Ovarian torsion: Difference between revisions
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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.]]
*Rotation of the ovary around its vascular pedicle (infundibulopelvic and utero-ovarian ligaments)
[[File:Blausen 0732 PID-Sites.png|thumb|Pelvic anatomy.]]
*Compromises venous/lymphatic drainage first → edema → eventual arterial compromise → ischemia and necrosis
*Ovarian torsion is the rotation of the ovary and portion of the fallopian tube on the supplying vascular pedicle
*'''5th most common gynecologic emergency'''
*Referred to as adnexal torsion and tubo-ovarian torsion
*Accounts for ~3% of all gynecologic emergencies
*Occurs in females of all ages
*Most common in reproductive-age women (20-40 years)
**Most common in reproductive age adults
*Risk factors:
**In children, it is most common in 9-14 years of age
**Ovarian mass >5 cm (most common risk factor; dermoid cysts particularly prone)
**Risk factors:
**Ovarian hyperstimulation syndrome (fertility treatment)
***Ovarian mass
**Pregnancy (especially first trimester; corpus luteum cysts)
***Fertility treatments
**Prior tubal ligation (increases ovarian mobility)
*Ovarian cysts (usually > 4 cm) and neoplasms account for 94% of cases in adults<ref>Amirbekian S et al. Ultrasound Evaluation of Pelvic Pain. Radiol. Clin. North Am. 2014;52 (6): 1215-1235</ref>
**Long utero-ovarian ligament
*Torsion more common on the right, as the sigmoid colon tends to stabilize the left
*Right side more common than left (sigmoid colon may limit left ovarian mobility)
*In children, hypermobility of the ovary many be the primary cause of torsion
*Can occur in prepubertal girls (often without predisposing mass — normal ovary)
*Dual blood supply from ovarian and uterine arteries
 
===Pathophysiology===
Torsion occurs from either of two causes:
#Hypermobility of the ovary
#Adnexal mass
*Cysts greater than 4 cm are more likely to torse<ref>M.L. Brandt et al. Surgical indications in antenatally diagnosed ovarian cysts J Pediatr Surg, 26 (1991), pp. 276–282</ref>
*Absence of ovarian Doppler flow is highly specific for torsion, but normal Doppler flow does not completely exclude torsion


==Clinical Features==
==Clinical Features==
*[[Nausea/vomiting]] (70%)
*Sudden onset, severe, unilateral lower abdominal/pelvic pain (most common presentation)
*Sudden and sharp [[abdominal pain|pain]] in the lower abdomen (50%)<ref>Houry, D. and Abbott, J.T. Ovarian torsion: a fifteen-year review. Ann Emerg Med. 2001; 38: 156–159.</ref>
*Pain may be intermittent (intermittent torsion/detorsion)
**Can be intermittent and insiduous, especially in those with history of cysts, PCOS<ref>Damigos, E., Johns, J., and Ross, J. An update on the diagnosis and management of ovarian torsion. Obstet Gynaecol. 2012; 14: 229–236.</ref>
*Nausea and vomiting (present in 70% — may be prominent)
**Commonly occurs simultaneously with vomiting
*Low-grade [[fever]] (late finding suggesting necrosis)
**May occur for days to months intermittently before diagnosis is made<ref>Sasaki, K.J. and Miller, C.E. Adnexal torsion: review of the literature. J Minim Invasive Gynecol. 2014; 21: 196–202.</ref>
*Adnexal tenderness on bimanual exam; palpable adnexal mass in ~50%
*Up to 30% have no tenderness on bimanual exam<ref>Houry, D. and Abbott, J.T. Ovarian torsion: a fifteen-year review. Ann Emerg Med. 2001; 38: 156–159.</ref>
*May mimic [[appendicitis]], [[renal colic]], or [[ectopic pregnancy]]
*Most adults with ovarian torsion have abnormal or enlarged ovaries that serves as lead point for torsion, but torsion is more likely to occur in normal sized ovaries in pediatrics<ref>Anders, J.F. and Powell, E.C. Urgency and evaluation and outcome of acute ovarian torsion in pediatric patients. Arch Pediatr Adolesc Med. 2005; 159: 532–535.</ref>
*Peritoneal signs are late and suggest necrosis
**More than 50% of cases have no palpable adnexal mass<ref>Houry, D. and Abbott, J.T. Ovarian torsion: a fifteen-year review. Ann Emerg Med. 2001; 38: 156–159.</ref>
*In children: may present with non-specific abdominal pain
*[[Fever]] (<2%)
*Up to 20% of cases seen in pregnant women, with most in the 1st trimester and/or received fertility treatments<ref>Albayram, F. and Hamper, U.M. Ovarian and adnexal torsion: spectrum of sonographic findings with pathologic correlation. J Ultrasound Med. 2001; 20: 1083–1089.</ref>


