Ovarian Torsion — Urgent Diagnosis and Detorsion

Key Points

• Ovarian torsion is a surgical diagnosis and a time-sensitive threat to ovarian viability.
• Sudden unilateral pelvic pain with nausea or vomiting is a classic presentation, but pain can be intermittent.
• Pregnancy, ovarian cysts or masses, and fertility treatment increase risk, but torsion can occur without a mass.
• Transvaginal ultrasound with Doppler is the preferred initial imaging study in most adults.
• Normal arterial or venous Doppler flow does not exclude torsion because the ovary has dual blood supply and torsion may be intermittent.
• High clinical suspicion warrants urgent gynecologic consultation and operative evaluation.
• Detorsion with ovarian preservation is preferred whenever feasible, even when the ovary appears dark or ischemic.
• A positive pregnancy test does not rule out torsion and should not delay appropriate surgical consultation.

Algorithm

1. Assess hemodynamic stability, pain severity, pregnancy status, and peritoneal signs.
2. Obtain pregnancy testing, CBC and basic studies as clinically indicated, and provide analgesia and antiemetics.
3. Perform pelvic ultrasound with transvaginal Doppler when feasible without delaying emergency surgical care.
4. Look for ovarian enlargement, edema, peripheral follicles, mass, free fluid, twisted pedicle, and altered flow.
5. If the clinical picture is highly suspicious, contact gynecology urgently even when Doppler flow is preserved.
6. Keep the patient NPO and prepare for operative detorsion.
7. At surgery, detorse and preserve the ovary when feasible; address a causative cyst or mass according to surgical findings.
8. Arrange postoperative pathology, gynecologic follow-up, and counseling regarding recurrence when appropriate.

Clinical Synopsis & Reasoning

Ovarian torsion is a time-sensitive surgical emergency because twisting of the adnexal pedicle first impairs venous and lymphatic drainage and can progress to arterial compromise, hemorrhagic infarction, necrosis, and loss of ovarian function. The most common presentation is abrupt unilateral lower abdominal or pelvic pain, often severe and frequently accompanied by nausea and vomiting. Pain may be intermittent when the ovary twists and partially detorses, so transient improvement does not reliably exclude the diagnosis. Fever and marked peritoneal signs are later findings and should raise concern for necrosis or another complicated intra-abdominal process.

Risk increases when the ovary is enlarged by a benign cyst, teratoma, fertility treatment, or pregnancy, although torsion can occur in a normal ovary, particularly in younger patients. The right side may be encountered more often, which can make appendicitis a close mimic. Ectopic pregnancy, ruptured or hemorrhagic ovarian cyst, pelvic inflammatory disease, tubo-ovarian abscess, renal colic, appendicitis, and other surgical abdominal conditions must be considered in parallel. Pregnancy testing is therefore essential in reproductive-age patients, but a positive test does not exclude torsion.

Transvaginal ultrasound with Doppler is the preferred initial imaging test in most adults. Findings can include ovarian enlargement, peripheral follicles, stromal edema, free fluid, an adnexal mass, twisted vascular pedicle, and reduced or absent venous or arterial flow. The key limitation is that the ovary has dual blood supply and torsion can be intermittent. Normal or preserved Doppler flow therefore cannot safely exclude torsion when the history and morphology remain suspicious. The definitive diagnosis is surgical, and high clinical suspicion should lead to urgent gynecologic consultation rather than serial imaging delays.

Treatment Strategy & Disposition

Give analgesia, antiemetics, IV fluids when needed, and keep the patient NPO once torsion is a serious consideration. Consult gynecology early. The treatment is prompt laparoscopy or laparotomy with detorsion and preservation of the ovary whenever feasible. A dark, enlarged, or hemorrhagic-appearing ovary can recover after detorsion and should not automatically be removed based solely on intraoperative color. Contemporary practice favors ovarian conservation, particularly in reproductive-age patients, unless there is unavoidable tissue destruction or another compelling surgical indication.

Treat the lesion that promoted torsion when appropriate, often with cystectomy while preserving ovarian tissue. Oophoropexy can be considered in selected recurrent cases or anatomic situations, but it is not universally required after a first event. If torsion occurs during pregnancy, surgery is still indicated when suspicion is high because the risk of ovarian loss and maternal complications outweighs the risk of necessary operative management. Choice of surgical approach and perioperative fetal considerations depend on gestational age and local obstetric expertise.

Antibiotics are not routine therapy for uncomplicated torsion. They are used when a concurrent infection or necrotic complication warrants coverage. The ED should avoid delaying surgery for MRI or repeated ultrasound when the clinical picture is compelling. If the initial ultrasound is nondiagnostic but suspicion remains substantial, the correct next step is specialist reassessment and consideration of diagnostic laparoscopy, not reassurance based on preserved flow alone.

Epidemiology / Risk Factors

• Torsion is most common during reproductive years but can occur at any age.
• Benign ovarian masses are more commonly associated with torsion than malignant masses.
• Pregnancy and ovarian stimulation increase ovarian size and torsion risk.
• Recurrence can occur, particularly in patients with prior torsion or persistent anatomic risk factors.

Investigations

Pearls

Pharmacology

Prognosis / Complications

• Ovarian function is often preserved when detorsion is performed promptly.
• Even markedly ischemic-appearing ovaries may recover function after blood flow is restored.
• Delayed diagnosis increases the risk of necrosis, oophorectomy, infection, and loss of fertility potential.
• Pregnancy outcomes are generally favorable when necessary surgery is performed with appropriate obstetric care.
• Recurrent torsion may require discussion of preventive surgical strategies.

Patient Education / Counseling

• Explain that the operation is required because imaging cannot reliably determine whether the ovary is safely perfused.
• Reassure patients that the surgical goal is preservation of the ovary whenever possible.
• Advise prompt reevaluation for recurrent sudden unilateral pelvic pain, especially after a prior torsion.
• Discuss follow-up for any ovarian cyst or mass found during evaluation.
• Pregnant patients should understand that untreated torsion also carries meaningful maternal and ovarian risk.
• Patients undergoing fertility treatment should be counseled about increased torsion risk and early reporting of acute pelvic pain.

Notes

The most important diagnostic error in ovarian torsion is over-reassurance from preserved Doppler flow. Ultrasound is valuable because it can reveal ovarian enlargement, edema, a mass, and vascular abnormalities, but no single sonographic finding reliably excludes the disease. When the history is classic and the ovary is morphologically abnormal, the decision is whether operative evaluation is warranted, not whether the Doppler tracing looks normal enough to send the patient home.

Modern management emphasizes organ preservation. Historical practice sometimes removed ischemic-appearing ovaries because of concern about embolization or presumed nonviability. Current gynecologic practice favors detorsion and observation because ovarian function often returns even when the initial appearance is alarming.

References

1. ACOG Committee Opinion: Adnexal Torsion in Adolescents — Link