eMedicine Specialties > Emergency Medicine > Obstetrics & Gynecology

Ovarian Torsion: Differential Diagnoses & Workup

Author: Erik D Schraga, MD, Consulting Staff, Department of Emergency Medicine, Mills-Peninsula Emergency Medical Associates; Consulting Staff, Permanente Medical Group, Kaiser Permanente, Santa Clara Medical Center
Coauthor(s): Michelle Blanda, MD, Chair, Department of Emergency Medicine, Summa Health System; Professor of Emergency Medicine, Northeastern Ohio Universities College of Medicine
Contributor Information and Disclosures

Updated: Aug 4, 2008

Differential Diagnoses

Appendicitis, Acute
Ovarian Cysts
Diverticular Disease
Pelvic Inflammatory Disease
Endometriosis
Pregnancy, Ectopic
Mesenteric Ischemia
Pregnancy, Urinary Tract Infections
Obstruction, Large Bowel
Renal Calculi
Obstruction, Small Bowel
Urinary Tract Infection, Female

Other Problems to Be Considered

Ovarian tumor
Tubal ovarian abscess
Ureteral calculi
Perforated colonic carcinoma

Workup

Laboratory Studies

  • A pregnancy test is the most critical laboratory test that can be performed in the ED.
  • General laboratory studies are not helpful in verifying a diagnosis of ovarian torsion; however, they may be indicated in ruling out alternative or coexisting diagnoses of lower abdominal or pelvic pain. These may include GC/chlamydia cultures, wet mount, and urinalysis.
  • The use of a complete blood count to evaluate for leukocytosis and anemia is nonspecific and unlikely to support or exclude the diagnosis.

Imaging Studies

  • Ultrasonography is the primary modality of imaging for patients with suspected ovarian torsion.
    • Ovarian enlargement secondary to impaired venous and lymphatic drainage is the most common sonographic finding in ovarian torsion.
    • The finding of an ovarian mass may suggest a focus for torsion but may also be misleading as to being the source of pain itself. Because implicated masses are most frequently non-neoplastic or hemorrhagic cysts, which can themselves produce pain of similar quality and location, diagnosis even with appropriate imaging can be challenging. Nevertheless, given a history reminiscent of torsion the discovery of an ovarian cyst should greatly increase one's suspicion of the diagnosis.
    • Combination of Doppler flow imaging with the morphologic assessment of the ovary may improve diagnostic accuracy. However, the interpretation of Doppler sonography is inconsistent due to dual ovarian blood supply from the uterine artery and the ovarian artery. Additionally, if the scan is performed during a transient period of detorsing of the ovary a normal Doppler flow may falsely suggest a normal ovary.
    • Although absence of arterial blood flow may be diagnostic, early in the progression of disease arterial perfusion may be preserved with only obstruction of venous and lymphatic flow.
    • Color Doppler sonography may be helpful in predicting viability of adnexal structures by depicting blood flow within the twisted vascular pedicle and presence of central venous flow.
  • Computed tomography may demonstrate an enlarged ovary and adnexal masses but is unable to evaluate the presence or absence of blood flow to the involved ovary. However, CT may be useful in ruling out other possible causes of lower abdominal pain in cases of diagnostic uncertainty. Additionally, CT can exclude the presence of a pelvic mass, which greatly adds in the ability to rule out torsion.

Procedures

  • Laparoscopy can be used for both confirmation of the diagnosis and treatment.
  • Culdocentesis is a nonspecific test that is unlikely to confirm or exclude torsion and is not recommended in the diagnostic workup.

More on Ovarian Torsion

Overview: Ovarian Torsion
Differential Diagnoses & Workup: Ovarian Torsion
Treatment & Medication: Ovarian Torsion
Follow-up: Ovarian Torsion
References
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References

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Further Reading

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Keywords

adnexal torsion, abdominal pain, ovaries, fallopian tubes, mesosalpinx, ovarian torsion, lower abdominal pain in women, enlarged ovary, ovarian tumor, dermoid tumor, elongated fallopian tube, ovarian enlargement, ovarian cyst

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Contributor Information and Disclosures

Author

Erik D Schraga, MD, Consulting Staff, Department of Emergency Medicine, Mills-Peninsula Emergency Medical Associates; Consulting Staff, Permanente Medical Group, Kaiser Permanente, Santa Clara Medical Center
Disclosure: Nothing to disclose.

Coauthor(s)

Michelle Blanda, MD, Chair, Department of Emergency Medicine, Summa Health System; Professor of Emergency Medicine, Northeastern Ohio Universities College of Medicine
Michelle Blanda, MD is a member of the following medical societies: American College of Emergency Physicians and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Medical Editor

Jerome FX Naradzay, MD, FACEP, Medical Director, Consulting Staff, Department of Emergency Medicine, Maria Parham Hospital; Medical Examiner, Vance County, North Carolina
Jerome FX Naradzay, MD, FACEP is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Mark Zwanger, MD, MBA, Assistant Professor, Department of Emergency Medicine, Thomas Jefferson University
Mark Zwanger, MD, MBA is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and American Medical Association
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Pamela L Dyne, MD, Associate Professor, Program Director, Department of Medicine, Division of Emergency Medicine, University of California at Los Angeles School of Medicine
Pamela L Dyne, MD is a member of the following medical societies: American College of Emergency Physicians and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

 
 
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