Ovarian Torsion

Ovarian torsion is the twisting of the ovary (often with the fallopian tube) causing vascular compromise. Prompt recognition and surgery are essential to preserve ovarian function and prevent necrosis.

Overview

A sudden rotation of the ovary around its ligamentous supports cuts off arterial inflow and venous outflow, leading to ischemia. It can occur at any age but is most common in reproductive‑age women with ovarian cysts or masses.

• Most often triggered by a cyst >5 cm
• Can be intermittent, causing recurrent pain
• Occurs in both sides, right side slightly more common

Key concepts

The torsion angle, duration of ischemia, and underlying lesion determine severity. Early detorsion may restore perfusion; prolonged torsion leads to necrosis and loss of ovarian tissue.

• Ischemia begins within minutes; irreversible damage after ~24 h
• Detorsion is attempted before oophorectomy when feasible
• Underlying mass often benign but malignancy must be excluded

Clinical relevance

Patients present with acute unilateral lower‑abdomen pain, often with nausea and vomiting. Physical exam may show a tender adnexal mass and absent ovarian blood flow on Doppler.

• Pain may be intermittent if torsion partially resolves
• Nausea/vomiting reflect peritoneal irritation
• Absence of fever helps differentiate from PID

Investigations

Imaging and labs guide diagnosis but should not delay surgery if clinical suspicion is high.

• Transvaginal/abdominal ultrasound with Doppler: Absent or markedly reduced flow suggests torsion; normal flow does not rule it out
• Serum β‑hCG: Positive test prompts consideration of ectopic pregnancy; negative supports torsion
• CBC, CRP: Mild leukocytosis is common; marked elevation suggests alternative diagnosis

Management

Immediate surgical detorsion (laparoscopy preferred) is the definitive treatment. Preserve the ovary when viable; remove necrotic tissue if necessary.

• If laparoscopy unavailable, perform open laparotomy
• Administer IV fluids and analgesia while awaiting OR
• Give broad‑spectrum antibiotics only if infection suspected

Often confused with

Conditions that mimic acute pelvic pain must be considered.

• Appendicitis (right lower quadrant pain)
• Ectopic pregnancy (positive β‑hCG, adnexal mass)
• Pelvic inflammatory disease (fever, discharge)

Where results can mislead

Certain findings may be falsely reassuring.

• Normal Doppler flow can occur with intermittent torsion
• Small cysts may be missed on ultrasound in obese patients

Exam pearls

Key points to remember for exams.

• Pain out of proportion to exam findings suggests torsion
• Urgent surgery is indicated even if imaging is equivocal
• Preserve ovarian tissue whenever possible

Questions an examiner may ask

• Explain the pathophysiology of ovarian torsion and why it causes acute pain.
• List the imaging findings that support the diagnosis and their limitations.
• Describe the surgical management steps and the rationale for ovarian preservation.

When to seek help

• Sudden severe pelvic pain with vomiting
• Persistent pain >6 hours despite analgesia
• Signs of peritoneal irritation (rebound, guarding)

Quick questions

Why is Doppler flow not 100% reliable?

Intermittent torsion may allow brief reperfusion, giving a false‑negative Doppler.

Can the ovary be saved after 24 hours?

Viability decreases sharply after 24 h, but detorsion is still attempted before removing the ovary.

Is prophylactic oophoropexy needed?

It is considered in recurrent torsion or when the ovary is otherwise healthy.