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What many of us were taught about ovarian torsion is either slightly wrong or really wrong. Matt Delaney dives deep and busts some torsion myths.
In a rather perverse statistical anomaly, i saw 2 patients with ovarian torsion within 48 hours of listening to this. This gets me to a career total of 4 episodes that i actually diagnosed. Anecdotally, the most striking characteristics of these cases was the intractable nature of the pain, High doses of narcotics were requied in each.
I feel a questionable logical conclusion was made in regards to imaging. Dr. Delaney rightly notes the frustratingly poor sensitivity of both CT and ultrasound in definitively identifying torsion. He points out the somewhat surprising fact that CT apparently has similar numbers to ultrasound. However I feel a mistake was made when he concludes that since they have similar sensitivities, if a CT has been performed and negative, pursuing an ultrasound is unnecessary.
If I were looking to identify all females in a group of people using two tests, one of which was looking for all those with long hair and the other was looking for all those wearing bras, although these two tests may have similar less than 100% sensitivities, the cases in which they fail to identify a person as female won't all be the same. So a woman may have short hair and therefore not be identified by the first test, but if I applied the second test and she's found to be wearing a bra, we have made our diagnosis so to speak.
So assuming an ultrasound won't identify a torsion simply because the CT didn't is a bridge too far for me. Not to mention that asking OB to admit for observation a potential occult torsion without getting a pelvic ultrasound (or conversely without getting a CT to rule out alternative non-OB cause like appendicitis) just wouldn't fly.
Josh,Good point. I think you bring up some interesting points involving the role of CT and US. If these two tests were looking for truly different findings, then I agree the overall sensitivity of these two tests together would be higher, but its not clear to me how different these tests actually are in practice. In reality the vast majority of patients who have torsion have underlying ovarian pathology (cysts,mass). Both CT and US seem like reasonable tests to identify the presence of underlying ovarian pathology. The incidence of torsion in patients with structurally normal seems to be extremely low. In my mind in a patient with undifferentiated abdominal pain and structurally normal ovaries I'm not sure that routinely adding an ultrasound would help us identify these extremely rare cases of torsion. Theoretically US could pick up a lack of doppler flow, which CT wouldn't see, but these cases seem to be extremely rare.I agree 100% if I'm worried enough about torsion to talk with OB, I'm happy to get the ultrasound, but in my practice these patients with negative studies and ongoing concern for torsion are pretty rare.
Hi Dr. DeLaney!
I am working on an M&M presentation for my residency program involving an ovarian torsion case. I was wondering what some of your sources were for the information you provided above?
This is a tough diagnosis. In addition to the EMRAP 5/2016 and 2/2023 episodes on ovarian torsion, this is a good 2015 podcast link of a pediatric gynecologist (Jennifer Dietrich) discussing torsion diagnosis/ treatmenthttps://podcasts.apple.com/gb/podcast/ovarian-torsion/id971122268?i=1000358596701
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