History

Classically, patients present with the sudden onset (commonly during exercise or other agitating movement) of severe, unilateral lower abdominal pain that worsens intermittently over many hours. A minority of patients, however, complain of mild pain that follows a more prolonged time course. The pain usually is localized over the involved side, often radiating to the back, pelvis, or thigh. Approximately 25% of patients experience bilateral lower quadrant pain. It may be described as sharp and stabbing or, less frequently, crampy.

Nausea and vomiting occur in approximately 70% of patients, mimicking a gastrointestinal source of pain and further obscuring the diagnosis.

A history of previous episodes may be elicited, possibly attributable to partial, spontaneously resolving torsion. Fever may occur as a late finding as the ovary becomes necrotic.

Ovarian torsion in premenarchal girls is associated with a longer interval from onset of symptoms and an increased rate of fever and pelvic mass at presentation compared to postmenarchal patients, according to one study. Median duration of symptoms before presentation was 24 hours for premenarchal patients, versus 8 hours for postmenarchal patients.^[1] In another study, of 32 premenarchal patients with ovarian torsion, the main presenting symptoms were abdominal pain (92.3%) and nausea and vomiting (84.6%). Abdominal tenderness was present in 64.1%. On abdominal ultrasound, an enlarged ovary was identified in 28.9%.^[2]

In a retrospective study of ovarian torsion in premenarchal and postmenarchal patients, there was a higher frequency of nausea and vomiting in the premenarchal patients. Ovarian cysts were more commonly demonstrated in postmenarchal patients, and a normal adnexal appearance on ultrasound was more common in premenarchal patients. Because of a normal adnexa in 69% of cases in premenarchal patients, a high index of suspicion is necessary in any premenarchal patient with acute-onset abdominal pain.^[3]

Ovarian torsion in the third trimester of pregnancy is likely to present as nonspecific symptoms of lower abdominal pain, nausea, and vomiting and can often be misdiagnosed as appendicitis or preterm labor. Although conservative treatment has been proposed during pregnancy, surgical intervention may be necessary if ovarian torsion is highly suspected. Ultrasonography in early pregnancy should address the cervix and the adnexa for early diagnosis and management of ovarian masses, thus avoiding later emergency situations and the possibility of preterm deliveries.^[4]

Physical examination

The physical examination, like the history, is typically nonspecific and is highly variable. A unilateral, tender adnexal mass has been reported in between 50 and 90% of patients. However, the absence of such a finding does not exclude the diagnosis. Tenderness to palpation is common; however, it is mild in approximately 30% and absent in another 30% of patients. Therefore, the absence of tenderness cannot be used to rule out torsion.

Peritoneal findings are infrequent and indicate advanced disease if present.

Differential Diagnoses

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Ashwal E, Krissi H, Hiersch L, Less S, Eitan R, Peled Y. Presentation, Diagnosis, and Treatment of Ovarian Torsion in Premenarchal Girls. J Pediatr Adolesc Gynecol. 2015 Mar 28. [QxMD MEDLINE Link].
Ganer Herman H, Shalev A, Ginat S, Kerner R, Keidar R, Bar J, et al. Clinical characteristics of adnexal torsion in premenarchal patients. Arch Gynecol Obstet. 2016 Mar. 293 (3):603-8. [QxMD MEDLINE Link].
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Media Gallery

Video depicts 2 findings: (1) enlarged hypovascular left ovary and (2) flow in healthy right ovary. Small amount of intraperitoneal fluid surrounds left ovary.

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Author

Erik D Schraga, MD Staff Physician, Department of Emergency Medicine, Mills-Peninsula Emergency Medical Associates

Disclosure: Nothing to disclose.

Coauthor(s)

Arthur C Fleischer, MD Professor, Chief of Ultrasound Imaging, Cornelius Vanderbilt Chair, Departments of Radiology and Obstetrics and Gynecology, Vanderbilt University Medical Center

Arthur C Fleischer, MD is a member of the following medical societies: American College of Radiology, American Institute of Ultrasound in Medicine, Society of Radiologists in Ultrasound

Disclosure: Nothing to disclose.

Chief Editor

Eugene C Lin, MD Attending Radiologist, Teaching Coordinator for Cardiac Imaging, Radiology Residency Program, Virginia Mason Medical Center; Clinical Assistant Professor of Radiology, University of Washington School of Medicine

Eugene C Lin, MD is a member of the following medical societies: American College of Nuclear Medicine, American College of Radiology, Radiological Society of North America, Society of Nuclear Medicine and Molecular Imaging

Disclosure: Nothing to disclose.

Acknowledgements

Michelle Blanda, MD Chair, Department of Emergency Medicine, Summa Health System Akron City/St Thomas Hospital; 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