Ovarian torsion - Revision history

Danbot: Strip excess bold

2026-03-22T09:35:37Z

Strip excess bold

← Older revision		Revision as of 09:35, 22 March 2026
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	*'''5th most common gynecologic emergency'''		*'''5th most common gynecologic emergency'''
	*Accounts for ~3% of all gynecologic emergencies		*Accounts for ~3% of all gynecologic emergencies
	*Most common in ~~'''~~reproductive-age women (20-40 years)~~'''~~		*Most common in reproductive-age women (20-40 years)
	*Risk factors:		*Risk factors:
	**~~'''~~Ovarian mass >5 cm~~'''~~ (most common risk factor; dermoid cysts particularly prone)		**Ovarian mass >5 cm (most common risk factor; dermoid cysts particularly prone)
	**Ovarian hyperstimulation syndrome (fertility treatment)		**Ovarian hyperstimulation syndrome (fertility treatment)
	**~~'''~~Pregnancy~~'''~~ (especially first trimester; corpus luteum cysts)		**Pregnancy (especially first trimester; corpus luteum cysts)
	**Prior tubal ligation (increases ovarian mobility)		**Prior tubal ligation (increases ovarian mobility)
	**Long utero-ovarian ligament		**Long utero-ovarian ligament
	*~~'''~~Right side more common than left~~'''~~ (sigmoid colon may limit left ovarian mobility)		*Right side more common than left (sigmoid colon may limit left ovarian mobility)
	*Can occur in ~~'''~~prepubertal girls~~'''~~ (often without predisposing mass — normal ovary)		*Can occur in prepubertal girls (often without predisposing mass — normal ovary)

	==Clinical Features==		==Clinical Features==
	*~~'''~~Sudden onset, severe, unilateral lower abdominal/pelvic pain~~'''~~ (most common presentation)		*Sudden onset, severe, unilateral lower abdominal/pelvic pain (most common presentation)
	*Pain may be ~~'''~~intermittent~~'''~~ (intermittent torsion/detorsion)		*Pain may be intermittent (intermittent torsion/detorsion)
	*~~'''~~Nausea and vomiting~~'''~~ (present in 70% — may be prominent)		*Nausea and vomiting (present in 70% — may be prominent)
	*Low-grade [[fever]] (late finding suggesting necrosis)		*Low-grade [[fever]] (late finding suggesting necrosis)
	*Adnexal tenderness on bimanual exam; ~~'''~~palpable adnexal mass~~'''~~ in ~50%		*Adnexal tenderness on bimanual exam; palpable adnexal mass in ~50%
	*May mimic [[appendicitis]], [[renal colic]], or [[ectopic pregnancy]]		*May mimic [[appendicitis]], [[renal colic]], or [[ectopic pregnancy]]
	*~~'''~~Peritoneal signs are late~~'''~~ and suggest necrosis		*Peritoneal signs are late and suggest necrosis
	*In children: may present with non-specific abdominal pain		*In children: may present with non-specific abdominal pain

	==Differential Diagnosis==		==Differential Diagnosis==
	*[[Ectopic pregnancy]] (~~'''~~always obtain pregnancy test first~~'''~~)		*[[Ectopic pregnancy]] (always obtain pregnancy test first)
	*Ruptured [[ovarian cyst]]		*Ruptured [[ovarian cyst]]
	*[[Appendicitis]]		*[[Appendicitis]]
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	==Evaluation==		==Evaluation==
	*~~'''~~Urine pregnancy test~~'''~~ (rule out [[ectopic pregnancy]])		*Urine pregnancy test (rule out [[ectopic pregnancy]])
	*~~'''~~CBC~~'''~~: leukocytosis may be present (nonspecific)		*CBC: leukocytosis may be present (nonspecific)
	*~~'''~~Urinalysis~~'''~~: rule out [[UTI]], [[nephrolithiasis]]		*Urinalysis: rule out [[UTI]], [[nephrolithiasis]]
	*~~'''~~Lactate~~'''~~: may be elevated in late presentations		*Lactate: may be elevated in late presentations

