Ovarian torsion: Difference between revisions

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==Background==
==Background==
*Ovarian torsion is the rotation of the ovary and portion of the fallopian tube on the supplying vascular pedicle. It is also referred to as adnexal torsion and tubo-ovarian torsion.
*Rotation of the ovary around its vascular pedicle (infundibulopelvic and utero-ovarian ligaments)
*Occurs in females of all ages
*Compromises venous/lymphatic drainage first → edema → eventual arterial compromise → ischemia and necrosis
**Most common in reproductive age adults
*'''5th most common gynecologic emergency'''
**In children: most common in 9-14 yrs old
*Accounts for ~3% of all gynecologic emergencies
*Ovarian cysts (usually > 4cm) 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> However in children they are only less common in children.
*Most common in reproductive-age women (20-40 years)
*Torsion more common on the right, sigmoid tends to stabilize the left
*Risk factors:
*In children hypermobility of the ovary many be the primary cause of torsion.
**Ovarian mass >5 cm (most common risk factor; dermoid cysts particularly prone)
*Dual blood supply from oarian and uterine arteries.
**Ovarian hyperstimulation syndrome (fertility treatment)
 
**Pregnancy (especially first trimester; corpus luteum cysts)
===Pathophysiology===
**Prior tubal ligation (increases ovarian mobility)
Torsion occurs from either of the two causes:
**Long utero-ovarian ligament
#Hypermobility of the ovary
*Right side more common than left (sigmoid colon may limit left ovarian mobility)
#Adnexal mass
*Can occur in prepubertal girls (often without predisposing mass — normal ovary)
*Cysts greater than 4cm 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 pain in the lower abdomen (59%)
*Pain may be intermittent (intermittent torsion/detorsion)
**Can be intermittent
*Nausea and vomiting (present in 70% — may be prominent)
**Commonly occurs simultaneously with vomiting
*Low-grade [[fever]] (late finding suggesting necrosis)
*[[Fever]] (<2%)
*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==
==Differential Diagnosis==
{{Abd DDX RLQ}}
*[[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


{{LLQ DDX}}
{{Pelvic pain DDX}}


==Diagnosis==
==Evaluation==
Although the gold standard is direct visualization in the operating room ultrasound is generally the first diagnostic test performed.  The ovary can torse intermittently so high clinical suspicion is need, especially in the setting of a negative ultrasound.
*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


===Pelvic exam===
===Transvaginal Ultrasound (Test of Choice)===
*May not have Adnexal TTP or adnexal mass.
*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


===[[Ultrasound]]===  
====Doppler Findings====
Findings suggestive of torsion may include:
*Absent or decreased ovarian arterial/venous flow supports diagnosis
*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>
*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>
**2/3 of patients with ovarian torsion have had normal blood flow.
**Sensitivity of absent flow is only ~50% — dual blood supply (ovarian and uterine arteries)
*Ovarian mass > 3 cm may be clue
**Intermittent torsion may show normal flow between episodes
*Enlarged ovarian volume
*If high clinical suspicion, proceed to OR despite normal Doppler
**'''MC finding'''
*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===
===CT Abdomen/Pelvis===
*CT will not diagnose torsion
*May show enlarged ovary, fat stranding, deviation of uterus toward affected side
*CT may be used to r/o other possible causes of lower abdominal pain; also exclude presence of pelvic mass
*Less sensitive than US for torsion but may identify alternative diagnoses
*"Ovarian mass with surrounding fat stranding" on CT should raise concern


==Treatment==
==Management==
*Emergent OB/GYN consult in ED
*Emergent gynecology consultation for operative intervention
**May consider if high suspicion despite negative US.
*Time-sensitive — ovarian salvage rates decrease with prolonged ischemia
*Surgical detorsion is required to prevent ovarian necrosis. If the ovary become necrotic there is a high risk of infection.
**Detorsion within 6 hours: high salvage rate
**Salvage rate may be high even if prolonged time <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>
**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==
==See Also==
*[[Abdominal pain]]
*[[Ovarian cyst]]
*[[Ectopic pregnancy]]
*[[Testicular torsion]]
*[[Pelvic pain]]
*[[Appendicitis]]


==References==
==References==
<references/>
<references/>
[[Category:OB/GYN]]
*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]]

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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