Treatment of adnexal torsion is surgical. Reichelt A, Meinel FG, Wirth S, Weber MA, Bath K. Radiologe. Point of Care urine pregnancy test and urinalysis were negative. NLM Search Strategy: Your friendly neighborhood medical librarian (Susan Fowler, MLIS [email protected]) provides you with the following search strategy (summarized at http://tinyurl.com/245dp8e). 2018 Feb;25(1):51-59. doi: 10.1007/s10140-017-1549-8. However, either ultrasound or CT may help you find other pathology to explain a patient’s pain (eg, kidney stone, appendicitis). 2020 Feb;30(2):1054-1061. doi: 10.1007/s00330-019-06434-y. Images courtesy of Dr. Maulik S Patel. Epub 2018 Feb 17. Interobserver agreement was excellent (Kappa = 0.85). Usefulness of Doppler sonography in the diagnosis of ovarian torsion. Her last normal menstrual period ended two-weeks ago. 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 The most dangerous condition in the differential for adnexal torsion is an ectopic pregnancy, and as such, a pregnancy test should be ordered to help screen for it. [Sudden chest pain and lower abdominal pain : The usual suspects]. A positive pregnancy test does not eliminate the diagnosis of ovarian torsion, especially early in pregnancy, as a corpus luteum cyst may be the source of torsion. Image 1 demonstrates a side by side comparison. As they predispose to ovarian torsion [2], they may present with acute pelvic pain. Ultrasound is the diagnostic modality of choice for detecting torsion. Imaging of common solid organ and bowel torsion in the emergency department. Initial actions are similar to the evaluation of other patients in the ED. doi: 10.1016/j.jemermed.2018.01.006. Ann Emerg Med 2001; 38(2): 156-159. The tube is dusky and engorged with engorgment of the ovary. [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. While the overall incidence of ovarian torsion is low and there is almost no associated mortality, when missed, ovarian torsion can result in a significant degree of morbidity forRead More The initial twisting causes obstruction of venous return. The classic presentation of adnexal torsion is sudden onset of unilateral lower abdominal pain which is often described as a stabbing pain and is commonly accompanied by nausea and vomiting. Ovarian/adnexal torsion is a rather frequent occurrence in women of reproductive age group worldwide. NIH Consult gynecology early if you have a high suspicion for torsion. Image from  EMLyceum https://emlyceum.com/2012/06/21/ovarian-torsion-answers/ Used by Creative Commons Attribution-Noncommercial-Share Alike 3.0 Unported licence (http://creativecommons.org/licenses/by-nc-sa/3.0/) (CC Licence). This site needs JavaScript to work properly. However, heightened awareness and suspicion of this condition are needed for timely intervention. Materials and methods: Radiographics. She is mildly tachycardic with intact distal pulses and has clear equal breath sounds. The incidence of torsion in patients with structurally normal seems to be extremely low. Emergency GYN consult is required in all suspected ovarian torsion cases. Get an ultrasound to look for Doppler flow. 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. Interobserver agreement was excellent (Kappa=0.85). Intraoperative photos of torsed adnexa. Ovarian enlargement with or without an underlying mass is the finding most frequently associated with torsion, but it is nonspecific. The cyst was decompressed and the pedicle of the right ovary was detorsed causing return of blood flow. Etiologies are quite diverse with ovarian lesions and corpus luteal cysts being the most two common. There are conflicting reports on the accuracy of different imaging modalities for OT. Interobserver agreement for pelvic US was fair (Kappa=0.60). Treat pain and nausea with IV medications as soon as you have IV access – there is no need to wait for the diagnosis. J Ultrasound Med 2008; 27: 7-13. In my mind in a patient with undifferentiated abdominal pain and structurally normal ovaries I'm not sure that routinely adding an ultrasound would help us identify these extremely rare cases of 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. Other symptoms may include nausea. Since clinical presentation may be nonspecific and physical findings are often inconclusive, imaging is required for a timely and accurate diagnosis. Both CT and US seem like reasonable tests to identify the presence of underlying ovarian pathology. Physical examination may reveal pelvic or lower abdominal tenderness. [13] For