	===Transvaginal Ultrasound (Test of Choice)===		===Transvaginal Ultrasound (Test of Choice)===
	*~~'''~~Enlarged ovary~~'''~~ (>4 cm) compared to contralateral side		*Enlarged ovary (>4 cm) compared to contralateral side
	*~~'''~~Ovarian edema~~'''~~ (heterogeneous appearance)		*Ovarian edema (heterogeneous appearance)
	*~~'''~~Peripherally displaced follicles~~'''~~ ("string of pearls" sign)		*Peripherally displaced follicles ("string of pearls" sign)
	*~~'''~~Whirlpool sign~~'''~~ on Doppler: twisted vascular pedicle (most specific finding)		*Whirlpool sign on Doppler: twisted vascular pedicle (most specific finding)
	*~~'''~~Free fluid~~'''~~ in cul-de-sac		*Free fluid in cul-de-sac

	====Doppler Findings====		====Doppler Findings====
	*~~'''~~Absent or decreased ovarian arterial/venous flow~~'''~~ supports diagnosis		*Absent or decreased ovarian arterial/venous flow supports diagnosis
	*~~'''~~HOWEVER: presence of Doppler flow does NOT exclude torsion~~'''~~<ref>Shadinger LL, et al. Surgically treated adnexal torsion: does the presence of doppler flow predict viability? ''J Ultrasound Med''. 2008;27(5):687-691. PMID 18424640</ref>		*HOWEVER: presence of Doppler flow does NOT exclude torsion<ref>Shadinger LL, et al. Surgically treated adnexal torsion: does the presence of doppler flow predict viability? ''J Ultrasound Med''. 2008;27(5):687-691. PMID 18424640</ref>
	**~~'''~~Sensitivity of absent flow is only ~50%~~'''~~ — dual blood supply (ovarian and uterine arteries)		**Sensitivity of absent flow is only ~50% — dual blood supply (ovarian and uterine arteries)
	**Intermittent torsion may show normal flow between episodes		**Intermittent torsion may show normal flow between episodes
	*If high clinical suspicion, proceed to OR despite normal Doppler		*If high clinical suspicion, proceed to OR despite normal Doppler
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	*May show enlarged ovary, fat stranding, deviation of uterus toward affected side		*May show enlarged ovary, fat stranding, deviation of uterus toward affected side
	*Less sensitive than US for torsion but may identify alternative diagnoses		*Less sensitive than US for torsion but may identify alternative diagnoses
	*~~'''~~"Ovarian mass with surrounding fat stranding"~~'''~~ on CT should raise concern		*"Ovarian mass with surrounding fat stranding" on CT should raise concern

	==Management==		==Management==
	*~~'''~~Emergent gynecology consultation for operative intervention~~'''~~		*Emergent gynecology consultation for operative intervention
	*~~'''~~Time-sensitive~~'''~~ — ovarian salvage rates decrease with prolonged ischemia		*Time-sensitive — ovarian salvage rates decrease with prolonged ischemia
	**Detorsion within ~~'''~~6 hours~~'''~~: high salvage rate		**Detorsion within 6 hours: high salvage rate
	**Detorsion at ~~'''~~24-36 hours~~'''~~: viable ovary still possible		**Detorsion at 24-36 hours: viable ovary still possible
	**'''Do not assume a black/dusky ovary is nonviable''' — most recover after detorsion		**'''Do not assume a black/dusky ovary is nonviable''' — most recover after detorsion
	*~~'''~~Laparoscopic detorsion~~'''~~ is procedure of choice (preserves fertility)		*Laparoscopic detorsion is procedure of choice (preserves fertility)
	*Oophoropexy (fixation) may be performed to prevent recurrence		*Oophoropexy (fixation) may be performed to prevent recurrence
	*Oophorectomy reserved for clearly necrotic tissue or suspected malignancy		*Oophorectomy reserved for clearly necrotic tissue or suspected malignancy
	*~~'''~~Supportive care~~'''~~ in ED:		*Supportive care in ED:
	**IV fluids, antiemetics (ondansetron 4 mg IV)		**IV fluids, antiemetics (ondansetron 4 mg IV)
	**Pain control: ~~'''~~ketorolac 15-30 mg IV~~'''~~ and/or ~~'''~~opioids~~'''~~		**Pain control: ketorolac 15-30 mg IV and/or opioids
	**NPO for OR preparation		**NPO for OR preparation

