Today, I review, link to, and excerpt from Emergency Medicine Cases’ Ovarian Torsion From EM Quick Hits #12* And #14**.
*Helman, A. Dorion, P. Swaminathan, A. Long, B. Klaiman, M. Rosenberg, H, Hensley, J. Ohle, R. Morgenstern J. EM Quick Hits 12 – AFib Early vs Delayed Cardioversion, Snake Bites, Ovarian Torsion Myths, Crystal Meth, Aortic Dissection, Severe Asthma Meds. Emergency Medicine Cases. January, 2020. https://emergencymedicinecases.com/em-quick-hits-january-2020/. Accessed 7-26-2025.
Myths in the utility of clinical features in diagnosis of ovarian torsion
- Myth: Ovarian torsion only occurs in women of reproductive age. Ovarian torsion affects women of all ages including children, postmenopausal and pregnant women.
- 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.
- 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.
- Robertson JJ, Long B, Koyfman A. Myths in the Evaluation and Management of Ovarian Torsion. J Emerg Med. 2017 Apr;52(4):449-456.
- EmDOCs deep dive on ovarian torsion: ttp://www.emdocs.net/em3am-ovarian-torsion/
- EmDOCs pearls and pitfalls on ovarian torsion: http://www.emdocs.net/ovarian-torsion-pearls-and-pitfalls/
**Helman, A. Swaminathan, A. Long, B. Rosenberg, H. EM Quick Hits 14 – Adrenal Crisis, Strep Throat, Posterior MI, DKA Just the Facts, Ovarian Torsion Imaging, HINTS Exam, Canadian CT Head Rule. Emergency Medicine Cases. April, 2020. https://emergencymedicinecases.com/em-quick-hits-april-2020/. Accessed 7-26-2025.
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.
- Robertson JJ, Long B, Koyfman A. Myths in the Evaluation and Management of Ovarian Torsion. J Emerg Med. 2017 Apr;52(4):449-456.
