Workup and Department Management for Suspected Ovarian Torsion
Initial Department and Imaging
Ovarian torsion is a gynecological emergency that should be evaluated in the Emergency Department with immediate ultrasound imaging as the first-line diagnostic modality, followed by urgent gynecologic consultation for surgical management. 1, 2, 3
Diagnostic Workup Algorithm
First-Line Imaging: Pelvic Ultrasound
Transvaginal ultrasound combined with transabdominal ultrasound is the essential initial imaging study and should be performed urgently in the Emergency Department. 1, 2
Key ultrasound findings to identify include:
- Unilaterally enlarged ovary (>4 cm diameter or volume >20 cm³) 2
- Peripheral follicles (present in up to 74% of cases) 2
- Abnormal or absent venous flow on Doppler (100% sensitivity, 97% specificity) 2
- Whirlpool sign (twisted vascular pedicle with 90% sensitivity in confirmed cases) 2
- Ovarian cyst or mass (present in 75% of cases) 4
Critical Pitfall to Avoid
Normal arterial blood flow on Doppler ultrasound does NOT rule out ovarian torsion, as torsion can be intermittent or partial, and venous flow abnormalities are more sensitive indicators. 2, 5 The presence of blood flow on Doppler has poor negative predictive value 5. Doppler ultrasound has only 80% sensitivity and 88% specificity, while grayscale ultrasound alone has 79% sensitivity and 76% specificity 2.
Second-Line Imaging When Ultrasound is Inconclusive
If ultrasound findings are equivocal but clinical suspicion remains high:
- MRI pelvis (80-85% sensitivity) showing enlarged ovary with stromal edema, surrounding fluid, and absent/diminished enhancement 2
- CT abdomen/pelvis with IV contrast showing asymmetrically enlarged ovary, twisted pedicle, abnormal/absent ovarian enhancement, and deviation of uterus to the affected side 1, 2
Clinical Presentation Details to Assess
Pain Characteristics
- Severe, constant pain that may fluctuate in intensity but rarely completely resolves without intervention 2, 6
- Most commonly right lower quadrant pain (60% of cases) 4
- Sudden onset with most patients (78.9%) presenting within 24 hours of symptom onset 4
Associated Symptoms
- Nausea and vomiting (present in 70-90% of cases) 3, 4
- Palpable adnexal mass on examination 7
- Severe pain requiring opioid analgesia (95% of cases) 4
Mimicking Conditions to Consider
Ovarian torsion can mimic renal colic, appendicitis, or urinary tract infection due to anatomical proximity 2, 6, 7. The presence of dysuria does not exclude torsion, as inflammation can affect nearby urinary structures 2.
Department Responsibility and Timing
The Emergency Department is responsible for initial evaluation, imaging coordination, pain management, and immediate gynecologic consultation. 3, 4 Mean time from door to ultrasound should be approximately 1.4 hours, with door-to-surgery time averaging 11.4 hours 4.
Gynecology performs the definitive surgical management via laparoscopic detorsion, which is the standard treatment regardless of ovarian appearance. 6 Emergency surgical intervention should be performed when torsion is suspected based on clinical presentation and imaging, as diagnostic uncertainty should not delay management 7, 8.
High-Risk Populations Requiring Lower Threshold
- Reproductive-aged women (mean age 27 years) 4
- Patients undergoing fertility treatment or ovarian stimulation 5, 8
- Pregnant women (especially first trimester) 5
- Patients with known ovarian cysts or masses 3, 4
When clinical suspicion is high based on severe unilateral pelvic pain with nausea/vomiting, proceed directly to surgical consultation even if imaging is not definitive, as 20% of confirmed cases went straight to surgery based on clinical suspicion alone. 4