What is the best course of action for a female patient of reproductive age presenting with sudden, severe abdominal pain, suspected of having ovarian torsion?

Ovarian Torsion: Diagnostic and Management Approach

Immediate Action Required

For a reproductive-age female with sudden, severe abdominal pain and suspected ovarian torsion, proceed immediately to transvaginal ultrasound with Doppler as the first-line diagnostic test, followed by urgent gynecologic consultation for diagnostic laparoscopy with ovarian-sparing detorsion, regardless of the ovary's macroscopic appearance. 1, 2, 3

Clinical Presentation

Ovarian torsion presents with characteristic features that should trigger immediate evaluation:

• Severe, constant unilateral pelvic/lower abdominal pain that may fluctuate in intensity but rarely resolves completely without intervention 1, 2
• Associated symptoms include nausea, vomiting, and anorexia 4, 3, 5
• Pain onset is typically sudden and sharp 4, 5
• Palpable adnexal mass may be present on examination 4, 3

Critical Diagnostic Pitfall

Ovarian torsion frequently mimics other conditions including appendicitis, renal colic, urinary tract infection, or ureterolithiasis, leading to dangerous diagnostic delays 2, 6, 7. The anatomical proximity of the ovaries to the bladder and urinary tract can cause dysuria, further confusing the clinical picture 2.

Diagnostic Algorithm

Step 1: First-Line Imaging - Transvaginal Ultrasound with Doppler

Ultrasound is the essential initial diagnostic modality and should be performed urgently in the Emergency Department using both transabdominal and transvaginal approaches 2, 6.

Key ultrasound findings include:

• Unilaterally enlarged ovary (>4 cm diameter or volume >20 cm³) 1, 2
• Peripheral follicles (present in up to 74% of cases) 1, 2
• Abnormal or absent venous flow (100% sensitivity, 97% specificity) 1, 2
• Whirlpool sign (twisted vascular pedicle) with 90% sensitivity in confirmed cases 1, 2, 6
• Stromal edema and surrounding fluid 2

Doppler ultrasound performance: 80% sensitivity and 88% specificity for diagnosing ovarian torsion 2. Grayscale ultrasound alone has lower accuracy (79% sensitivity, 76% specificity) 2.

Critical Pitfall: Normal Arterial Flow Does NOT Rule Out Torsion

Normal arterial blood flow on Doppler does not exclude ovarian torsion because torsion can be intermittent or partial, and venous flow abnormalities are more sensitive and specific 1, 2, 6. Always assess venous flow patterns, as absent or abnormal venous flow has 100% sensitivity 2.

Step 2: Second-Line Imaging When Ultrasound is Inconclusive

If ultrasound findings are equivocal but clinical suspicion remains high:

• MRI provides 80-85% sensitivity with findings of enlarged ovary, stromal edema, and absent/diminished enhancement 1, 2, 6
• CT abdomen/pelvis with IV contrast shows asymmetrically enlarged ovary, twisted pedicle, abnormal/absent ovarian enhancement, deviation of uterus to the affected side, and engorged vessels on the twisted side 8, 2. CT has 74-95% sensitivity and 80-90% specificity 8

Surgical Management

Definitive Treatment Approach

The standard of care is immediate laparoscopic detorsion with ovarian preservation, even when the ovary appears necrotic. 1, 3

Rationale for ovarian conservation:

• Intraoperative visual assessment of ovarian viability is highly inaccurate: only 18-20% of ovaries that appear necrotic are actually necrotic on pathological examination 3
• Necrotic-appearing ovaries can recover: follicular activity has been documented on ultrasound one year postoperatively in ovaries that appeared necrotic at surgery 3
• The risk of ovarian damage/loss from delayed intervention outweighs the risk of diagnostic laparoscopy in reproductive-age women 3

When to Consider Oophorectomy

Oophorectomy should only be performed in specific circumstances: 1

• Definitive necrosis with no signs of recovery after detorsion
• Large malignant masses (particularly relevant in postmenopausal women where malignancy risk is higher) 9
• Postmenopausal patients 9

Time-Critical Nature

Early detection and timely surgical intervention are essential to preserve ovarian function and prevent adnexal necrosis leading to infertility 2, 4, 3. Retention of ovarian function is directly dependent on minimizing time from symptom onset to detorsion 3.

Special Population Considerations

Postmenopausal Women

In postmenopausal women with ovarian torsion, there is higher risk of malignancy and increased likelihood of delayed diagnosis due to lower clinical suspicion 9. These patients require full malignancy evaluation and different management strategies, with oophorectomy being more appropriate 1, 9.