Ovarian Torsion Diagnosis and Management

Clinical Presentation and Diagnostic Considerations

• Ovarian torsion pain typically presents as severe, constant pain that may fluctuate in intensity but rarely completely resolves without intervention, according to the American College of Radiology 1
• Ultrasound is the first-line imaging modality for suspected ovarian torsion, with key findings including unilaterally enlarged ovary, peripheral follicles, abnormal or absent venous flow, and whirlpool sign, as recommended by the American College of Radiology 1, 2, 3

Imaging Findings and Interpretation

• Ultrasound findings of ovarian torsion include unilaterally enlarged ovary (>4 cm or volume >20 cm³), peripheral follicles (found in up to 74% of cases), and abnormal or absent venous flow (100% sensitivity, 97% specificity), according to the American College of Radiology 1
• CT findings of ovarian torsion include enlarged, featureless, hypoenhancing ovary with swirling of vascular pedicle, as reported by the American College of Radiology 4, 5
• MRI has 80-85% sensitivity for ovarian torsion with findings of enlarged ovary, stromal edema, and absent/diminished enhancement, according to the American College of Radiology 6

Diagnostic Pitfalls and Management Considerations

• Normal arterial blood flow on ultrasound does not rule out ovarian torsion, as torsion can be intermittent or partial, and venous flow abnormalities are more sensitive, as noted by the American College of Radiology 1, 3

Ovarian Torsion Diagnosis and Management

Diagnostic Findings

• The American College of Radiology recommends using the "whirlpool sign" on ultrasound, which represents the twisted vascular pedicle and supporting ligaments, as a key diagnostic finding in ovarian torsion, with a sensitivity of 90% in patients with confirmed adnexal torsion on laparoscopy 7
• The whirlpool sign can be located either lateral or medial to the affected ovary, with the location potentially related to the size of the ovarian mass, and is a significant diagnostic indicator of ovarian torsion 7

Ultrasound Diagnosis of Intermittent Ovarian Torsion

Multimodal Approach for Intermittent Torsion

• The American College of Radiology recommends using MRI, which provides 80-85% sensitivity for torsion, when ultrasound findings are inconclusive but clinical suspicion remains high 8
• MRI findings of intermittent torsion include enlarged ovary with stromal edema, surrounding fluid, and potentially subtle enhancement abnormalities, as noted by the American College of Radiology 8
• The American College of Radiology suggests that CT may show an enlarged, featureless, hypoenhancing ovary with swirling of vascular pedicle in cases where ultrasound is inconclusive 8

Clinical Integration of Imaging Findings

• The American College of Radiology notes that transvaginal ultrasound combined with transabdominal views provides the most comprehensive assessment for suspected torsion 8

Diagnostic Imaging for Ovarian Torsion

CT Findings

• The American College of Radiology recommends considering CT findings such as asymmetrically enlarged ovary with or without an underlying mass, twisted pedicle, subacute ovarian hematoma, abnormal/absent ovarian enhancement, and deviation of the uterus to the side of the twist for diagnosing ovarian torsion 9

Ovarian Torsion Diagnosis and Clinical Presentation

Clinical Presentation and Diagnostic Challenges

• Ovarian torsion can mimic urinary tract infection symptoms, including burning during urination (dysuria), due to the anatomical proximity of the ovaries to the bladder and urinary tract, with inflammation from the torsion affecting nearby structures 10
• Cystitis (bladder inflammation) is typically diagnosed through symptoms including dysuria, urgency, and suprapubic pain, according to the American College of Obstetricians and Gynecologists 10, 11
• The diagnostic value of urinalysis for UTI is limited, as pyuria often indicates genitourinary inflammation that can be caused by many non-infectious conditions, including ovarian torsion, with a low positive predictive value for diagnosing UTI 10, 11
• The absence of pyuria can help rule out infection, but the positive predictive value of pyuria for diagnosing UTI is exceedingly low, highlighting the need for clinical symptoms integrated with urinalysis findings for evidence-based diagnosis 11

Ovarian Torsion Diagnosis and Imaging

Clinical Presentation and Diagnostic Challenges

• Ovarian torsion can mimic other conditions, such as appendicitis, with a similar presentation pattern, according to the American College of Radiology 12

