Ovarian torsionMANAGEMENT

GENITOURINARY AND REPRODUCTIVE PRESENTATIONS · 12 SECTIONS

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361 items

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Cardiovascular Presentations66▾

Respiratory Presentations47▾

Neurological Presentations77▾

Gastrointestinal Presentations63▾

Genitourinary and Reproductive Presentations44▾

Acute Kidney Injury (ATN)Acute Kidney Injury (Post-renal)Acute Kidney Injury (Pre-renal)Amniotic Fluid Embolism Balanitis Bladder Rupture Breast Abscess Cystitis Ectopic pregnancy Epididymitis Glomerulonephritis Hematuria (gross)Hydrocele Interstitial Cystitis Mastitis Mittelschmerz Nephrolithiasis Nephrotic Syndrome Flare Nutcracker Syndrome Orchitis Ovarian Cyst Rupture Ovarian torsion Paraphimosis Pelvic Congestion Syndrome Pelvic Inflammatory Disease (PID)Phimosis Priapism Prostatitis Pyelonephritis Renal laceration Ruptured ovarian cyst Testicular torsion Torsion of Appendix Testis Tubo-ovarian abscess Ureteral Rupture Urethritis Urinary Retention Urinary tract infection (uncomplicated)Urolithiasis (renal colic)Vaginal bleeding (non-pregnant)Vaginitis (Bacterial)Vaginitis (Candidal)Varicocele Vulvovaginal Hematoma