	==Disposition==		==Disposition==
	*~~'''~~Admit for emergent surgical intervention~~'''~~		*Admit for emergent surgical intervention
	*'''Do NOT delay surgery for additional imaging''' if clinical suspicion is high		*'''Do NOT delay surgery for additional imaging''' if clinical suspicion is high
	*Consult gynecology early — even if US is equivocal, operative evaluation may be warranted		*Consult gynecology early — even if US is equivocal, operative evaluation may be warranted

Danbot: Major update: added Disposition section, whirlpool sign, Doppler limitations (50% sensitivity), salvage rates by time, do not assume nonviable, string of pearls sign, references with PMIDs

2026-03-21T19:43:40Z

Major update: added Disposition section, whirlpool sign, Doppler limitations (50% sensitivity), salvage rates by time, do not assume nonviable, string of pearls sign, references with PMIDs

Show changes

Rossdonaldson1 at 20:51, 11 December 2024

2024-12-11T20:51:16Z

← Older revision		Revision as of 20:51, 11 December 2024
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	==Background==		==Background==
	[[File:Gray1170.png\|thumb\|Arteries of the female reproductive tract: uterine artery, ovarian artery and vaginal arteries. Ovary and ovarian artery visible in upper right.]]		[[File:Gray1170.png\|thumb\|Arteries of the female reproductive tract: uterine artery, ovarian artery and vaginal arteries. Ovary and ovarian artery visible in upper right.]]
	[[File:Blausen 0732 PID-Sites.png\|thumb\|~~Pelvic~~ anatomy.]]		[[File:Blausen 0732 PID-Sites.png\|thumb\|Female pelvic anatomy.]]
	*Ovarian torsion is the rotation of the ovary and portion of the fallopian tube on the supplying vascular pedicle		*Ovarian torsion is the rotation of the ovary and portion of the fallopian tube on the supplying vascular pedicle
	*Referred to as adnexal torsion and tubo-ovarian torsion		*Referred to as adnexal torsion and tubo-ovarian torsion

Rossdonaldson1: /* Evaluation */

2023-05-03T16:46:12Z

Evaluation

← Older revision		Revision as of 16:46, 3 May 2023
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	==Evaluation==		==Evaluation==
	[[File:PMC4603210 usg-15013-f10.png\|thumb\|Gray-scale (A) and power Doppler (B) sonograms show the swirling of the ovarian vascular pedicle, the “whirlpool sign,” in a case of ovarian torsion.]]		[[File:PMC4603210 usg-15013-f10.png\|thumb\|Gray-scale (A) and power Doppler (B) sonograms show the swirling of the ovarian vascular pedicle, the “whirlpool sign,” in a case of ovarian torsion.]]
	[[File:PMC4899704 ~~gr2b~~.png\|thumb\|Contrast-enhanced CT axial image shows thickened right adnexa (thick arrow) interposed between the cystic lesion (thin arrow) and uterus (Ut) which raised suspicion of adnexal torsion.<ref>Ghonge NP, Lall C, Aggarwal B, Bhargava P - Radiology case reports (2015). The MRI whirlpool sign in the diagnosis of ovarian torsion.</ref>]]		[[File:PMC4899704 gr2.png\|thumb\|Contrast-enhanced CT axial image shows thickened right adnexa (thick arrow) interposed between the cystic lesion (thin arrow) and uterus (Ut) which raised suspicion of adnexal torsion.<ref>Ghonge NP, Lall C, Aggarwal B, Bhargava P - Radiology case reports (2015). The MRI whirlpool sign in the diagnosis of ovarian torsion.</ref>]]
	[[File:PMC4899704 gr3b.png\|thumb\|Sagittal MR image showing "whirlpool appearance" of the right adnexa (thick arrow) suggestive of ovarian torsion. Right ovarian cystic mass is also seen (thin arrow). MRI is not typically first line imaging for ovarian torsion.<ref>Ghonge NP, Lall C, Aggarwal B, Bhargava P - Radiology case reports (2015). The MRI whirlpool sign in the diagnosis of ovarian torsion.</ref>]]		[[File:PMC4899704 gr3b.png\|thumb\|Sagittal MR image showing "whirlpool appearance" of the right adnexa (thick arrow) suggestive of ovarian torsion. Right ovarian cystic mass is also seen (thin arrow). MRI is not typically first line imaging for ovarian torsion.<ref>Ghonge NP, Lall C, Aggarwal B, Bhargava P - Radiology case reports (2015). The MRI whirlpool sign in the diagnosis of ovarian torsion.</ref>]]
	===Doppler [[Ultrasound]]===		===Doppler [[Ultrasound]]===