==Differential Diagnosis==
==Differential Diagnosis==
*[[Ectopic pregnancy]] (always obtain pregnancy test first)
*Ruptured [[ovarian cyst]]
*[[Appendicitis]]
*[[Renal colic]] / [[nephrolithiasis]]
*[[Pelvic inflammatory disease]] / [[tubo-ovarian abscess]]
*[[Endometriosis]]
*[[Testicular torsion]] (analogous condition)
*Hemorrhagic corpus luteum
{{Pelvic pain DDX}}
{{Pelvic pain DDX}}
{{Abd DDX RLQ}}
{{LLQ DDX}}


==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.]]
*Urine pregnancy test (rule out [[ectopic pregnancy]])
[[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>]]
*CBC: leukocytosis may be present (nonspecific)
[[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>]]  
*Urinalysis: rule out [[UTI]], [[nephrolithiasis]]
===Doppler [[Ultrasound]]===
*Lactate: may be elevated in late presentations
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>
===Transvaginal Ultrasound (Test of Choice)===
**2/3 of patients with ovarian torsion have had normal blood flow
*Enlarged ovary (>4 cm) compared to contralateral side
**Venous and lymphatic obstruction occurs before arterial disruption, especially early in disease process<ref>Cicchiello, L.A., Hamper, U.M., and Scoutt, L.M. Ultrasound evaluation of gynecologic causes of pelvic pain. Ultrasound Clin. 2010; 38: 85–114.</ref>
*Ovarian edema (heterogeneous appearance)
**Abnormal blood flow, whether venous or arterial, is ~85% sensitive, ~37% specific when not combined with below findings<ref>Cicchiello, L.A., Hamper, U.M., and Scoutt, L.M. Ultrasound evaluation of gynecologic causes of pelvic pain. Ultrasound Clin. 2010; 38: 85–114.</ref>
*Peripherally displaced follicles ("string of pearls" sign)
*Enlarged ovarian volume
*Whirlpool sign on Doppler: twisted vascular pedicle (most specific finding)
**'''MC finding'''
*Free fluid in cul-de-sac
**''A maximum ovarian diameter (MOD) < 3cm in a postmenarchal patient is unlikely to represent ovarian'' torsion<ref>Budhram G, Elia T, Dan J, et al. A Case-Control Study of Sonographic Maximum Ovarian Diameter as a Predictor of Ovarian Torsion in Emergency Department Females With Pelvic Pain. Acad Emerg Med. 2019;26(2):152-159.</ref>
*Loss of echogenicity
*Peripherally displaced follicles with hyperechoic central stroma
*Midline ovary
*Pelvic free fluid
*An infarcted ovary may have a more complex appearance with cystic or hemorrhagic degeneration
*Whirlpool sign of twisted vascular pedicle may be seen but rare<ref name="Lee"></ref>


===CT Abd/Pelvis===
====Doppler Findings====
*CT has a low sensitivity for torsion
*Absent or decreased ovarian arterial/venous flow supports diagnosis
**Examine for asymmetric ovarian enlargement, which warrants a pelvic US if concerning symptoms exist<ref>Lourenco, A.P., Swenson, D., Tubbs, R.J. et al. Ovarian and tubal torsion: imaging findings on US, CT and MRI. Emerg Radiol. 2014; 21: 179–187.</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>
*CT may be used to rule out other possible causes of lower abdominal pain; also exclude presence of pelvic mass
**Sensitivity of absent flow is only ~50% — dual blood supply (ovarian and uterine arteries)
**Intermittent torsion may show normal flow between episodes
*If high clinical suspicion, proceed to OR despite normal Doppler
 
===CT Abdomen/Pelvis===
*May show enlarged ovary, fat stranding, deviation of uterus toward affected side
*Less sensitive than US for torsion but may identify alternative diagnoses
*"Ovarian mass with surrounding fat stranding" on CT should raise concern


==Management==
==Management==
*Emergent OB/GYN consult in ED
*Emergent gynecology consultation for operative intervention
**Consider if high suspicion exists even after equivocal US
*Time-sensitive — ovarian salvage rates decrease with prolonged ischemia
*Surgical detorsion is required to prevent ovarian necrosis
**Detorsion within 6 hours: high salvage rate
**If the ovary becomes necrotic, there is a high risk of infection
**Detorsion at 24-36 hours: viable ovary still possible
**Salvage rate may be high even if time is prolonged beyond several hours of symptoms<ref>Anders JF, Powell EC. Urgency of evaluation and outcome of acute ovarian torsion in pediatric patients. Arch Pediatr Adolesc Med. 2005;159:532–535</ref>
**'''Do not assume a black/dusky ovary is nonviable''' — most recover after detorsion
*Laparoscopic detorsion is procedure of choice (preserves fertility)
*Oophoropexy (fixation) may be performed to prevent recurrence
*Oophorectomy reserved for clearly necrotic tissue or suspected malignancy
*Supportive care in ED:
**IV fluids, antiemetics (ondansetron 4 mg IV)
**Pain control: ketorolac 15-30 mg IV and/or opioids
**NPO for OR preparation
 