Infectious Disease Presentations146▾

Trauma Presentations88▾

Toxicologic Presentations67▾

Psychiatric Presentations25▾

Musculoskeletal and Rheumatologic Presentations89▾

Dermatology Presentations21▾

Environmental and Exposure Presentations26▾

Hematologic and Oncologic Presentations30▾

Pediatric-Specific Presentations13▾

Endocrine and Metabolic Presentations42▾

ENT and Maxillofacial Presentations21▾

Ophthalmologic Presentations15▾

Obstetric Presentations17▾

Systemic and Miscellaneous Presentations15▾

01Approach to the Critical Patient/attcp40

Time critical priorities

›High risk states

›Hemodynamic instability

›Immediate resuscitation bay escalation

›Uncontrolled pain

›Early parenteral analgesia pathway

›Peritonitis

›Immediate gynecology and surgery notification

›Initial stabilization

›Airway and breathing threats

›If vomiting or altered mental status, aspiration risk mitigation

›Circulation threats

›If hypotension, isotonic crystalloid bolus 10-20 ml/kg

›If ongoing shock, vasopressor pathway and urgent source clarification

›Time dependent decision point

›Suspected ovarian torsion

›Diagnostic laparoscopy time priority over complete ED workup

›Imaging not used to delay operative management when clinical suspicion high

Monitoring and access

›Monitoring bundle

›Continuous pulse oximetry

›If saturation decline, respiratory evaluation and opioid adjustment

›Cardiac monitoring

›If tachyarrhythmia, pain and volume status reassessment

›Noninvasive blood pressure cycling

›If shock concern, q5 minute interval

›Vascular access

›Peripheral IV x2

›Large bore preferred

›If poor access, ultrasound guided peripheral IV

›If persistent failure, intraosseous per local protocol

Consult triggers

›Specialty activation

›Gynecology immediate notification

›Persistent unilateral pelvic pain with adnexal tenderness or mass

›Pregnancy with acute pelvic pain and adnexal mass

›Anesthesia early notification

›Anticipated urgent laparoscopy

›Surgery consultation

›Peritonitis or unclear abdomen with ischemic concern

›Transfer triggers

›No operative gynecology capability

›Transfer for urgent laparoscopy without delay for definitive imaging

02History/hx30

Presenting features

›Symptom pattern

›Acute unilateral pelvic or lower abdominal pain

›Sudden onset peak pain

›Intermittent waxing and waning pain

›Nausea and vomiting

›Pain associated emesis

›Fever

›Alternative diagnosis consideration

›Timeline details

›Time of onset

›Hours since onset for salvage window awareness

›Episodes of similar pain

›Intermittent torsion and detorsion possibility

Risk factors and context

›Adnexal mass risks

›Known ovarian cyst or tumor

›Size progression or recent imaging

›Prior torsion history

›Recurrence risk

›Reproductive and pregnancy factors

›Last menstrual period

›Pregnancy probability estimate

›Fertility treatment or ovarian stimulation

›Enlarged ovaries risk

›Early pregnancy symptoms

›Corpus luteum cyst context

›Other gynecologic history

›Prior pelvic surgery

›Adhesions consideration

›Endometriosis

›Ovarian endometrioma context

03Physical Exam/exam28

Vitals and general appearance

›Physiologic risk markers

›Tachycardia

›Pain severity correlation

›Hypotension

›Hemorrhage or sepsis alternative diagnosis consideration

›Fever

›PID or tubo-ovarian abscess consideration

›Clinical appearance

›Distress level

›Analgesia adequacy assessment

›Volume status

›Dehydration from vomiting

Abdominal and pelvic exam

›Abdominal findings

›Lower abdominal tenderness

›Unilateral predominance

›Guarding or rigidity

›Peritonitis escalation

›Rebound tenderness

›Alternative surgical abdomen consideration

›Pelvic exam considerations

›Adnexal tenderness

›Focal unilateral tenderness

›Adnexal mass

›Size and mobility impression

›Cervical motion tenderness

›PID alternative diagnosis consideration

›Vaginal discharge

›Infectious alternative diagnosis consideration

04Differential Diagnosis/ddx34

Life threatening and time sensitive

›Gynecologic emergencies

›Ectopic pregnancy

›ICD-10 O00

›Hemorrhagic ovarian cyst with hemoperitoneum

›ICD-10 N83.2 with complication coding as applicable

›Tubo-ovarian abscess

›ICD-10 N70.93

›Septic abortion

›ICD-10 O03.3

›Non-gynecologic emergencies

›Appendicitis

›ICD-10 K35

›Ureteral stone with obstruction

›ICD-10 N20.1

›Bowel obstruction or ischemia

›ICD-10 K56

›Ruptured abdominal aortic aneurysm

›ICD-10 I71.3

Common mimics

›Gynecologic mimics

›Pelvic inflammatory disease

›ICD-10 N73

›Degenerating fibroid

›ICD-10 D25

›Endometriosis flare

›ICD-10 N80

›Gastrointestinal and urinary mimics

›Gastroenteritis

›ICD-10 A09

›Constipation

›ICD-10 K59.0

›Urinary tract infection

›ICD-10 N39.0

›Pyelonephritis

›ICD-10 N10

05Laboratory Tests/lt24

Core labs

›Baseline evaluation set

›Urine or serum beta hCG

›Pregnancy status determination

›If positive, ectopic risk pathway

›Complete blood count

›Leukocytosis nonspecific

›Anemia for hemorrhage alternative diagnosis consideration

›Electrolytes and creatinine

›Dehydration and vomiting effects

›Contrast imaging readiness if needed

›Urinalysis

›Hematuria

›Urolithiasis alternative diagnosis consideration

›Pyuria or nitrites

›UTI alternative diagnosis consideration

Targeted labs

›Infection and inflammation

›If fever or PID concern, cervical or vaginal NAAT testing

›Gonorrhea and chlamydia testing

›If sepsis concern, blood cultures before antibiotics

›Two sets from separate sites

›Metabolic and perfusion markers

›If shock or ischemia concern, lactate mmol/L

›Elevated value supports severe physiology

›Normal value does not exclude torsion

06Diagnostic Tests/dt47

Scoring Systems

›Clinical decision support

›No widely validated ED scoring system for ovarian torsion

›Imaging and clinical judgment combined approach

›High suspicion features

›Acute unilateral pelvic pain with vomiting

›Known adnexal mass

›Pregnancy or fertility treatment context

MRI

›MRI pelvis role

›Indications

›Nondiagnostic ultrasound with persistent suspicion

›Pregnancy when ultrasound equivocal and MRI available without delay

›Typical findings

›Enlarged ovary with stromal edema

›Twisted vascular pedicle sign

›Limitations

›Time and access constraints in emergencies

›Surgical diagnosis remains definitive

›CT abdomen and pelvis role

›Indications

›Broad abdominal differential with unclear source

›Concern for appendicitis or alternate surgical abdomen

›Typical findings

›Enlarged ovary or adnexal mass

›Peripheral follicles and stromal edema

›Uterine deviation toward affected side

›Diagnostic performance notes

›Reported high sensitivity with secondary findings in some studies

›Normal CT without secondary findings reduces likelihood but does not fully exclude

