Guidelines Summary

The American College of Radiology (ACR) approriateness criteria for acute pelvic pain in the reporductive age group includes the following recommendations^[47]:

The choice of the correct imaging test depends on the results of a careful clinical evaluation in order to narrow the differential diagnosis.
Transvaginal (TVS) and transabdominal (TAS) pelvic sonography is the preferred imaging modality.
TVS with Doppler is useful in the diagnosis of ovarian torsion.
In a pregnant patient without acute signs of infection and with a suspected gynecologic etiology for pain, pelvic ultrasonography (US) with adnexal Doppler would be the initial modality to assess the etiology. If the US is inconclusive, then MRI without contrast can be done for further evaluation.

The Society of Obstetricians and Gynaecologists of Canada (SOGC) released guidelines for the diagnosis and management of adnexal torsion in children, adolescents, and adults. Key recommendations include the following^[48]:

Ultrasound with and without color flow Doppler is the imaging modality of choice for any suspected adnexal torsion.
Decreased or absent color Doppler flow, increased total ovarian volume, and abnormal adnexal volume ratios may all be suggestive of adnexal torsion, but the decision to operate should not be based exclusively on sonographic findings.
The theoretical risk of a thromboembolic event following detorsion is unfounded and should not preclude conservative management.
Laparoscopy is the preferred surgical approach for adnexal torsion.
Conservative surgical treatment of ovarian torsion, including detorsion with or without cystectomy, should be performed if torsion is confirmed, even in cases of a blue-black ovary.
An oophorectomy rather than a cystectomy should only be considered in the postmenopausal female population with ovarian torsion, due to the increased risk of malignancy.
Oophoropexy can be considered in situations where the ovarian ligament is congenitally long, in patients with repeat torsion, or when no obvious cause for the torsion can be found.

Medication

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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