Ovarian Torsion

Overview

Ovarian torsion, also known as adnexal torsion, is a serious gynecological emergency that occurs when an ovary twists around the ligaments that support it. This twisting motion cuts off the ovary's blood supply, leading to severe pain and potentially causing permanent damage to the ovarian tissue if not treated promptly. The condition can affect women of all ages, from infants to postmenopausal women, though it most commonly occurs in women of reproductive age.

The twisting typically involves not just the ovary but also the fallopian tube, and in many cases, an ovarian cyst or mass is present that increases the weight of the ovary, making it more prone to twisting. The degree of twisting can vary from partial to complete rotation, with multiple twists possible. The severity of symptoms and the urgency of treatment depend on the degree of torsion and how much blood flow has been compromised.

Ovarian torsion accounts for approximately 2.7% of all gynecological emergencies and requires immediate surgical intervention to prevent irreversible damage to the ovary. Early recognition and treatment are crucial for preserving ovarian function and fertility. With prompt surgical intervention, the ovary can often be saved, but delays in treatment may necessitate removal of the affected ovary. Understanding the symptoms and risk factors of ovarian torsion is essential for women and healthcare providers to ensure timely diagnosis and treatment of this potentially serious condition.

Symptoms

The symptoms of ovarian torsion typically develop suddenly and can be severe. The presentation may vary depending on whether the torsion is complete or partial, and whether it involves just the ovary or includes the fallopian tube.

Primary Symptoms

• Sharp abdominal pain: Sudden onset of severe, sharp pain in the lower abdomen or pelvis, typically on one side. The pain may be constant or intermittent if the ovary is twisting and untwisting.
• Lower abdominal pain: Intense pain localized to the lower abdomen, often described as the worst pain the patient has ever experienced. The pain may radiate to the back, groin, or thigh.
• Pelvic pain: Deep, severe pain in the pelvis that may worsen with movement or physical activity. The pain is typically unilateral (one-sided) corresponding to the affected ovary.
• Nausea and vomiting: Present in approximately 70% of cases, often accompanying the severe pain. Vomiting may be persistent and not relieved by antiemetics.

Associated Symptoms

• Skin swelling: Abdominal distension or bloating may occur due to the enlarged twisted ovary or associated fluid accumulation.
• Groin mass: A palpable mass may be felt in the groin or lower abdomen, representing the enlarged, twisted ovary.
• Ache all over: Generalized body aches and malaise may accompany the acute pain, particularly if the torsion has been present for several hours.
• Fever: Low-grade fever may develop, especially if the torsion has led to tissue necrosis.
• Urinary symptoms: Frequent urination or difficulty urinating due to pressure on the bladder.
• Abnormal vaginal bleeding: Light spotting or irregular bleeding may occur in some cases.

Symptom Patterns

• Intermittent torsion: Pain that comes and goes as the ovary twists and untwists spontaneously
• Complete torsion: Constant, severe pain that progressively worsens
• Chronic torsion: Recurrent episodes of pain over weeks or months

Red Flag Symptoms

• Sudden, severe unilateral pelvic pain
• Pain associated with nausea and vomiting
• Signs of shock (rapid pulse, low blood pressure, pale skin)
• Rigid abdomen or rebound tenderness
• High fever suggesting tissue necrosis

Causes

Ovarian torsion occurs when the ovary rotates on its vascular pedicle, which contains the blood vessels supplying the ovary. Several factors can contribute to this rotation.

Anatomical Causes

• Ovarian masses: Present in 50-80% of torsion cases
  • Benign ovarian cysts (most common)
  • Mature cystic teratomas (dermoid cysts)
  • Cystadenomas
  • Endometriomas
  • Malignant tumors (rare, <2% of cases)
• Enlarged ovaries: Can occur without discrete masses
  • Ovarian hyperstimulation syndrome
  • Polycystic ovary syndrome (PCOS)
  • Massive ovarian edema
• Long ovarian ligaments: Congenitally long utero-ovarian ligaments or infundibulopelvic ligaments allow greater mobility

Physiological Causes

• Pregnancy:
  • 15-20% of torsions occur during pregnancy
  • Most common in first trimester and immediately postpartum
  • Enlarged corpus luteum cysts
  • Ovarian hyperstimulation from fertility treatments
• Normal ovarian changes:
  • Follicular cysts during normal menstrual cycles
  • Corpus luteum cysts

Mechanical Factors

• Sudden movements: Abrupt changes in position or physical activity
• Increased abdominal pressure: Coughing, vomiting, or straining
• Changes in blood flow: Venous congestion leading to ovarian enlargement
• Previous pelvic surgery: Adhesions that alter normal anatomy

Age-Related Factors

• Prepubertal girls: Long ovarian pedicles and increased mobility
• Reproductive age women: Functional cysts and pregnancy-related changes
• Postmenopausal women: Usually associated with ovarian masses

Risk Factors

Several factors increase the likelihood of developing ovarian torsion. Understanding these risk factors helps identify women at higher risk who may benefit from closer monitoring.

