Ovarian torsion: a fifteen-year review. She has no past medical history, is a social alcohol drinker, and does not use tobacco products. Pena JE, Ufberg D, Cooney N, et al. 2005; 17(3):231-7. Ultrasound has a sensitivity for ovarian torsion of 79% and computerized tomographic scan of 42.2%. USA.gov. 2008 Sep-Oct;28(5):1355-68. doi: 10.1148/rg.285075130. This site needs JavaScript to work properly. However, either ultrasound or CT may help you find other pathology to explain a patient’s pain (eg, kidney stone, appendicitis). Epub 2017 Sep 7. The most common ultrasound finding in torsion is enlargement or edema of the ovary. She complains of persistent nausea and multiple episodes of vomiting. Radiographics. What every radiologist should know about adnexal torsion. Materials and methods: This leads to vascular congestion, which causes engorgement and edema. Although ultrasound is the ideal non-invasive first-line technique, … The absence of blood flow within the ovary on Doppler exam is a highly specific finding but the presence of Doppler flow does not exclude the diagnosis of torsion. Swenson D et al. Positive Doppler flow to the ovary does not rule out torsion. Symptoms typically include pelvic pain on one side. As the premier organization for high-quality research and educational innovation in emergency care, the Society for Academic Emergency Medicine (SAEM) creates and promotes scientific discovery, advancement of education, and the highest professional and ethical standards for clinicians, educators, and researchers. The cause of this twisting can be multifactorial. Her abdomen exhibits tenderness and guarding to the right lower quadrant, normal bowel sounds and no organomegaly. US) that delays therapy is unlikely to improve preoperative diagnostic yield. Children have a higher incidence of torsion of a normal ovary than in the adult population. While it can rarely occur with a normal ovary, the majority of cases are associated with some type of ovarian pathology (e.g., tumor, cyst, hyperstimulation syndrome secondary to infertility treatments). Her last normal menstrual period ended two-weeks ago. These results suggest that when CT demonstrates findings of ovarian torsion, the performance of another imaging exam (i.e. The bottom line – there is no single finding that can definitively “rule in” or “rule out” ovarian torsion. [12] A prospective study of 199 patients showed doppler ultrasound has a sensitivity and specificity for torsion of 100 and 97%. Predicting necrosis in adnexal torsion in women of reproductive age using magnetic resonance imaging. However, heightened awareness and suspicion of this condition are needed for timely intervention. Phone: 847.813.9823 2018 Aug;55(2):e43-e45. Would you like email updates of new search results? O… 2014 Apr;21(2):179-87. doi: 10.1007/s10140-013-1163-3. Sensitivity and specificity were respectively 42.9% and 81.8% for B-Mode ultrasound and 100% and 81.8% for contrastenhanced ultrasonography. Interobserver agreement for pelvic US was fair (Kappa=0.60). Interobserver agreement was excellent (Kappa = 0.85). NIH Objective The purpose of our study was to assess computed tomographic (CT) findings of adnexal torsion through a matched case-control analysis. Fever is uncommon, and usually low-grade if present. Des Plaines, IL 60018 Get an ultrasound to look for Doppler flow. The congestion progresses until arterial flow is compromised, leading to ischemia and infarction. 2020 Feb;30(2):1054-1061. doi: 10.1007/s00330-019-06434-y. Cureus. Ovarian torsion should also be considered in infants and small children with feeding intolerance, abdominal distension, vomiting, irritability, and/or a palpable pelvic mass. We compared the CT and MR imaging findings in adnexal torsion in patients with versus those without hemorrhagic infarction in terms of the presence of tube thickening, size of the twisted ovarian mass, wall thickness of the twisted ovarian mass, and presence of ascites and uterine deviation using the Student t test and the Fisher exact two-tailed test. A history of prior ovarian cyst or mass, prior ovarian torsion, or current pregnancy should increase your suspicion for torsion. 2019. PURPOSE: Ovarian torsion (OT) is a true surgical emergency that requires prompt diagnosis and therapy. Ovarian torsion is an uncommon cause of acute abdominal pain in females, but diagnostic delay can have disastrous results. doi: 10.1016/j.jemermed.2018.01.006. Left maintains normal flow. The patient was closed and taken to recovery where she had resolution of her symptoms. Flow is normal in 54% to 60% of cases. Lack of ovarian blood flow on doppler sonography seems to be a good predictor of ovarian torsion. Women with pathologically low flow are more likely to have torsion. The sensitivity and specificity of CT for ovarian torsion was 100.0% and 85.0% respectively for reader 1, and 90.0% and 90.0% for reader 2. The best initial imaging for ovarian torsion is a transvaginal ultrasound with Doppler. Ovarian/adnexal torsion is a rather frequent occurrence in women of reproductive age group worldwide. Please enable it to take advantage of the complete set of features! Copyright © 2014 Elsevier Ireland Ltd. All rights reserved. Image 2. CT has high sensitivity in the diagnosis of cystic teratomas [3]. Torsion is more common in an ovary that is greater than 5.0 cm in diameter (86 to 95% per multiple case studies.)  |  Even if a dusky, edematous ovary is discovered in the OR, there is often functional recovery if the tissue is not necrotic. She is slightly obese but is otherwise well-appearing. Torsion occurs due to two main reasons 2: 1. hypermobility of the ovary: <50% 2. adnexal mass: ~50-80% 2.1. most lesions are dermoid cysts or paraovarian cysts 2.2. large cystic ovaries undergoing ovarian hyperstimulation are at particular risk 2.3. masses between 5-10 cm are at most risk 13 Treat pain and nausea with IV medications as soon as you have IV access – there is no need to wait for the diagnosis. Epub 2018 Feb 17. High clinical suspicion, even if tests are negative, necessitates consultation with obstetricians for possible OR management. CT may as sensitive as US. While classically the pain is sudden in onset, this is not always the case. National Center for Biotechnology Information, Unable to load your collection due to an error, Unable to load your delegates due to an error. Results: Sixty-one percent of right ovarian torsion case and 27% of left ovarian torsion cases had normal Doppler flow. Physical examination may reveal pelvic or lower abdominal tenderness. Intraoperative photos of torsed adnexa. There are no laboratory tests to establish the diagnosis of adnexal torsion. COPYRIGHT © 2021 SAEM, ALL RIGHTS RESERVED. Materials and methods This retrospective, single-institution case-control study included 43 women with adnexal torsion and 43 age- and ovarian mass-matched control women. Rush Medical College, Originally Written By: Lynne Yancey University of Colorado School of Medicine. The CT and MRI features of ovarian torsion are illustrated with gross pathologic correlation. 2014 Nov;203(5):W470-81. [7] The sensitivity and specificity of abnormal ovarian flow are 44% and 92%, respectively, with a positive and negative predictive value of 78% and 71%, respectively. The most common finding in adnexal torsion on both ultrasound and CT is simply enlargement of the ovary in question. To investigate adnexal torsion, ultrasound is a good first‐line diagnostic test with a pooled sensitivity of 0.79 and specificity of 0.76. Pediatric patients with torsion are more likely to have a normal ovary and their increased risk is thought to be due to an elongated utero-ovarian ligament. Sensitivity, specificity and interobserver variation were calculated for each imaging modality. Lack of flow is a helpful sign, but remember that a significant number of patients with torsion confirmed on laparoscopy had an ultrasound that showed intact blood flow. Failure to establish the diagnosis in a timely fashion can result in irreversible ovarian ischemia with implications for future fertility. There does not appear to be any increase in adverse events after detorsion when compared to salpingo-oophorectomy. Shadinger LL, Andreotti RF, Kurian RL. Presence of ovarian cysts was significantly associated with torsion. Houry DL, Abbott JT. Listen for key features on history: sudden onset of unilateral pelvic pain, sometimes radiating to the groin, often associated with nausea and vomiting. A urinalysis may reveal blood consistent with nephrolithiasis, or it may show nitrites and leukocyte esterase more consistent with a urinary tract infection. Pregnancy also results in an increased risk of torsion due to an enlarged corpus luteum. Successful Oocyte Retrieval After Follicular Fluid Aspiration in Suspicious of Ovarian Torsion. If, on surgical examination, the ovarian tissue is obviously necrotic, there is a mass concerning for malignancy, or the patient is postmenopausal, then a salpingo-oophorectomy will likely be performed. In this study, we performed a meta-analysis of all the published studies on B-mode ultrasound (US, morphological criteria), Doppler US (DUS, flow criteria), and computed tomography (CT) for the diagnosis of OT. Treatment of adnexal torsion is surgical. Table 3 shows the accuracy of the various sonographic signs for diagnosis of ovarian torsion. The ovary has a dual blood supply (ovarian artery and uterine artery) so even if the supply is cut off to one there still may be Doppler blood flow to the ovary. Since clinical presentation may be nonspecific and physical findings are often inconclusive, imaging is required for a timely and accurate diagnosis. Absence of Doppler flow has high specificity but low sensitivity. Conclusion:Identifying a twisted pedicle in a patient is therefore, suggestive of ovarian torsion. Ovarian torsion has a bimodal age distribution occurring mainly in young women (15-30 years) and post-menopausal women. Keywords: If all your tests are negative, but you still suspect it, call your gynecologist to discuss taking the patient to the OR for laparoscopy. Ann Emerg Med 2001; 38(2): 156-159. Early recognition and restoration of blood flow are important to avoid irreversible ovarian damage. [Acute Pelvic pain in women-gynecological causes]. Chang HC, Bhatt S, Dogra VS. Pearls and pitfalls in diagnosis of ovarian torsion. doi: 10.2214/AJR.13.12279. The pain may radiate to the groin. As they predispose to ovarian torsion [2], they may present with acute pelvic pain. Radiologe. The remainder of findings on ultrasound and CT are nonspecific. A bedside transabdominal ultrasound was obtained to evaluate for possible free abdominal/pelvic fluid. The surrounding fallopian tube was dusky and ischemic appearing. The diagnostic performance of CT is not shown to be significantly different from that of US in identifying ovarian torsion in this study. The Clerkship Directors in Emergency Medicine (CDEM) is an Academy of SAEM. Epub 2016 Nov 17. The greatest risk factor for ovarian torsion is ovarian enlargement, typically caused by an ovarian cyst or mass. Interobserver agreement was excellent (Kappa=0.85). Initial actions are similar to the evaluation of other patients in the ED. 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