Tubo-Ovarian Abscess (TOA): A twisted pedicle, although not often detected on imaging, is … 2005; 17(3):231-7. White M, Stella J. PMID: 24480106. Pelvic US was interpreted as demonstrating an abnormal ovary in 90.0% of ovarian torsion cases by reader 1, and in 100.0% by reader 2, whereas CT was interpreted as revealing an abnormal ovary in 100.0% of torsion cases by both readers. Interobserver agreement was excellent (Kappa=0.85). Ovarian torsion: a fifteen-year review. She is slightly obese but is otherwise well-appearing. Commonly an ovarian mass or cyst can be visualized and in, later stages, free pelvic fluid (indicating hemorrhage) can be seen. Ovarian torsion is a common concern in girls presenting to emergency care with pelvic or abdominal pain. AJR Am J Roentgenol. Ultrasound has a sensitivity of approaching 100% and specificity of 97% if there is an enlarged ovary with an absence of arterial and venous blood flow 14. This leads to vascular congestion, which causes engorgement and edema. 2014 Nov;203(5):W470-81. Fax: 847.813.5450. Clipboard, Search History, and several other advanced features are temporarily unavailable. In addition we aim to describe patterns in the clinical presentation of the disease. Presence of ovarian cysts was significantly associated with torsion. Objective: Left maintains normal flow. MRI findings are similar to those on CT, but  MRI is not commonly ordered from the ED. The risk goes down when the size of the ovary becomes more massive (> 20.0 cm) due to decreased motility. Positive Doppler flow to the ovary does not rule out torsion. This is a retrospective study of 20 cases of ovarian torsion and 20 control patients, all of whom had both US and CT performed in the emergency department. The most common ultrasound finding in torsion is enlargement or edema of the ovary. Listen for key features on history: sudden onset of unilateral pelvic pain, sometimes radiating to the groin, often associated with nausea and vomiting. Most surgeons will try to salvage any normal ovarian tissue in a premenopausal patient. Phone: 847.813.9823 Establishing IV access and administering antiemetics and pain medication may aid in evaluation of the patient. Cureus. 1111 East Touhy Ave, Suite 540 There is no absolute cutoff to ensure viability. The patient was closed and taken to recovery where she had resolution of her symptoms. Even if a dusky, edematous ovary is discovered in the OR, there is often functional recovery if the tissue is not necrotic. A urinalysis may reveal blood consistent with nephrolithiasis, or it may show nitrites and leukocyte esterase more consistent with a urinary tract infection. Conclusion:Identifying a twisted pedicle in a patient is therefore, suggestive of ovarian torsion. The diagnostic performance of CT is not shown to be significantly different from that of US in identifying ovarian torsion in this study. Ovarian torsion represents a true gynecological emergency and requires rapid evaluation and management in order to salvage the ovary. [12] A prospective study of 199 patients showed doppler ultrasound has a sensitivity and specificity for torsion of 100 and 97%. These results suggest that when CT demonstrates findings of ovarian torsion, the performance of another imaging exam (i.e. 2014 Apr;21(2):179-87. doi: 10.1007/s10140-013-1163-3. Ovarian torsion can occur in all ages. The CT and MRI features of ovarian torsion are illustrated with gross pathologic correlation. There are no laboratory tests to establish the diagnosis of adnexal torsion. For US studies, the radiologists graded the adnexal Doppler waveforms as either normal or suspicious for torsion. Emerg Med Australas. Results: Other signs on CT include asymmetric adnexal enhancement, thickened fallopian tube, associated free fluid/hemorrhage, and deviation of the uterus to the affected side. The bottom line – there is no single finding that can definitively “rule in” or “rule out” ovarian torsion. CT. good at ruling out ovarian torsion if a normal ovary/adnexa is seen on ultrasound; the twisted ovarian pedicle is pathognomonic for ovarian torsion if demonstrated 11 It is more commonly seen in the right ovary due to an increased length of the utero-ovarian ligament on the right and the presence of the sigmoid colon on the left. She has no past medical or surgical history (including no STD’s) and she has never been pregnant. Approximately 20% of the cases occur during pregnancy 1. Get the latest public health information from CDC: https://www.coronavirus.gov, Get the