blood flow
- Free fluid in the pelvis
- A twisted vascular pedicle
- Ovarian tissue edema
- Absence of intraovarian vascularity
- Absence of arterial flow
- Absence or abnormal venous flow Laboratory tests, such as a complete blood count, C-reactive protein, and a pregnancy test, may also be included, although they are not diagnostic 1. If ultrasound findings are inconclusive but clinical suspicion remains high, CT or MRI may be considered, though these should not delay surgical intervention when torsion is strongly suspected 1. Definitive diagnosis and treatment require prompt surgical intervention, typically laparoscopy, as delayed management can lead to ovarian necrosis, with the goal of preserving ovarian function by untwisting the ovary and removing any underlying pathology like cysts or masses that may have predisposed to torsion 1. Time is critical, as ovarian viability decreases significantly after 8 hours of compromised blood flow, making this a true gynecologic emergency requiring urgent evaluation and management 1. Some specific TVUS findings that can aid in the diagnosis of ovarian torsion include a unilaterally enlarged ovary with central afollicular stroma and multiple uniform 8 to 12 mm peripheral follicles, which can be found in up to 74% of cases 1. Additionally, the presence of an incomplete septum of the tubal wall can be a useful marker for tubal inflammatory disease, as reported in a prospective study 1. It is essential to note that the whirlpool sign, which can be located either lateral or medial to the affected ovary, can also be an indicator of adnexal torsion 1. Overall, a combination of clinical presentation, TVUS findings, and laboratory tests can aid in the diagnosis of ovarian torsion, and prompt surgical intervention is crucial to preserve ovarian function and prevent long-term complications 1.
From the Research
Ovarian Torsion Workup
- Ovarian torsion is a rare but emergency condition in women, requiring early diagnosis to preserve ovarian function and prevent severe morbidity 2.
- The main risk factor for ovarian torsion is an ovarian mass, and the most common symptom is acute onset of pelvic pain, followed by nausea and vomiting 2, 3.
- Pelvic ultrasonography can provide information on ovarian cysts, and once ovarian torsion is suspected, surgery or detorsion is the mainstay of diagnosis and treatment 2.
Diagnostic Criteria
- Abdominal pain, nausea, and vomiting are normal clinical presentations of ovarian torsion 4, 3.
- Computed tomography findings, plasma d-dimer level, and the time from pain onset play a critical role in distinguishing ovarian necrosis 4.
- Normal arterial blood flow on ultrasound does not rule out ovarian torsion, and not every patient will have a mass on imaging or a palpable mass on examination 3.
Surgical Management
- Surgical management of ovarian torsion commonly includes oophorectomy, although leading guidelines recommend preservation of the ovary 5.
- Laparoscopic management with detorsion of the torquated ovaries, cystectomy on an ischemic ovary, and oophoropexy to the pelvic side wall and utero-ovarian ligament can prevent recurrence 5.
- Conservative laparoscopic surgical treatment for acute ovarian torsion in pediatric and adolescent populations has emerged as a promising approach, with a low incidence of recurrence and need for oophorectomy 6.
Prognosis
- Early diagnosis of ovarian torsion is likely to preserve ovarian function, and most patients with early diagnosis may have a better prognosis with conservative surgery 4.
- A high percentage of patients show evidence of ovarian function on postoperative ultrasound after conservative management of ovarian torsion 6.