Major Risk Factors

• Ovarian masses:
  • Cysts larger than 5 cm significantly increase risk
  • Dermoid cysts have particularly high risk due to their weight distribution
  • Multiple cysts or bilateral ovarian masses
• Previous ovarian torsion:
  • 10-25% recurrence rate
  • Higher risk if ovary was detorsed without fixation
  • May occur on the same or opposite side
• Pregnancy and fertility treatments:
  • Ovarian hyperstimulation syndrome
  • In vitro fertilization (IVF) procedures
  • Multiple follicle development
  • First trimester of pregnancy

Anatomical Risk Factors

• Congenital abnormalities:
  • Abnormally long ovarian ligaments
  • Absent or malformed mesosalpinx
  • Paratubal cysts
• Tubal pathology:
  • Hydrosalpinx
  • Paraovarian cysts
  • Tubal ligation (may alter ovarian mobility)

Age-Specific Risk Factors

• Children and adolescents:
  • Normal ovaries can tort more easily due to increased mobility
  • Developmental abnormalities
  • Athletic activities with sudden movements
• Reproductive age women:
  • Functional ovarian cysts
  • Endometriosis with endometriomas
  • Polycystic ovary syndrome
• Postmenopausal women:
  • Ovarian neoplasms (benign or malignant)
  • Previous pelvic surgery with adhesions

Other Risk Factors

• Family history of ovarian torsion
• Sudden weight loss or gain affecting intra-abdominal pressure
• Vigorous physical activity or sports
• Conditions causing increased abdominal pressure

Diagnosis

Diagnosing ovarian torsion can be challenging as symptoms may mimic other conditions. A high index of suspicion is necessary, especially in women presenting with acute pelvic pain.

Clinical Evaluation

• History:
  • Sudden onset of severe unilateral pelvic pain
  • Previous episodes of similar pain (intermittent torsion)
  • Associated nausea and vomiting
  • Known ovarian cysts or masses
  • Recent fertility treatments or pregnancy
• Physical examination:
  • Unilateral adnexal tenderness
  • Palpable adnexal mass (in 50-70% of cases)
  • Cervical motion tenderness
  • Abdominal guarding or rigidity
  • Absence of fever (unless necrosis present)

Imaging Studies

• Pelvic Ultrasound with Doppler:
  • First-line imaging modality
  • Enlarged ovary (>5 cm) with peripheral follicles
  • Absent or decreased arterial and venous flow on Doppler
  • "Whirlpool sign" - twisted vascular pedicle
  • Free fluid in pelvis
  • Normal Doppler does not exclude torsion (due to dual blood supply)
• CT Scan:
  • May show enlarged ovary with peripheral follicles
  • Twisted vascular pedicle
  • Deviation of uterus toward affected side
  • Associated ovarian mass or cyst
  • Less sensitive than ultrasound for torsion
• MRI:
  • Reserved for complex cases or when diagnosis unclear
  • Better soft tissue characterization
  • Can show hemorrhagic infarction
  • Time-consuming, not ideal for emergencies

Laboratory Tests

• Complete blood count: May show mild leukocytosis
• Pregnancy test: Essential in all women of reproductive age
• Tumor markers: If malignancy suspected (CA-125, AFP, hCG)
• Urinalysis: To rule out urinary tract infection

Differential Diagnosis

Conditions that may present similarly include:

• Ruptured ovarian cyst
• Ectopic pregnancy
• Appendicitis
• Pelvic inflammatory disease
• Kidney stones
• Endometriosis
• Bowel obstruction

Diagnostic Challenges

• Normal Doppler flow doesn't exclude torsion
• Intermittent torsion may have normal findings between episodes
• Symptoms may be less specific in children and postmenopausal women
• Bilateral torsion is rare but possible

Treatment Options

Ovarian torsion is a surgical emergency requiring immediate intervention to restore blood flow and preserve ovarian function. The approach depends on the viability of the ovary and patient factors.

Emergency Management

• Immediate stabilization:
  • IV access and fluid resuscitation
  • Pain management with appropriate analgesics
  • Antiemetics for nausea and vomiting
  • NPO (nothing by mouth) status
  • Preoperative laboratory tests and imaging
• Surgical consultation: Immediate gynecological evaluation for emergency surgery

Surgical Treatment

• Laparoscopic detorsion:
  • Preferred approach when ovary appears viable
  • Untwisting of the ovary to restore blood flow
  • Assessment of ovarian viability after detorsion
  • Ovarian cystectomy if cyst present
  • Success rate >90% when performed early
• Ovarian fixation (oophoropexy):
  • Suturing ovary to pelvic sidewall or uterus
  • Considered for recurrent torsion
  • May be performed bilaterally in selected cases
  • Controversial due to potential complications
• Oophorectomy:
  • Removal of ovary if clearly necrotic
  • Black, friable ovarian tissue with no improvement after detorsion
  • Presence of malignancy
  • Less commonly performed now due to recognition that appearance can be deceiving
• Salpingo-oophorectomy:
  • Removal of both ovary and fallopian tube
  • When both structures are necrotic
  • Postmenopausal women with suspected malignancy