Rossdonaldson1: /* Evaluation */

2023-05-03T16:45:42Z

Evaluation

← Older revision		Revision as of 16:45, 3 May 2023
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	==Evaluation==		==Evaluation==
	[[File:PMC4603210 usg-15013-f10.png\|thumb\|Gray-scale (A) and power Doppler (B) sonograms show the swirling of the ovarian vascular pedicle, the “whirlpool sign,” in a case of ovarian torsion.]]		[[File:PMC4603210 usg-15013-f10.png\|thumb\|Gray-scale (A) and power Doppler (B) sonograms show the swirling of the ovarian vascular pedicle, the “whirlpool sign,” in a case of ovarian torsion.]]
			[[File:PMC4899704 gr2b.png\|thumb\|Contrast-enhanced CT axial image shows thickened right adnexa (thick arrow) interposed between the cystic lesion (thin arrow) and uterus (Ut) which raised suspicion of adnexal torsion.<ref>Ghonge NP, Lall C, Aggarwal B, Bhargava P - Radiology case reports (2015). The MRI whirlpool sign in the diagnosis of ovarian torsion.</ref>]]
	[[File:PMC4899704 gr3b.png\|thumb\|Sagittal MR image showing "whirlpool appearance" of the right adnexa (thick arrow) suggestive of ovarian torsion. Right ovarian cystic mass is also seen (thin arrow). MRI is not typically first line imaging for ovarian torsion.<ref>Ghonge NP, Lall C, Aggarwal B, Bhargava P - Radiology case reports (2015). The MRI whirlpool sign in the diagnosis of ovarian torsion.</ref>]]		[[File:PMC4899704 gr3b.png\|thumb\|Sagittal MR image showing "whirlpool appearance" of the right adnexa (thick arrow) suggestive of ovarian torsion. Right ovarian cystic mass is also seen (thin arrow). MRI is not typically first line imaging for ovarian torsion.<ref>Ghonge NP, Lall C, Aggarwal B, Bhargava P - Radiology case reports (2015). The MRI whirlpool sign in the diagnosis of ovarian torsion.</ref>]]
	===Doppler [[Ultrasound]]===		===Doppler [[Ultrasound]]===

Rossdonaldson1: /* Evaluation */

2023-05-03T16:37:39Z

Evaluation

← Older revision		Revision as of 16:37, 3 May 2023
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	==Evaluation==		==Evaluation==
	[[File:PMC4603210 usg-15013-f10.png\|thumb\|Gray-scale (A) and power Doppler (B) sonograms show the swirling of the ovarian vascular pedicle, the “whirlpool sign,” in a case of ovarian torsion.]]		[[File:PMC4603210 usg-15013-f10.png\|thumb\|Gray-scale (A) and power Doppler (B) sonograms show the swirling of the ovarian vascular pedicle, the “whirlpool sign,” in a case of ovarian torsion.]]
	[[~~The MRI whirlpool sign in the diagnosis of ovarian torsion~~.		[[File:PMC4899704 gr3b.png\|thumb\|Sagittal MR image showing "whirlpool appearance" of the right adnexa (thick arrow) suggestive of ovarian torsion. Right ovarian cystic mass is also seen (thin arrow). MRI is not typically first line imaging for ovarian torsion.<ref>Ghonge NP, Lall C, Aggarwal B, Bhargava P - Radiology case reports (2015). The MRI whirlpool sign in the diagnosis of ovarian torsion.</ref>]]
	~~Ghonge NP, Lall C, Aggarwal B, Bhargava P - Radiology case reports (2015)~~\|thumb\|~~18-year-old female with ovarian torsion. T2-weighted, sagittal~~ MR image showing "whirlpool appearance" of the right adnexa (thick arrow) suggestive of ovarian torsion. Right ovarian cystic mass is also seen (thin arrow). MRI is not typically first line imaging for ovarian torsion.]]
	===Doppler [[Ultrasound]]===		===Doppler [[Ultrasound]]===
	Findings suggestive of torsion may include:		Findings suggestive of torsion may include:

Rossdonaldson1: /* Differential Diagnosis */

2023-05-03T16:33:08Z

Differential Diagnosis

← Older revision		Revision as of 16:33, 3 May 2023
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	==Differential Diagnosis==		==Differential Diagnosis==
			{{Pelvic pain DDX}}
	{{Abd DDX RLQ}}		{{Abd DDX RLQ}}

	{{LLQ DDX}}		{{LLQ DDX}}

Rossdonaldson1: /* Evaluation */

2021-12-02T19:05:35Z

Evaluation

← Older revision		Revision as of 19:05, 2 December 2021
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	==Evaluation==		==Evaluation==
			[[File:PMC4603210 usg-15013-f10.png\|thumb\|Gray-scale (A) and power Doppler (B) sonograms show the swirling of the ovarian vascular pedicle, the “whirlpool sign,” in a case of ovarian torsion.]]
			[[The MRI whirlpool sign in the diagnosis of ovarian torsion.
			Ghonge NP, Lall C, Aggarwal B, Bhargava P - Radiology case reports (2015)\|thumb\|18-year-old female with ovarian torsion. T2-weighted, sagittal MR image showing "whirlpool appearance" of the right adnexa (thick arrow) suggestive of ovarian torsion. Right ovarian cystic mass is also seen (thin arrow). MRI is not typically first line imaging for ovarian torsion.]]
	===Doppler [[Ultrasound]]===		===Doppler [[Ultrasound]]===
	~~[[File:PMC4603210 usg-15013-f10.png\|thumb\|Gray-scale (A) and power Doppler (B) sonograms show the swirling of the ovarian vascular pedicle, the “whirlpool sign,” in a case of ovarian torsion.]]~~
	Findings suggestive of torsion may include:		Findings suggestive of torsion may include:
	*Diminished or absent blood flow in the ovarian vessels<ref name="Lee">Lee EJ et-al. Diagnosis of ovarian torsion with color Doppler sonography: depiction of twisted vascular pedicle. J Ultrasound Med. 1998;17 (2): 83-9.</ref>		*Diminished or absent blood flow in the ovarian vessels<ref name="Lee">Lee EJ et-al. Diagnosis of ovarian torsion with color Doppler sonography: depiction of twisted vascular pedicle. J Ultrasound Med. 1998;17 (2): 83-9.</ref>

Rossdonaldson1: /* Background */

2021-12-02T19:02:58Z

Background

← Older revision		Revision as of 19:02, 2 December 2021
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	==Background==		==Background==
			[[File:Gray1170.png\|thumb\|Arteries of the female reproductive tract: uterine artery, ovarian artery and vaginal arteries. Ovary and ovarian artery visible in upper right.]]
	[[File:Blausen 0732 PID-Sites.png\|thumb\|Pelvic anatomy.]]		[[File:Blausen 0732 PID-Sites.png\|thumb\|Pelvic anatomy.]]
	*Ovarian torsion is the rotation of the ovary and portion of the fallopian tube on the supplying vascular pedicle		*Ovarian torsion is the rotation of the ovary and portion of the fallopian tube on the supplying vascular pedicle

Elcatracho: /* See Also */

2021-03-06T12:10:11Z

← Older revision		Revision as of 12:10, 6 March 2021
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	==See Also==		==See Also==
	*[[Abdominal pain]]		*[[Abdominal pain]]

			==External Links==
			*[https://coreem.net/core/ovarian-torsion/ Core EM: Ovarian Torsion]

	==References==		==References==
	<references/>		<references/>
	[[Category:OBGYN]]		[[Category:OBGYN]]