latest research information from NIH: https://www.nih.gov/coronavirus, Find NCBI SARS-CoV-2 literature, sequence, and clinical content: https://www.ncbi.nlm.nih.gov/sars-cov-2/. What every radiologist should know about adnexal torsion. A markedly elevated serum white blood cell count may favor tubo-ovarian abscess over torsion. [Acute Pelvic pain in women-gynecological causes]. Successful Oocyte Retrieval After Follicular Fluid Aspiration in Suspicious of Ovarian Torsion. Lack of ovarian blood flow on doppler sonography seems to be a good predictor of ovarian torsion. “Ovarian Torsion.” EmDOCs.net - Emergency Medicine Education, www.emdocs.net/. Bridwell, Rachel. The pain may radiate to the groin. The greatest percentage of cases occur in the reproductive years but torsion also occurs in children and post-menopausal females. Two radiologists who were blinded to clinical data interpreted all studies as (1) demonstrating an abnormal ovary or not, and (2) suggestive of torsion or not. A large fluid filled cyst was located on the right ovary. CT images were evaluated independently by two readers for the … Purulent cervical discharge and cervical motion tenderness point towards PID with a tubo-ovarian abscess. The objective of this thesis is to determine the trends in usage of CT scanning and its sensitivity during the workup of pelvic pain and suspected torsion. 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). Ovarian torsion (OT) is when an ovary twists on its attachment to other structures, such that blood flow is decreased. Her abdomen exhibits tenderness and guarding to the right lower quadrant, normal bowel sounds and no organomegaly. Epub 2017 Sep 7. Radiopedia Case Ovarian Torsion https://radiopaedia.org/cases/ovarian-torsion-10?lang=us. A 25 year-old female presents to the ED with a chief complaint of RLQ abdominal pain. 2020 Dec 20;12(12):e12192. On pelvic exam, the patient may have adnexal tenderness or an adnexal mass. Physical exam should include an abdominal exam and a pelvic exam, including a bimanual exam, to assess for adnexal tenderness and fullness that may be present. Epub 2019 Oct 18. Abdominopelvic CT for ovarian torsion was 100.0% sensitive (95% CI, 83.9-100.0%) and 85.0% specific (95% CI, 64.0-94.5%) for reader 1, while 90.0% sensitive (95% CI, 69.9-97.2%) and 90.0% specific (95% CI, 69.9-97.2%) for reader 2. https://www.saem.org/.../m4-curriculum/group-m4-approach-to/ovarian-torsion Des Plaines, IL 60018 Ovarian torsion does occur in normal ovaries. CT may as sensitive as US. The congestion progresses until arterial flow is compromised, leading to ischemia and infarction. In this study, we have adopted a case-based statistical analysis to identify important sonographic markers and further evaluated their contribution in identifying ovarian to… doi: 10.2214/AJR.13.12279. Complications may include infection, bleeding, or infertility. A pelvic exam demonstrates right adnexal fullness and significant pain on exam without bleeding or discharge. 2017 Apr;213(4):637-639. doi: 10.1016/j.amjsurg.2016.11.021. She is monogamous with her heterosexual partner. Results: Sixty-one percent of right ovarian torsion case and 27% of left ovarian torsion cases had normal Doppler flow. Torsion is more common in an ovary that is greater than 5.0 cm in diameter (86 to 95% per multiple case studies.) Look for corroborating evidence on pelvic exam: adnexal tenderness on the same side as the pain and, less commonly, an adnexal mass.  |  Flow is normal in 54% to 60% of cases. Torsion does occur in infants, children, and postmenopausal women. As with any emergency department patient, start with a primary assessment: airway, breathing, circulation. Predicting necrosis in adnexal torsion in women of reproductive age using magnetic resonance imaging. Rush Medical College, Originally Written By: Lynne Yancey University of Colorado School of Medicine. “Ovarian Torsion.” UpToDate, 10 Apr. Ovarian torsion should also be considered in infants and small children with feeding intolerance, abdominal distension, vomiting, irritability, and/or a palpable pelvic mass. There is a significant diagnostic delay at 101.8 hours (median). RadioGraphics 2008; 28: 1355-1368. Pelvic or intravaginal ultrasound remains the first-line imaging modality used for diagnosis and evaluation of suspected ovarian/adnexal torsion. CT has high sensitivity in the diagnosis of cystic teratomas [3]. Absence of Doppler blood flow is a helpful finding (high specificity), but this finding has a low sensitivity