Links To And Excerpts From “Ovarian Torsion Myths” And “Ovarian Torsion Imaging” From EMC

Please see also Links To And Excerpts “Adnexal Torsion in Adolescents” from ACOG
Posted on April 25, 2020 by Tom Wade MD

In this post I link to and excerpt from the following resources:

Here are the show notes from Ovarian Torsion Myths*above:

*And of course all women and girls with abdominal pain should have a urine pregnancy test and a pelvic ultrasound.

Myths in the utility of clinical features in diagnosis of ovarian torsion

  1. Myth: Ovarian torsion only occurs in women of reproductive age. Ovarian torsion affects women of all ages including children, postmenopausal and pregnant women.
  2. Myth: My patient’s pain is mild, and she has had it off and on for a few days. This cannot possibly be torsion, right? The classic presentation of ovarian torsion is not always present; patients may have intermittent pain or no pain at all. Intermittent torsion can occur. Only 50% of patients have acute, severe pain.
  3. Myth: My patient is minimally tender, and no mass can be palpated on bimanual examination. Therefore, torsion can be ruled out. Do not rely on a normal abdominal, pelvic, or bimanual examination to rule out torsion. Literature suggests the abdominal and bimanual exams, whether conducted by emergency clinicians or obstetricians, do not have adequate sensitivity (23-26%). Our bimanual exam often fails to detect ovarian masses < 5 cm in diameter.

If your patient has lower quadrant pain but an otherwise unrevealing evaluation, keep torsion on the differential.

And here are the show notes from Ovarian Torsion Imaging above:

Ovarian torsion imaging myths

Myth #1: Normal arterial flow on Doppler ultrasound rules out ovarian torsion.

  • Normal Doppler US cannot rule out ovarian torsion
  • Many cases of surgically confirmed ovarian torsion have completely normal venous and arterial blood flow
  • The most common finding on US is an enlarged ovary (> 4 cm).
  • Consider using a combination of US findings, such as abnormal vascular flow, free fluid on US, an ovary pushed towards the midline, or increased ovarian size.

Myth #2: CT of the abdomen/pelvis is not helpful in evaluation of suspected ovarian torsion.

  • CT with IV contrast can suggest torsion.
  • The most common finding on CT is an enlarged ovary. If this is found on CT and no other pathology is present, move to US.
  • Other findings include an underlying ovarian lesion, lack of enhancement, inflammatory fat stranding around the ovary, free pelvic fluid surround the ovary, and twisting of the vascular pedicle.


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