›Radiation considerations

›Pregnancy shared decision pathway for CT

Ultrasound

›Ultrasound first line

›Approach

›Transvaginal ultrasound preferred when feasible

›Transabdominal ultrasound for pediatrics or when transvaginal not feasible

›Gray scale findings

›Enlarged ovary

›Peripheral follicles

›Ovarian stromal edema

›Free pelvic fluid

›Twisted pedicle whirlpool sign

›Doppler findings limitations

›Normal arterial flow does not exclude torsion

›Venous flow compromise often earlier than arterial

›Diagnostic performance notes

›Reported ultrasound sensitivity approximately 0.79 and specificity approximately 0.76 in meta-analysis

›Reported sonography sensitivity 72.1% and specificity 99.6% in a study population

›Reported sensitivity range broad in ED focused reviews

07Disposition/dispo17

Operative management pathway

›Admission and OR criteria

›Suspected torsion

›Operating room for diagnostic laparoscopy

›NPO status and perioperative preparation

›Persistent severe unilateral pelvic pain with nondiagnostic imaging

›Gynecology decision for diagnostic laparoscopy acceptable outcome

›Level of care

›Postoperative stable

›Ward admission per gynecology

›Hemodynamic instability or sepsis physiology

›ICU or monitored bed

Discharge considerations

›ED discharge uncommon

›Alternative diagnosis established

›Pain controlled on oral regimen

›Reliable follow up arranged

›Negative laparoscopy or resolved symptoms per specialist plan

›Clear return precautions

08Treatment/t50

Symptom control and stabilization

›Analgesia

›Opioid pathway

›Morphine IV 0.05-0.1 mg/kg

›Repeat q10-15 minutes to effect

›Monitor respiratory rate and oxygen saturation

›Hydromorphone IV 0.5-1 mg adult typical

›Repeat q15 minutes to effect

›Caution with opioid naive patients

›NSAID pathway

›Ketorolac IV 15-30 mg

›Avoid in third trimester pregnancy

›Avoid in renal failure or GI bleeding risk

›Antiemetics

›Ondansetron IV 4 mg

›Repeat 4 mg once if needed

›QT prolongation risk awareness

›Metoclopramide IV 10 mg

›Akathisia risk mitigation plan

›Fluids

›Isotonic crystalloid

›If dehydration, 10-20 ml/kg bolus

›Reassess after each bolus

Definitive management

›Surgical management principles

›Diagnostic laparoscopy

›Surgical diagnosis confirmation

›Time priority when suspicion high

›Detorsion and ovarian preservation

›Detorsion recommended even with concerning gross appearance

›Reperfusion expected after detorsion in many cases

›Cyst management

›Cystectomy or cyst drainage per surgeon judgment

›Avoid unnecessary trauma when ovary edematous

›Oophorectomy

›Avoid unless unavoidable

›Example scenario severely necrotic tissue falling apart

Antibiotics and adjuncts

›Antibiotics

›If PID or tubo-ovarian abscess suspected, empiric broad spectrum regimen per local protocol

›Coverage for gonorrhea, chlamydia, anaerobes

›Blood cultures if sepsis physiology

›VTE prophylaxis

›Postoperative prophylaxis per surgical protocol

›Mechanical prophylaxis common

›Pharmacologic prophylaxis individualized

Evidence and recommendation levels

›Evidence framing

›Timely diagnostic laparoscopy for suspected torsion recommended by professional society guidance

