Ovarian Torsion – Diagnosis and Treatment
Obstetrics and Gynecology
First 5 Minutes
- A high index of clinical suspicion is the most important factor in making the diagnosis of ovarian torsion in a timely manner to avoid ovarian ischemia (1)
Context
- Ovarian torsion involves partial or complete rotation of the ovarian vascular pedicle which causes obstruction to the venous and arterial flow, which can lead to ischemia of the ovaries if not treated in time (1,3).
- Most common in females of reproductive age (mean of age of 30) but can occur at any age (1).
- The most common risk factor is adnexal mass > 5 cm, but ovarian torsion cannot be ruled out in the absence of an ovarian mass or cyst (2,3).
- Other risk factors include IVF, recent tubal ligation surgery, polycystic ovarian syndrome, and previous ovarian torsion (2,3).
- The classic presentation of ovarian torsion is severe lower abdominal pain (90%) with nausea and vomiting (70%) (2,3). The presentation is variable, thereby, no single historical or physical examination finding should be used to rule in or rule out the diagnosis.
Diagnostic Process
- Ultrasound (transabdominal or transvaginal) is the first-line imaging modality for suspected ovarian torsion. Ultrasound can rule in ovarian torsion, but cannot rule out ovarian torsion as the sensitivity ranges from 35-85% (4).
- Pelvic examination has poor sensitivity in detecting an ovarian mass or cyst, and the reliability of pelvic examinations is further reduced by obesity and age > 55 (5).
- Diagnostic certainty can only be established from laparoscopic evaluation by a gynecologist (6).
Recommended Treatment
- The first-line treatment is laparoscopic adnexal detorsion (1,6).
Criteria For Hospital Admission
- Patients with suspected ovarian torsion are admitted to hospital. Gynecology should be consulted immediately whenever this diagnosis is suspected.
Criteria For Transfer To Another Facility
- Dependent on local guidelines. In general, transfer may be considered if:
- Patient care requirements exceed hospital capabilities (e.g., cardiac monitoring, intensive care, maternal care, etc.).
- Treatment is not available at current facility (no operating rooms).
- Specialist consultations are required and not available at current facility.
Criteria For Close Observation And/or Consult
- Ovarian torsion is a time-sensitive diagnosis and warrants consultation with the obstetrics and gynecology service if there is suspicion of torsion based on history and examination (1)
Criteria For Safe Discharge Home
- Dependent on surgical outcome and clinical presentation.
Quality Of Evidence?
High
We are highly confident that the true effect lies close to that of the estimate of the effect. There is a wide range of studies included in the analyses with no major limitations, there is little variation between studies, and the summary estimate has a narrow confidence interval.
Moderate
We consider that the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. There are only a few studies and some have limitations but not major flaws, there are some variations between studies, or the confidence interval of the summary estimate is wide.
Low
When the true effect may be substantially different from the estimate of the effect. The studies have major flaws, there is important variations between studies, of the confidence interval of the summary estimate is very wide.
Justification
- Moderate quality. Prospective studies are limited in number and do not include randomized or blinded trials of treatment protocols. Much of the key literature is 10-15 years old.
Related Information
Reference List
Nair S, Joy S, Nayar J. Five year retrospective case series of adnexal torsion. J Clin Diagn Res. 2014 Dec;8(12):OC09-13. doi: 10.7860/JCDR/2014/9464.5251.
White M, Stella J. Ovarian torsion: 10-year perspective. Emerg Med Australas 2005;17:231–237
Houry D, Abbott JT. Ovarian torsion: a fifteen-year review. Ann Emerg Med 2001;38:156–159.
Swenson DW, Lourenco AP, Beaudoin FL, et al. Ovarian torsion: case-control study comparing the sensitivity and specificity of ultrasonography and computed tomography for diagnosis in the emergency department. Eur J Radiol 2014;83:733–738.
Close RJ, Sachs CJ, Dyne PL. Reliability of bimanual pelvic examinations performed in emergency departments. West J Emerg Med 2001;175:240–244.
Bar-On S, Mashiach R, Stockheim D, et al. Emergency laparoscopy for suspected ovarian torsion: are we too hasty to operate? Fertility and sterility 2010;93(6):2012-2015. DOI: https://doi.org/10.1016/j.fertnstert.2008.12.022
RESOURCE AUTHOR(S)
DISCLAIMER
The purpose of this document is to provide health care professionals with key facts and recommendations for the diagnosis and treatment of patients in the emergency department. This summary was produced by Emergency Care BC (formerly the BC Emergency Medicine Network) and uses the best available knowledge at the time of publication. However, healthcare professionals should continue to use their own judgment and take into consideration context, resources and other relevant factors. Emergency Care BC is not liable for any damages, claims, liabilities, costs or obligations arising from the use of this document including loss or damages arising from any claims made by a third party. Emergency Care BC also assumes no responsibility or liability for changes made to this document without its consent.
Last Updated Dec 29, 2022
Visit our website at https://emergencycarebc.ca
COMMENTS (0)
Add public comment…
SHARE POST
POST COMMENT
We welcome your contribution! If you are a member, log in here. If not, you can still submit a comment but we just need some information.