Ovarian Torsion: Examination & Management

00:02 On the physical exam what you’ll have is you'll unilateral adnexal tenderness as well as a palpable adnexal mass felt.

00:09 Now palpable adnexal mass is not felt all the time when you do feel it its concerning that the ovary is swollen and enlarged.

00:16 The differential diagnosis here is to generally quite broad.

00:22 I always tell women that when they’re having lower abdominal pain that it’s tricky because you have your uterus and your ovaries in addition to all of your intestines.

00:30 Patients who are having right lower adnexal or pelvic and abdominal pain, that can potentially be appendicitis.

00:38 If it’s on the left side, it can possibly be diverticulitis.

00:42 It could also be an ectopic pregnancy.

00:45 Again, to stress, that you wanna get a pregnancy test in all women of child bearing age.

00:50 It could be a kidney stone.

00:52 It could be PID, pelvic inflammatory disease.

00:56 Or possibly even a urinary tract infection.

00:58 So the differential here is broad.

01:00 But again, similar to testicular torsion, this is the time where blood supply is cut off to an organ.

01:07 You wanna make sure that this is one of the things that’s on the very top of your differential of consequence.

01:13 So first things first, we wanna go ahead and get that pregnancy test for the women of child bearing age.

01:20 You wanna get an ultrasound.

01:22 Similar to testicular torsion, ultrasound is gonna be the things that’s gonna help you most with your diagnosis.

01:29 What you’re gonna see on ultrasound is your gonna see asymmetric enlarged ovaries.

01:34 You potentially may see a mass or cyst on those ovaries.

01:37 It’s important to know that the Doppler finding can still be inconsistent.

01:41 So patients who have had surgically proven torsion.

01:45 So someone went in, did surgery on them because they had concerning findings and concerning symptoms, they actually had okay blood flow on their Doppler exam.

01:54 So the blood flow to that area actually looked reasonably okay.

01:58 One of the big things to look for is decreased venous flow.

02:02 So is the venous flow decreased, because remember, that’s gonna be the first thing to go.

02:07 You know CT scan, I said ultrasound is the first test you wanna reach for but CT scan can be helpful as well.

02:14 What a CT scan can show you is that first and foremost it can evaluate for other possible diagnoses.

02:21 So it can tell you if there’s any appendicitis or diverticulitis or a lot of those other things that we discussed.

02:27 But a normal appearing ovary is very reassuring on a CT scan.

02:31 So the CT scan can take a look, it can see if the ovary looks inflamed or irritated in any way.

02:38 It can take an okay look at the blood supply to that ovary and if they’re able to visualize and see the ovary, and it looks normal, oftentimes that’s good.

02:48 That’s a really good and reassuring test.

02:51 And then laparoscopy is our gold standard test here.

02:55 So I mentioned that the ultrasound can look okay for a lot of these patients but then on surgery, the patient end up having ovarian torsion.

03:04 If you have a patient in whom you’re worried about this and the imaging is potentially reassuring but you're still worried, go ahead and consult GYN, because the patient may benefit from a laparoscopy, for someone to take a look and see if the ovary does in fact do look okay, by looking at it and visualizing it.

03:25 So urgent gynecologic consult may be indicated for operative management.

03:29 Go ahead and involve your consults services if you feel like it’s necessary.

03:33 Now due to that dual blood supply, there’s a good chance of functional recovery for these patients.

03:39 So our conclusion here, testicular torsion, you wanna think about at the most in kids who are less than one year of age and pubertal males.

03:50 You wanna have a very low threshold to perform a GU exam, especially in those teenage patients.

03:55 They may not necessarily be wanna admit to you or tell you that they’re having pain and swelling in their testicle.

04:01 Have a very low threshold.

04:03 Ask about whether they’re having testicular pain.

04:06 Ultrasound is our diagnostic test of choice but keep in mind that there are some limitations and false negative and false positives.

04:13 If you're worried about this get the Urology service involved.

04:18 You might want to attempt manual detorsion.

04:20 So when you're doing that you wanna think about opening the book, so rotating the testicle away from the midline.

04:26 Ovarian torsion, most common in reproductive age woman due to the fact that they get corpus luteum cysts and are more prone to having benign cysts and masses.

04:36 Ultrasound does have its limitations so have a low suspicion for consultation because laparoscopy, someone actually going in, taking a look, and visualizing the ovary can sometimes reveal these diagnosis.

04:48 And a CT scan with normal appearing ovaries in a patient with a low suspicion of disease is very reassuring.