Ovarian Torsion

OVARIAN TORSION
Background
1. Definition: Ovarian Torsion: torsion of ovarian pedicle leading to vascular flow
obstruction.
2. General Information
o Commonly associated with cysts or tumors - usually benign1
o Clinical presentation can be non-specific; can lead to diagnosis and definitive
treatment delay
Pathophysiology
1. Pathology of Disease: in affected ovary, venous and lymphatic outflow becomes
compromised due to torsion of suspensory ligament pedicle.
o Can lead to edema, increased pressure in ovary, ischemia and infarction.
o Incomplete torsion leads to lymphatic obstruction and ovarian edema1
2. Incidence, Prevalence
o 3% of gynecologic surgical emergencies
o 80% occur in reproductive aged women
o >90% related to cysts and neoplasms2
o 10-20% associated with early pregnancy (6-14 weeks)
o Right ovary more commonly affected
3. Risk Factors:
o Patient age - may limit possible causes
o Anatomic:
Malformed or elongated fallopian tubes
Pregnancy, secondary to combination of enlarged corpus luteum cyst and
ovarian supporting tissue laxity 1
o Medical:
Early pregnancy due to progesterone stimulation
Ovarian tumors
Ovarian cysts
Ectopic pregnancy
Hydrosalpinx
o Iatrogenic:
Pelvic surgery (ex: tubal ligation) increases adhesion risk
Increased cysts from ovulation induction for infertility treatment (ovarian
hyper-stimulation syndrome)
4. Morbidity / Mortality: infection, peritonitis, sepsis, adhesions, chronic pain, infertility,
death rare.
Diagnostics
1. History:
o Sudden onset of severe, sharp, stabbing abdominal pain
o Often unilateral; worsens over hours.
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o Pain radiates to back, pelvis, or thighs.
o Associated symptoms: nausea, vomiting, fever
o History of ovarian or fallopian tube disease, prior ovarian torsion, prior pelvic
surgery
2. Physical Examination
o Non-specific, unilateral pelvic pain
o Tender adnexal mass
o Fever can occur with ovarian necrosis
3. Laboratory evaluation:
o Urine pregnancy test
o Urinalysis
o CBC with differential, if infectious process suggested
o Tumor markers, if tumor suggested
Not used as screening tool (SOR:B)3
4. Diagnostic imaging:
o Ultrasound:
Doppler sonography (method of choice) can depict blood flow, and predict
viability of adnexal structures4
Flow does not exclude ovarian torsion, but can indicate ovarian
viability
Twisted vascular pedicle
Cystic mass
Free pelvic fluid
Enlarged ovary
o Gray scale transvaginal ultrasound preferred imaging modality for adnexal masses
(SOR:B)3
o CT and MRI helpful if ultrasound findings non-diagnostic5
Differential Diagnosis
1. Key differential diagnoses:
o Urinary:
Urinary tract infection, ureteral calculi, nephrolithiasis
o Genitourinary:
Ovarian tumor, ovarian cysts, ectopic pregnancy, pelvic inflammatory
disease
o Gastrointestinal:
Appendicitis, diverticulitis, pancreatitis
2. Extensive differential diagnoses
o Genitourinary:
Endometriosis, tubal ovarian abscess
o Gastrointestinal:
Small bowel obstruction, large bowel obstruction, mesenteric ischemia,
perforated colonic carcinoma

Therapeutics
1. Acute Treatment: emergent gynecology consult
o Laparoscopic adnexal de-torsion
Procedure of choice
Study in pediatric patients: mean time from initial exam to ovarian salvage
11 hours; mean time in salvage failure - 21 hours11
o Laparoscopic salpingo-oophorectomy if:
Non-reversible ischemic damage
Tubal or ovarian neoplasm
Cystectomy if cyst present
o If 1 or 2nd trimester pregnancy, laparoscopy preferred
st
o 3rd trimester pregnancy, laparotomy because of technical difficulty6