for detecting torsion. Pelvic US for ovarian torsion was 80.0% sensitive (95% CI, 58.4-91.9%) and 95.0% specific (95% CI, 76.4-99.1%) for reader 1, while 80.0% sensitive (95% CI, 58.4-91.9%) and 85.0% specific (95% CI, 64.0-95.0%) for reader 2. “Ovarian Torsion.” Rosen's Emergency Medicine: Concepts and Clinical Practice, by Ron M. Walls et al., Elsevier, 2018. It is important to remember that approximately 40% of patients will report gradual pain instead of the acute onset pain that is frequently associated with torsion and some patients may describe back or flank pain. Its use results in decreased time to diagnosis. She denies fever, vaginal bleeding, discharge, dysuria or change in bowel habits. Would you like email updates of new search results? Other risk factors resulting in ovarian enlargement include patients with polycystic ovarian syndrome and those undergoing fertility treatment (ovarian hyperstimulation syndrome.) The ovary, and often the fallopian tube (adnexal torsion), become twisted around their vascular pedicle. Lourenco AP, Swenson D, Tubbs RJ, Lazarus E. Emerg Radiol. In this article, we discuss and illustrate the normal appearance and arterial flow … Although ultrasound is the ideal non-invasive first-line technique, … Career Development and Mentorship Committee, Communications and Social Media Committee, Effective Consultation in Emergency Medicine Video, Residency Match in the Era of COVID: Advice for Medical Educators in Emergency Medicine, SAEMF/CDEM Innovations in Undergraduate Emergency Medicine Education Grant, The Power of Mentorship: Pearls and Pitfalls in Medical Education Research, Clerkship Coordinator’s Handbook Clerkship Coordinator’s Handbook, Virtual Rotation and Educational Resources, Diversity, Equity, and Inclusion (DEI) Library, https://radiopaedia.org/cases/ovarian-torsion-10?lang=us, http://creativecommons.org/licenses/by-nc-sa/3.0/, https://emlyceum.com/2012/06/21/ovarian-torsion-answers/, Pain may be reminiscent of a kidney stone: colicky, fairly sudden onset, radiation to the groin. Acute gynaecologic disorders are commonly encountered in daily clinical practice of emergency departments (ED) and predominantly occur in reproductive-age women. 2019. Diagnostic evaluation of ovarian torsion: An analysis of pediatric patients using the Nationwide Emergency Department Sample. Ultrasound has a sensitivity for ovarian torsion of 79% and computerized tomographic scan of 42.2%.  |  COPYRIGHT © 2021 SAEM, ALL RIGHTS RESERVED. Ovarian torsion has a bimodal age distribution occurring mainly in young women (15-30 years) and post-menopausal women. Diagnostic testing is essential when evaluating a patient with suspected ovarian torsion. CT for ovarian torsion was 100.0% sensitive (95% CI, 83.9–100.0%) and 85.0% specific (95% CI, 64.0–94.5%) for reader 1, while 90.0% sensitive (95% CI, 69.9–97.2%) and 90.0% specific (95% CI, 69.9–97.2%) for reader 2. Eur J Radiol. The diagnosis of ovarian torsion is made definitively in the operating room. Typically CT images demonstrate fat (areas with very low Hounsfield values), fat fluid level, calcification (sometimes … 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. “Time is ovary,” to borrow a phrase, so consult your gynecologist early. Ovarian and tubal torsion: imaging findings on US, CT, and MRI. Pearls and pitfalls in diagnosis of ovarian torsion. O… Pena JE, Ufberg D, Cooney N, et al. Rapid urine or serum pregnancy testing should be obtained. Symptoms typically include pelvic pain on one side. Any female patient who presents with abdominal pain should prompt consideration of torsion in ED providers.  |  Houry DL, Abbott JT. Right Lower Quadrant Abdominal Pain: Do Not Forget About Ovarian Torsion on the Computed Tomography Scan. To investigate adnexal torsion, ultrasound is a good first‐line diagnostic test with a pooled sensitivity of 0.79 and specificity of 0.76. A complete blood count, basic metabolic panel, and urinalysis can provide additional information pointing you toward an alternative diagnosis. 2018 Aug;55(2):e43-e45. Ovarian torsion is an uncommon cause of acute abdominal pain in females, but diagnostic delay can have disastrous results. 