Recommendations

Key Recommendations

The presentation of ovarian/adnexal torsion is nonspecific, with no absolute clinical profile, which makes the diagnosis a challenge.[1][19] In patients with confirmed ovarian torsion, correct preoperative diagnosis is as low as 37% to 47%.[2][14] Therefore, when a female presents with pelvic or abdominal pain, ovarian torsion must be considered. The difficulty for the clinician lies in differentiating between ovarian torsion and other etiologies such as ectopic pregnancy, appendicitis, ovarian cysts, pelvic inflammatory disease (PID), urinary tract infection (UTI), nephrolithiasis, and endometriosis.

Although use of imaging modalities can assist in the diagnosis, the characteristic imaging features are not consistently detected. Therefore, the burden lies on clinical judgment. Laboratory and imaging evaluation should not delay consult if the clinician suspects ovarian torsion.[19]

A definitive diagnosis is based on surgical findings. It is imperative that ovarian torsion be suspected in order to be diagnosed and surgically managed to preserve ovarian function.

Overview of presentation

Most patients present with sudden-onset, severe lower abdominal pain, often associated with nausea and vomiting.[1] The pain is usually intermittent or fluctuating, can rarely be chronic, and may sometimes radiate to the back, flank, or groin.[1] The most common signs and symptoms of ovarian/adnexal torsion are:[14][22][25][26][27][28]

  • Pain: 70% to 96%

  • Nausea or vomiting: 25% to 70%

  • Diarrhea: 8%

  • Palpable adnexal mass: 43% to 53%

  • Rebound or guarding: 14% to 18%

  • Tenderness

    • Localized: 68% to 90%

    • Diffuse: 20%

    • Adnexal: 73%

  • Cervical motion tenderness: 13%

  • Fever: <2%.

Ovarian torsion should be considered in patients presenting with severe lower-quadrant pain who have a recent history of either infertility treatment or strenuous physical activity. It is sometimes seen in pregnancy and may also be associated with sudden increases in intra-abdominal pressure that can occur with coughing or hiccupping. Ovarian and paraovarian cysts and neoplasms are sometimes associated with ovarian torsion.[4][22]

Diagnosis in specific populations

Pregnancy

  • The diagnosis of ovarian torsion must be considered in pregnant women who present with abdominal pain. The incidence of ovarian torsion during spontaneous pregnancy is typically <0.1%; an estimated 12% to 18% of patients with ovarian torsion are pregnant.[14][20][29][30] Ovarian torsion is more common in the first and early second trimester.[2][31][32]

  • The presentation is usually nonspecific, with severe lower-quadrant pain, nausea, vomiting, leukocytosis, and possibly a palpable mass. Clinical suspicion is the most important tool in diagnosis.[6][9][10] Incidental adnexal masses can also be found on routine ultrasonography in pregnancy.[31]

Infancy and childhood

  • In very young children who present with acute abdominal or pelvic pain accompanied by vomiting, the diagnosis of ovarian torsion should not be overlooked as approximately 15% of cases occur during infancy and childhood.[17][33] In addition, pediatric patients may present with diffuse abdominal pain rather than localized abdominal pain.[15] In the neonatal period, ovarian torsion may present with feeding intolerance, vomiting, abdominal distention, and fussiness.

  • Pelvic abdominal ultrasound is the most important diagnostic tool in this patient population because transvaginal ultrasound (TVUS) is not appropriate.[1][34][35]

Postmenopause

  • The postmenopausal period accounts for 10% of cases with adnexal torsion.[5] Just over half (56%) of patients in a large series of adnexal torsion had an ovarian mass, mostly with benign histology, including dermoid cysts and paraovarian cysts.[5]

Laboratory investigations

All female patients presenting with abdominal or pelvic pain should have a pregnancy test and a complete blood count.[19][36] However, while a pregnancy test should be obtained, it should not delay imaging if ovarian torsion is suspected.[19] There are no specific laboratory findings, although a raised white cell count may be present.[19][28][37] C-reactive protein (CRP) may be raised in adnexal torsion.[38] A negative result can also be helpful in pointing away from appendicitis, which may present in a similar manner to ovarian torsion.[39]

A urinalysis may be performed to rule out a UTI, and a genetic probe or cervical cultures to assess for PID.

Imaging studies

Transvaginal and/or abdominal ultrasound

In patients with pelvic pain and suspected ovarian torsion, a TVUS should be performed to determine presence of ovarian cysts, peritubal cysts, or ovarian enlargement.[19][40][41] An abdominal ultrasound is appropriate for children with suspicion of ovarian torsion.[1][19][34][35] Abdominal ultrasound may also be preferable to 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]

The most common finding on ultrasound is an enlarged heterogeneous-appearing ovary.[40][42] The ultrasound findings depend on the duration and degree of torsion, as well as the presence or absence of an ovarian mass.[26] 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 flow ultrasound

Doppler ultrasound imaging is integral for evaluation of abnormal vascularity (in case of inflammation) or lack of vascularity (in case of ovarian torsion).[40]

A review of surgically diagnosed ovarian torsion cases found that Doppler flow was 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] The presence of blood flow has poor predictive value for ruling out ovarian torsion, and should not be used to exclude ovarian torsion if clinical suspicion is high.[47][48] The absence of blood flow to the ovary by Doppler flow studies on ultrasound is highly specific.

The use of Doppler in conjunction with 3-dimensional and 2-dimensional ultrasonography, in correlation with clinical suspicion in the setting of abnormal results, decreases the time to diagnosis, increasing the preservation of ovarian function. However, it is important to reiterate that positive Doppler flow to the ovary does not rule out the possibility of torsion.[43][47][48][49][50][51][52]

Computed tomography (CT) and magnetic resonance imaging (MRI)

CT and MRI findings in ovarian torsion include fallopian tube thickening, smooth wall thickening of the twisted adnexal cystic mass, ascites, and uterine deviation toward the twisted side.[46][53][54] CT and MRI have less diagnostic value than TVUS, with increased time and cost for evaluation.[28][40][41][55]

Definitive diagnosis is surgical

Direct visualization of torsion during surgery is the ultimate diagnostic tool in patients where there is a high clinical suspicion of torsion.[1] Surgery also allows for treatment.

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