Imaging Findings

• CT findings for ovarian torsion may include an asymmetrically enlarged ovary with or without an underlying mass, twisted pedicle, abnormal or absent ovarian enhancement, deviation of the uterus to the side of the twist, and engorged vessels on the twisted side, as reported by the American College of Radiology 12, 13
• MRI has 80-85% sensitivity for ovarian torsion, with findings of enlarged ovary, stromal edema, and absent/diminished enhancement, according to the American College of Radiology 14

Ultrasound Diagnosis of Ovarian Torsion

Diagnostic Performance

• Doppler ultrasound has a sensitivity of 80% and specificity of 88% for diagnosing ovarian torsion, according to a meta-analysis of 7 studies with 845 patients, as recommended by the American College of Radiology 15
• Doppler ultrasound is considered a standard component of pelvic ultrasound evaluation for suspected ovarian torsion, with key findings including absent flow or abnormal flow pattern in the ovarian vein, which has 100% sensitivity in a prospective study of 159 patients, as per the American College of Radiology 16, 15
• Grayscale ultrasound alone has a sensitivity of 79% and specificity of 76% for diagnosing adnexal torsion, based on a meta-analysis of 12 studies with 1,187 patients, according to the American College of Radiology 15

Clinical Considerations

• A combined transabdominal and transvaginal ultrasound approach provides the most comprehensive assessment for suspected torsion, as recommended by the American College of Radiology 15, 16
• The whirlpool sign on ultrasound is highly specific, with 90% of patients with this sign having adnexal torsion confirmed on laparoscopy, as per the American College of Radiology 16
• Early detection of ovarian torsion is essential as it may lead to adnexal necrosis and infertility if left untreated, according to the American College of Radiology 16

Ovarian Torsion Diagnosis and Management

Initial Evaluation and Imaging

• Ovarian torsion is a gynecological emergency that should be evaluated in the Emergency Department with immediate ultrasound imaging as the first-line diagnostic modality, followed by urgent gynecologic consultation for surgical management, as recommended by the American College of Radiology 17
• Transvaginal ultrasound combined with transabdominal ultrasound is the essential initial imaging study and should be performed urgently in the Emergency Department, according to the American College of Radiology 17
• CT abdomen/pelvis with IV contrast may be used as a second-line imaging modality when ultrasound is inconclusive, showing asymmetrically enlarged ovary, twisted pedicle, abnormal/absent ovarian enhancement, and deviation of uterus to the affected side, as suggested by the American College of Radiology 17

Ovarian Torsion: Diagnostic and Management Approach

Diagnostic Imaging

• The American College of Radiology recommends CT abdomen/pelvis with IV contrast as a second-line imaging modality, which shows asymmetrically enlarged ovary, twisted pedicle, abnormal/absent ovarian enhancement, deviation of uterus to the affected side, and engorged vessels on the twisted side, with 74-95% sensitivity and 80-90% specificity 18, 19

Surgical Management

• The standard of care for ovarian torsion involves immediate laparoscopic detorsion with ovarian preservation, even when the ovary appears necrotic, as intraoperative visual assessment of ovarian viability is highly inaccurate, with only 18-20% of ovaries that appear necrotic being actually necrotic on pathological examination 18, 19

Ovarian Torsion Diagnosis and Management

Clinical Presentation and Diagnosis

• The American College of Radiology suggests that the sudden onset of severe pain is more characteristic of ovarian torsion than the typical periumbilical pain migrating to the right lower quadrant seen in appendicitis 20
• A negative urine pregnancy test essentially rules out intrauterine or ectopic pregnancy, with serum β-hCG becoming positive approximately 9 days after conception, making a negative test highly reliable, as recommended by the American College of Radiology 21
• The presence of fever is not typically associated with ovarian torsion, but rather with tuboovarian abscess, which is a less likely diagnosis in this case, according to the American College of Radiology 21

Diagnostic Imaging and Management

First‑Line Imaging Recommendation for Suspected Ovarian Torsion

Imaging Modality

• The American College of Radiology recommends that the initial study for patients with suspected ovarian torsion be a combined transabdominal and transvaginal pelvic ultrasound performed with color and spectral Doppler, with systematic documentation of ovarian size, any masses, peripheral follicle pattern, the whirl‑pool sign, and both arterial and venous flow characteristics. 22