==Disposition==
*Admit for emergent surgical intervention
*'''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


==See Also==
==See Also==
*[[Abdominal pain]]
*[[Ovarian cyst]]
 
*[[Ectopic pregnancy]]
==External Links==
*[[Testicular torsion]]
*[https://coreem.net/core/ovarian-torsion/ Core EM: Ovarian Torsion]
*[[Pelvic pain]]
*[[Appendicitis]]


==References==
==References==
<references/>
<references/>
*Huchon C, Fauconnier A. Adnexal torsion: a literature review. ''Eur J Obstet Gynecol Reprod Biol''. 2010;150(1):8-12. PMID 20189289
*Chang HC, et al. Pearls and pitfalls in diagnosis of ovarian torsion. ''Radiographics''. 2008;28(5):1355-1368. PMID 18794312
*Houry D, Abbott JT. Ovarian torsion: a fifteen-year review. ''Ann Emerg Med''. 2001;38(2):156-159. PMID 11468611
*Oelsner G, Shashar D. Adnexal torsion. ''Clin Obstet Gynecol''. 2006;49(3):459-463. PMID 16885652
[[Category:OBGYN]]
[[Category:OBGYN]]

Latest revision as of 09:35, 22 March 2026

Background

  • Rotation of the ovary around its vascular pedicle (infundibulopelvic and utero-ovarian ligaments)
  • Compromises venous/lymphatic drainage first → edema → eventual arterial compromise → ischemia and necrosis
  • 5th most common gynecologic emergency
  • Accounts for ~3% of all gynecologic emergencies
  • Most common in reproductive-age women (20-40 years)
  • Risk factors:
    • Ovarian mass >5 cm (most common risk factor; dermoid cysts particularly prone)
    • Ovarian hyperstimulation syndrome (fertility treatment)
    • Pregnancy (especially first trimester; corpus luteum cysts)
    • Prior tubal ligation (increases ovarian mobility)
    • Long utero-ovarian ligament
  • Right side more common than left (sigmoid colon may limit left ovarian mobility)
  • Can occur in prepubertal girls (often without predisposing mass — normal ovary)

Clinical Features

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

Differential Diagnosis

Acute Pelvic Pain

Differential diagnosis of acute pelvic pain

Gynecologic/Obstetric

Genitourinary

Gastrointestinal

Musculoskeletal

Vascular

Evaluation

  • Urine pregnancy test (rule out ectopic pregnancy)
  • CBC: leukocytosis may be present (nonspecific)
  • Urinalysis: rule out UTI, nephrolithiasis
  • Lactate: may be elevated in late presentations

Transvaginal Ultrasound (Test of Choice)

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

Doppler Findings

  • Absent or decreased ovarian arterial/venous flow supports diagnosis
  • HOWEVER: presence of Doppler flow does NOT exclude torsion[2]
    • Sensitivity of absent flow is only ~50% — dual blood supply (ovarian and uterine arteries)
    • Intermittent torsion may show normal flow between episodes
  • If high clinical suspicion, proceed to OR despite normal Doppler

CT Abdomen/Pelvis

  • May show enlarged ovary, fat stranding, deviation of uterus toward affected side
  • Less sensitive than US for torsion but may identify alternative diagnoses
  • "Ovarian mass with surrounding fat stranding" on CT should raise concern

Management

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

Disposition

  • Admit for emergent surgical intervention
  • 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

See Also

References

  1. ↑ Norris DL, Young JD. UTI. EM Clin N Am. 2008; 26:413-30.
  2. ↑ 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
  • Huchon C, Fauconnier A. Adnexal torsion: a literature review. Eur J Obstet Gynecol Reprod Biol. 2010;150(1):8-12. PMID 20189289
  • Chang HC, et al. Pearls and pitfalls in diagnosis of ovarian torsion. Radiographics. 2008;28(5):1355-1368. PMID 18794312
  • Houry D, Abbott JT. Ovarian torsion: a fifteen-year review. Ann Emerg Med. 2001;38(2):156-159. PMID 11468611
  • Oelsner G, Shashar D. Adnexal torsion. Clin Obstet Gynecol. 2006;49(3):459-463. PMID 16885652
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