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. Right ovary without Doppler flow suggesting ovarian torsion. Sensitivity and specificity were respectively 42.9% and 81.8% for B-Mode ultrasound and 100% and 81.8% for contrastenhanced ultrasonography. Table 3 shows the accuracy of the various sonographic signs for diagnosis of ovarian torsion. If all your tests are negative, but you still suspect it, call your gynecologist to discuss taking the patient to the OR for laparoscopy. Untreated ovarian torsion can result in complete loss of the ovary, as well as ovarian necrosis and infection. Keep the patient NPO in preparation for the OR. The right ovary has no Doppler flow while the left maintains flow. Ovarian torsion is a gynecological emergency and is caused by the twisting of the ovary and fallopian tube on the vascular pedicle. Image 1. She has no past medical history, is a social alcohol drinker, and does not use tobacco products. Am J Surg. COVID-19 is an emerging, rapidly evolving situation. Pregnancy also results in an increased risk of torsion due to an enlarged corpus luteum. 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. The bedside ultrasound was inconclusive. Copyright © 2014 Elsevier Ireland Ltd. All rights reserved. She tells the triage nurse that she has had intermittent episodes of the pain but over the past 45 minutes the pain has become unbearable and excruciating. Some studies have shown as high as 60% of cases of surgically verified ovarian torsion will have arterial blood flow on ultrasound. The sensitivity of the individual signs ranged from 36.2% to 85.1%, … Absence of Doppler flow has high specificity but low sensitivity. Epub 2016 Nov 17. Ssi-Yan-Kai G, Rivain AL, Trichot C, Morcelet MC, Prevot S, Deffieux X, De Laveaucoupet J. Emerg Radiol. Interobserver agreement was excellent (Kappa = 0.85). Conclusion: Update Author: Lauren Evans, MD University of Arkansas for Medical Sciences (UAMS), Christopher Fowler, DO University of Arkansas for Medical Sciences (UAMS), Edited By: G. Carolyn Clayton, M.D. Fever is uncommon, and usually low-grade if present. A consultative transvaginal ultrasound was obtained which demonstrated a decreased Doppler flow to the right ovary. The Clerkship Directors in Emergency Medicine (CDEM) is an Academy of SAEM. For ovarian torsion: A retrospective study of 834 patients showed the NPV of a contrast enhanced CT of the pelvis for ovarian torsion is 100%. The surrounding fallopian tube was dusky and ischemic appearing. Some patients will describe several episodes of pain over the course of hours, days, or even weeks, if the ovary has been torsing intermittently. The remainder of findings on ultrasound and CT are nonspecific. 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Et al Quadrant abdominal pain: Do not Forget About ovarian torsion, but it is nonspecific and infection case-control... Has never been pregnant have a higher incidence of torsion due to adhesions remainder of findings US! Delay at 101.8 hours ( median ) airway, breathing, circulation never been.. K. Radiologe tube on the right ovary is made definitively in the emergency patient... No STD ’ S ) and she has never been pregnant excludes the diagnosis of due. Those undergoing fertility treatment ( ovarian hyperstimulation syndrome. features of ovarian torsion ; ultrasound pregnancy. The best initial imaging for ovarian torsion Rao M, Chen R. Eur Radiol: computed tomography for and! Rr 21, Tmax 98.9 SpO2 99 % RA however, heightened awareness and suspicion of condition... Is challenging to make accurately and quickly, relying on a combination of physical,... Demonstrates findings of adnexal torsion on the accuracy of different imaging modalities for OT you toward an alternative.! Borrow a phrase, so consult your gynecologist early in a premenopausal patient of... Doppler ultrasound has a bimodal age distribution occurring mainly in young women ( years. With ovarian lesions and corpus luteal cysts being the most common finding is an of... Their vascular pedicle ovary ovarian torsion: ct sensitivity discovered in the reproductive years but torsion also occurs in children and females! Twisted pedicle in a patient with suspected ovarian torsion cases M. Walls et al. Elsevier! The computed tomography ; emergency department patient, start with a chief complaint of RLQ abdominal pain and diagnosis... Return of blood flow is normal in 54 % to 60 % of the right ovary has no past or... Challenging to make accurately and quickly, relying on a combination of physical exam, patient. Right ovarian torsion case and 27 % of the patient NPO in preparation for diagnosis... Therapy is unlikely to improve preoperative diagnostic yield of cystic teratomas [ 3 ] result in irreversible ovarian.. 1 ):51-59. doi: 10.1007/s10140-013-1163-3 the Clerkship Directors in emergency Medicine ( CDEM ) is ovary.