Tests
1st tests to order
CBC
pregnancy test
Test
If positive, critical alternatives such as ectopic pregnancy should be considered.
Regardless of result, torsion must still be considered, as torsion can occur in pregnancy. While a pregnancy test should be obtained, it should not delay imaging if ovarian torsion is suspected.[19]
Result
negative or positive
C-reactive protein
transvaginal ultrasound with Doppler flow
Test
Findings depend on duration of symptoms; degree of torsion, and whether torsion is intermittent or chronic; whether a mass is present; or whether the fallopian tube is twisted along with the ovary.
Thickening of the fallopian tube may be noted as a fusiform or tubular structure. Ovary may be enlarged, with prominent heterogeneous central stroma and small peripheral follicles. In 70% of surgically confirmed cases of torsion, a cystic, solid, or complex adnexal mass, in addition to free fluid in the cul-de-sac, is visualized at ultrasound prior to surgery.[4][43][44]
Ultrasound findings described as predictors of torsion include adnexal location that is cranial to the uterine fundus, thickening of the adnexal wall, unilateral ovarian enlargement with multiple peripherally located follicles, and cystic hemorrhage.[40][45][46] Thickening of the fallopian tube may be visualized as a heterogeneous fusiform or tubular structure between the adnexal mass and the uterus.[40][45] Ultrasound is a good first-line diagnostic test.[41] One meta-analysis of 12 studies reported a pooled sensitivity of 79% and a pooled specificity of 76%.[40][41] However, normal ovaries seen by ultrasound do not rule out the possibility of torsion.
Doppler ultrasound imaging is integral for evaluation of abnormal vascularity (in case of inflammation) or lack of vascularity (in case of ovarian torsion).[40] Flow is normal in 54% to 60% of cases.[45][47] One meta-analysis reported a similar pooled sensitivity and specificity in diagnosing adnexal torsion using Doppler US (7 studies, 845 patients, sensitivity 80% and specificity 88%) compared with grayscale US only (12 studies, 1,187 patients, sensitivity 79% and specificity 76%).[40][41] Absence of Doppler flow has high specificity but low sensitivity. Its use results in decreased time to diagnosis. However, positive Doppler flow to the ovary does not rule out torsion.[47][48]
The whirlpool sign results from a side-by-side arrangement of vessels with opposing flow directions, giving an image reminiscent of a whirlpool.
TVUS is not considered appropriate in children; abdominal ultrasound is recommended.[34]
Result
enlarged ovary; solid, cystic, or complex adnexal mass; diminished or absent blood flow to the ovary
abdominal ultrasound
Test
Appropriate for children with suspicion of ovarian torsion.[1][34][35]
Full bladder is needed, which may be challenging in children in an emergency situation. Abdominal ultrasound may also be preferable to transvaginal ultrasound (TVUS) in select other circumstances (patient discomfort, large fibroids, surgical changes) or when TVUS is uncomfortable or inappropriate (posttreatment vaginal stenosis/fibrosis, sexually naïve patient).[40][42]
Result
solid, cystic, or complex adnexal mass
genetic probe or cervical culture
Test
If positive for Neisseria gonorrhoeae and/or Chlamydia trachomatis, an alternative diagnosis such as pelvic inflammatory disease should be considered.
Result
negative
urinalysis
Test
If positive for red blood cells, white blood cells, or nitrates, an alternative diagnosis, such as renal colic or urinary tract infection, should be considered.
Result
negative
surgical visualization
Test
Direct visualization of torsion during surgery is the ultimate diagnostic tool in patients where there is high clinical suspicion of torsion.[1] Also allows for treatment.
Result
confirms diagnosis
Tests to consider
CT abdomen/pelvis
MRI abdomen/pelvis
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