On the physical exam what you’ll have
is you'll unilateral adnexal tenderness as well as a palpable adnexal mass felt.
Now palpable adnexal mass is not felt all the time
when you do feel it its concerning that the ovary is swollen and enlarged.
The differential diagnosis here is to generally quite broad.
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.
Patients who are having right lower adnexal
or pelvic and abdominal pain, that can potentially be appendicitis.
If it’s on the left side, it can possibly be diverticulitis.
It could also be an ectopic pregnancy.
Again, to stress, that you wanna get a pregnancy test in all women of child bearing age.
It could be a kidney stone.
It could be PID, pelvic inflammatory disease.
Or possibly even a urinary tract infection.
So the differential here is broad.
But again, similar to testicular torsion,
this is the time where blood supply is cut off to an organ.
You wanna make sure that this is one of the things
that’s on the very top of your differential of consequence.
So first things first,
we wanna go ahead and get that pregnancy test for the women of child bearing age.
You wanna get an ultrasound.
Similar to testicular torsion,
ultrasound is gonna be the things
that’s gonna help you most with your diagnosis.
What you’re gonna see on ultrasound
is your gonna see asymmetric enlarged ovaries.
You potentially may see a mass or cyst on those ovaries.
It’s important to know that the Doppler finding can still be inconsistent.
So patients who have had surgically proven torsion.
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.
So the blood flow to that area actually looked reasonably okay.
One of the big things to look for is decrease venous flow.
So is the venous flow decreased, because remember,
that’s gonna be the first thing to go.
You know CT scan, I said ultrasound is the first test you wanna reach for
but CT scan can be helpful as well.
What a CT scan can show you is that first and foremost
it can evaluate for other possible diagnoses.
So it can tell you if there’s any appendicitis or diverticulitis
or a lot of those other things that we discussed.
But a normal appearing ovary is very reassuring on a CT scan.
So the CT scan can take a look,
it can see if the ovary looks inflamed or irritated in any way.
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.
That’s a really good and reassuring test.
And then laparoscopy is our gold standard test here.
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.
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.
So urgent gynecologic consult may be indicated for operative management.
Go ahead and involve your consults services if you feel like it’s necessary.
Now due to that dual blood supply,
there’s a good chance of functional recovery for these patients.
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.
You wanna have a very low threshold to perform a GU exam,
especially in those teenage patients.
They may not necessarily be wanna admit to you
or tell you that they’re having pain and swelling in their testicle.
Have a very low threshold.
Ask about whether they’re having testicular pain.
Ultrasound is our diagnostic test of choice
but keep in mind that there are some limitations and false negative and false positives.
If you're worried about this get the Urology service involved.
You might want to attempt manual detorsion.
So when you're doing that you wanna think about opening the book,
so rotating the testicle away from the midline.
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.
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.
And a CT scan with normal appearing ovaries
in a patient with a low suspicion of disease is very reassuring.