Conservative Management Principles

• Even blue-black ovaries may recover after detorsion
• Ovarian conservation preferred in reproductive-age women
• Biopsy generally not recommended due to bleeding risk
• Follow-up ultrasound to confirm ovarian recovery

Special Considerations

• Pregnancy:
  • Laparoscopy safe in all trimesters with appropriate precautions
  • Conservative management strongly preferred
  • Tocolytics may be needed to prevent preterm labor
• Pediatric patients:
  • Maximum effort to preserve ovarian tissue
  • Consider bilateral oophoropexy for normal ovary torsion
• Bilateral torsion:
  • Extremely rare but requires preservation of at least one ovary
  • Consider staged procedures if both ovaries compromised

Postoperative Care

• Pain management and early mobilization
• Prophylactic antibiotics if tissue necrosis suspected
• Follow-up ultrasound in 6-8 weeks to assess ovarian function
• Hormonal evaluation if oophorectomy performed
• Fertility counseling if indicated

Prevention

While ovarian torsion cannot always be prevented, certain measures can reduce risk or enable early detection and treatment.

Risk Reduction Strategies

• Management of ovarian cysts:
  • Regular monitoring of known ovarian cysts
  • Surgical removal of large cysts (>5-6 cm)
  • Consider intervention for persistent cysts
  • Hormonal contraceptives may reduce functional cyst formation
• Fertility treatment modifications:
  • Close monitoring during ovarian stimulation
  • Consideration of milder stimulation protocols
  • Early intervention for ovarian hyperstimulation
  • Prophylactic aspiration of large follicles

Surgical Prevention

• Prophylactic oophoropexy:
  • Consider for girls/women with previous torsion
  • May be performed on contralateral ovary
  • Technique and long-term outcomes still being studied
• Management during other procedures:
  • Careful inspection of ovaries during abdominal surgery
  • Removal of paraovarian cysts when encountered
  • Documentation of ovarian mobility

Early Recognition

• Patient education:
  • Awareness of symptoms in women with risk factors
  • Importance of seeking immediate care for severe pelvic pain
  • Understanding personal risk factors
• Healthcare provider awareness:
  • High index of suspicion in at-risk patients
  • Prompt evaluation and imaging
  • Low threshold for surgical consultation

Follow-up Care

• Regular ultrasound monitoring after conservative surgery
• Evaluation of contralateral ovary
• Hormonal assessment if ovarian function compromised
• Genetic counseling if familial tendency suspected

When to See a Doctor

Ovarian torsion is a medical emergency. Any woman experiencing symptoms suggestive of torsion should seek immediate medical attention to prevent permanent ovarian damage.

Seek Emergency Care Immediately For:

• Sudden, severe sharp abdominal pain or pelvic pain, especially if one-sided
• Severe lower abdominal pain with nausea and vomiting
• Pain that doesn't improve with over-the-counter pain medications
• Known ovarian cyst with new severe pain
• Previous ovarian torsion with recurrent symptoms
• Severe pelvic pain during pregnancy
• Signs of shock (rapid pulse, dizziness, pale skin, confusion)

Risk Factors Requiring Vigilance:

• Women undergoing fertility treatments
• Known large ovarian cysts (>5 cm)
• Previous episode of ovarian torsion
• Pregnancy, especially first trimester
• History of ovarian masses or tumors

Warning Signs Not to Ignore:

• Intermittent severe pelvic pain that comes and goes
• Pain accompanied by palpable groin mass
• Abdominal swelling with severe pain
• Pain that wakes you from sleep
• Generalized body aches with severe pelvic pain

Important Reminders:

• Time is critical - delays reduce chances of saving the ovary
• Don't wait to see if pain improves on its own
• Even if pain temporarily improves, seek evaluation
• Inform healthcare providers about risk factors
• Bring any recent imaging reports or medical records

Related Conditions

• Ovarian Cyst - Common cause and risk factor for torsion
• Ectopic Pregnancy - Important differential diagnosis for acute pelvic pain
• Appendicitis - Can present with similar right-sided pain
• Pelvic Inflammatory Disease - Another cause of acute pelvic pain
• Endometriosis - Can cause ovarian cysts that increase torsion risk
• Ovarian Hyperstimulation Syndrome - Increases risk of torsion

Frequently Asked Questions

References

1. American College of Obstetricians and Gynecologists. (2023). ACOG Committee Opinion: Adnexal Torsion in Adolescents. Obstet Gynecol.
2. Sasaki, K. J., & Miller, C. E. (2023). Adnexal Torsion: Review of the Literature. J Minim Invasive Gynecol, 21(2), 196-202.
3. Huang, C., Hong, M. K., & Ding, D. C. (2023). A review of ovary torsion. Tzu Chi Medical Journal, 29(3), 143-147.
4. Robertson, J. J., Long, B., & Koyfman, A. (2023). Myths in the evaluation and management of ovarian torsion. J Emerg Med, 52(4), 449-456.
5. Childress, K. J., & Dietrich, J. E. (2023). Pediatric Ovarian Torsion. Surg Clin North Am, 97(1), 209-221.