What are the symptoms and clinical criteria for diagnosing ovarian torsion in women of reproductive age with a history of ovarian cysts or other gynecological conditions?

Ovarian Torsion: Clinical Presentation and Diagnostic Criteria

Ovarian torsion presents as severe, constant pelvic pain that may fluctuate in intensity but rarely resolves completely without intervention, accompanied by nausea and vomiting in 90% of cases, with ultrasound as the first-line diagnostic modality showing unilaterally enlarged ovary (>4 cm), peripheral follicles, and abnormal venous flow. 1, 2, 3

Clinical Symptoms

Pain Characteristics:

• Acute onset of severe, constant pelvic pain is the hallmark symptom, present in 95% of cases 3
• Pain typically localizes to the right lower quadrant in 60% of patients, though it can occur on either side 3
• Pain may fluctuate in intensity but rarely completely resolves without surgical intervention 1, 2
• Most patients (78.9%) present within 24 hours of symptom onset 3
• Almost all patients (95%) require opioid analgesia for pain management in the emergency setting 3

Associated Symptoms:

• Nausea and vomiting occur in 90% of cases, making this the second most common presenting symptom 3
• Dysuria (burning during urination) may occur due to anatomical proximity of the ovaries to the bladder, potentially mimicking urinary tract infection 1, 4

Key Diagnostic Pitfalls

Critical Clinical Traps:

• Ovarian torsion can mimic appendicitis, renal colic, or urinary tract infection, leading to diagnostic delays 1, 2
• 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 1, 2, 4
• In pregnancy, 38-60% of patients with confirmed torsion have normal Doppler flow, making this a clinical diagnosis requiring high suspicion 4
• The presence of pyuria may falsely suggest UTI when ovarian torsion is the actual diagnosis, as genitourinary inflammation from torsion can affect nearby structures 1

Diagnostic Imaging Criteria

Ultrasound Findings (First-Line Modality):

• Unilaterally enlarged ovary >4 cm or volume >20 cm³ 1, 2, 4
• Peripheral follicles (present in up to 74% of cases) 1, 2
• Abnormal or absent venous flow (100% sensitivity, 97% specificity) 1, 2
• "Whirlpool sign" representing the twisted vascular pedicle has 90% sensitivity in confirmed cases 1, 2
• Doppler ultrasound has 80% sensitivity and 88% specificity overall for diagnosing ovarian torsion 1
• Transvaginal combined with transabdominal ultrasound provides the most comprehensive assessment 1

Advanced Imaging When Ultrasound Inconclusive:

• MRI provides 80-85% sensitivity with findings of enlarged ovary, stromal edema, and absent/diminished enhancement 1, 2
• CT findings include asymmetrically enlarged ovary, twisted pedicle, abnormal/absent ovarian enhancement, and deviation of uterus to the affected side 1, 2

Clinical Risk Factors

High-Risk Populations:

• Women of reproductive age (mean age 27.3 years in recent series) 3
• Presence of ovarian masses or cysts is the main risk factor, with torsed cysts having a mean size of 10 cm 4, 5
• Ovarian torsion occurs in 2-15% of patients with adnexal masses requiring surgical treatment 5
• Pregnancy increases risk, with 3-12% of pregnant women with adnexal masses experiencing torsion 4
• Fertility treatment and ovarian stimulation are major risk factors 6, 7

Diagnostic Algorithm

Emergency Department Approach:

• Immediate ultrasound imaging should be performed as soon as clinical suspicion arises 1, 2
• Mean time from door to ultrasonography is 1.4 hours in tertiary centers 3
• Do not be falsely reassured by normal arterial flow—proceed to surgical consultation if clinical suspicion remains high 1, 2, 4
• If ultrasound is inconclusive but clinical suspicion persists, obtain MRI or CT before dismissing the diagnosis 1, 2
• Urgent gynecologic consultation for surgical management should be initiated immediately upon diagnosis 1, 2

Surgical Findings and Outcomes

Intraoperative Characteristics:

• 94.7% of surgically managed cases have viable ovaries at the time of surgery when diagnosed promptly 3
• Mean time from door to surgery is 11.4 hours 3
• Mature cystic teratoma (dermoid cyst) is found in 46.2% of histopathologic specimens from torsion cases 3
• Laparoscopic detorsion is the standard approach to preserve ovarian function, regardless of macroscopic appearance 2