Ovarian Torsion: Examination & Management

by Sharon Bord, MD

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    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.

    About the Lecture

    The lecture Ovarian Torsion: Examination & Management by Sharon Bord, MD is from the course Abdominal and Genitourinary Emergencies.

    Included Quiz Questions

    1. Asymmetric enlarged ovary
    2. Follicular cysts
    3. Atrophic ovary
    4. Hyperechoic ovary
    5. Anechoic mass with septations
    1. Laparoscopy
    2. CT scan
    3. Ultrasound
    4. Venous doppler
    5. CT angiography

    Author of lecture Ovarian Torsion: Examination & Management

     Sharon Bord, MD

    Sharon Bord, MD

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