Comparative Analysis of Clinical and Ultrasound Features Distinguishing Ovarian Torsion From Ruptured or Hemorrhagic Ovarian Cysts

Ovarian torsion is a surgical emergency whose nonspecific presentation overlaps with ruptured or hemorrhagic ovarian cysts, complicating early diagnosis. This study presents clinical and ultrasound features that differentiate ovarian torsion from ruptured or hemorrhagic ovarian cysts in the emergency department setting.

We conducted a retrospective case-control study of females aged 14–45 years presenting to the VCU Medical Center ED between 2021-2024 with discharge diagnoses of surgically confirmed ovarian torsion versus ruptured/hemorrhagic cyst. Data were extracted from EPIC by trained research interns. Symptoms assessed included abdominal tenderness and nausea/vomiting. Data extraction from ED ultrasound included cyst size, presence of ovarian engorgement, free pelvic fluid, and Doppler quantification of blood flow to the ovary. Continuous variables were compared using t-tests, categorical variables using Fisher’s exact test. Odds ratios (ORs) with 95% confidence intervals and continuity correction were calculated for differentiating features. Significance was defined as P < 0.05. This study was reviewed and approved by the local IRB.

Ninety-two patients were identified for inclusion (n = 5 torsion, 87 cyst). Ovarian torsion patients were younger (mean 21 vs. 30 years, p < 0.05). Nausea/vomiting occurred in 100% of torsion vs. 45% of cyst cases (p = 0.022, OR = 13.5). Ovarian cyst size >5 cm (80% vs. 12%, p = 0.0016, OR = 31) and ovarian enlargement >5 cm (40% vs. 2%, p = 0.014, OR = 28) were significantly associated with torsion; abdominal tenderness (100% vs. 91%, p = 1), and presence of free pelvic fluid (20% vs. 47%, p = 0.37) were not significantly associated with ovarian torsion. Doppler flow abnormalities were not significantly different (20% vs. 0%, p = 0.054).

The presence of nausea/vomiting, ovarian cyst >5 cm, and ovarian enlargement of >5 cm on US were statistically significant features differentiating ovarian torsion from ruptured/hemorrhagic cyst in this cohort. These findings suggest that integrating select clinical and imaging features may improve early recognition of torsion and prompt timely surgical management. Future work could focus on developing a multifactorial clinical decision tool with high negative predictive value.