›Preservation of ovarian function and fertility rationale

›Ultrasound cannot reliably rule out torsion

›ACEP Level C style recommendation for risk of false negative imaging

›Urgent surgical intervention for suspected torsion

›Class I recommendation style framing based on time dependent organ salvage

09Special Populations/sp27

Pregnancy

›Pregnancy specific considerations

›Incidence estimate

›Approximately 1-5 per 10,000 pregnancies reported

›Common timing

›First trimester and early second trimester association with corpus luteum and adnexal masses

›Imaging approach

›Ultrasound first line

›MRI option when ultrasound equivocal and MRI available without delay

›Medication safety

›Avoid NSAIDs in third trimester

›Opioid use lowest effective dose with monitoring

Geriatric

›Older adult considerations

›Malignancy risk

›Adnexal mass evaluation escalated suspicion

›Atypical presentation

›Less specific pain description possible

›Comorbidity impact

›Higher perioperative risk assessment needs

Pediatrics

›Pediatric considerations

›Transabdominal ultrasound common

›Bladder filling optimization when feasible

›Clinical features

›Abdominal pain with vomiting common pattern

›Ovarian preservation priority

›Detorsion and salvage emphasized

›Child protection sensitive approach

›Chaperone and age appropriate communication

10Background/b28

Epidemiology

›Burden and context

›Gynecologic emergency proportion

›Torsion represents a notable cause of acute pelvic pain requiring surgery

›Pregnancy incidence

›Approximately 1-5 per 10,000 pregnancies reported

›Risk distribution

›Increased risk with enlarged ovaries or adnexal masses

›Increased risk with fertility treatments and ovarian stimulation

Pathophysiology

›Mechanism

›Twisting of adnexa

›Ovary alone or ovary with fallopian tube

›Vascular compromise sequence

›Venous and lymphatic obstruction leading to edema

›Arterial compromise leading to ischemia and infarction

›Clinical consequence

›Time dependent loss of ovarian function

›Necrosis and peritonitis risk if prolonged

Therapeutic Considerations

›Rationale for urgency

›Salvage probability declines with duration of torsion

›Early operative intervention prioritization

›Imaging limitations

›Doppler arterial flow may persist due to dual blood supply

›Normal Doppler flow does not exclude torsion

›Preservation approach

›Detorsion favored

›Fertility preservation emphasis

›Avoidance of routine oophorectomy

›Necrotic appearance alone not definitive for nonviability

11Patient Discharge Instructions/pdi16

copy discharge instructions

›Discharge instructions set

›Diagnosis and expectations

›Explanation of evaluation results and working diagnosis

›Pain control plan and medication safety

›Return to ED now

›Worsening pelvic or abdominal pain

›Persistent vomiting or inability to keep fluids down

›Fever or chills

›Fainting, severe weakness, or new shortness of breath

›Heavy vaginal bleeding

›Follow up

›Gynecology follow up timing as directed

›Imaging follow up for ovarian cyst if recommended

›Activity and safety

›No driving after opioid use

›NPO instructions if returning for planned procedure

12References/r20

Clinical guidelines and society statements

›Professional guidance

›ACOG Committee Opinion Adnexal Torsion in Adolescents

›Timely intervention with diagnostic laparoscopy when torsion suspected

›Minimally invasive approach with detorsion and ovarian preservation

›Merck Manual professional Adnexal torsion

›Immediate laparoscopy when suspected to salvage adnexa

Evidence based sources

›Imaging performance literature

›Meta-analysis of imaging accuracy for adnexal torsion

›Ultrasound pooled sensitivity approximately 0.79

›Ultrasound pooled specificity approximately 0.76

›Sonography diagnostic efficacy study

›Sonography sensitivity 72.1%

›Sonography specificity 99.6%

›CT case-control diagnostic study

›CT sensitivity 90-100% reported in study readers

›CT specificity 85-90% reported in study readers

›Emergency medicine review

›Ovarian torsion in the emergency department setting review

›Ultrasound sensitivity reported variable

›Ultrasound not used to rule out torsion in isolation

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Reviewed by SymptomDx Medical Team · Last reviewed June 16, 2026

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