o Cystectomy with adnexal fixation prevents recurrence7
2. Further Management (24 hrs)
o Monitor for post-surgical signs of infection, peritonitis.
3. Long-Term Care
o Pain related to possible re-torsion, infertility, adhesion with related chronic pain
Follow-Up
1. Return to surgeons office in 1 week
2. Recommendations for earlier follow-up: if pain recurs, or symptoms related to
complication, such as infection, sepsis, peritonitis
3. Return to office if symptoms related to other complications, such as chronic pain,
adhesions, infertility, risk for torsion of other ovary
4. Refer to Specialist:
o Gynecology
5. Admit to Hospital
o Admit for anesthesia and surgical intervention
Prognosis
1. Excellent prognosis
2. >88% ovarian function retained with timely surgical intervention8
3. Recurrence ranges from 2-5%
4. Recurrence more common in children with no underlying pathology at time of surgery9
Prevention
1. Currently no methods for prevention of ovarian torsion
2. Oophoropexy in pre-menarche adolescent females with recurrent torsion10
3. Oral contraceptives to prevent formation of recurrent cysts often used clinically
4. Studies have indicated individuals on fertility treatment should avoid exercise/strenuous
activity12
Patient Education
1. AAFP reference: Evaluation of Acute Pelvic Pain in Women
2. Ovarian torsion and hyperstimulation

References
1. Chang HC, Bhatt S, Dogra VS. Pearls and Pitfalls in diagnosis in Ovarian Torsion.
Radiographics. Sept-Oct 2008; 28(5): 1355-68.
2. Varrus M, Tsikin A, Polyzos D, et al. Uterine Adnexal Torsion: Pathologic and Gray
Scale Ultrasonographic Findings. Obstet Gynecol 2004; 31: 34-38.
3. Givens V, Mitchell G, Harraway-Smith C, Reddy A, Maness MD DL. Diagnosis and
Management of Adnexal Masses. American Family Physicians. 2009 Oct 15; 80(8): 815-
820.
4. Lee EJ, Kwon HC, Joo HJ, Suh JH, Fleischer AC. Diagnosis of Ovarian Torsion with
Color Doppler Sonography: Depiction of twisted vascular pedicle. J Ultrasound Med. Feb
1998; 17(2): 83-9.
5. Van Kenchove F, Cannie M, Op de beek K, Timmerman D, Pienaar A, Smet MH, et al.
Ovarian Torsion in a Premenarchal Girl; MRI Findings Abdominal Imaging. May-Jun
2007; 32(3): 424-7.
6. Krissi H, Shaleve J, Bar-Hava I, Lange R, Herman A, Kaplan B. Fallopian tube torsion:
laparoscopic evaluation and treatment of a rare gynecological entity. J Am Board Fam
Pract 2001; 14: 274-7.
7. Tsafrir Z, Hasson J, Levin I, Solomon E, Lessing JB, Azem F. Adnexal Torsion:
Cystectomy and Ovarian Fixation are Equally Important in Preventing Recurrence. Eur J
Obstet Gynecol Reprod Biol. 2012 Jun; 162(2):203-205.
8. Delsner G, Shashar D. Adnexal Torsion. Clin Obstet Gynecol. 2006; 49: 459-463.
9. Cass DC. Ovarian Torsion. Semin Pediatr Surg. 2005; 14:86-92.
10. Rollene N, Nann M, Wilson T, Coddington C. Recurrent Ovarian Torsion in a
Premenarchal Adolescent Girl: Contemporary Surgical Management. Obstet Gynecol
2009 Aug; 114(2 pt 2): 422-4.
11. Ander JF, Powell EC. Urgency of evaluation and outcome of acute ovarian torsion in
Pediatric Patients. Archives Pediatric Adolescent Medicine. 2005, June; 159(6): 532-5.
12. Littman ED, Rydfors J, Milki AA. Exercise Induced Ovarian Torsion in the Cycle
Following Gonadotrophin Therapy: Case Report. Oxford Journals. 2003, May 7; 18(8):
1641-1642.
Authors: Malinda Baker, MD, & Nathan Carlson, MD,

Kaiser Permanente Fontana FMRP, CA
Editor: Carol Scott, MD,

University of Nevada Reno FPRP

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OVARIAN TORSION

Ovarian Torsion Page 1 of 4 9.20.12

Ovarian Torsion Page 2 of 4 9.20.12

o 3rd trimester pregnancy, laparotomy because of technical difficulty6

Ovarian Torsion Page 3 of 4 9.20.12

Authors: Malinda Baker, MD, & Nathan Carlson, MD,

Editor: Carol Scott, MD,

Ovarian Torsion Page 4 of 4 9.20.12

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