Ovarian torsion
Background
- Ovarian torsion is the rotation of the ovary and portion of the fallopian tube on the supplying vascular pedicle
- Referred to as adnexal torsion and tubo-ovarian torsion
- Occurs in females of all ages
- Most common in reproductive age adults
- In children, it is most common in 9-14 years of age
- Risk factors:
- Ovarian mass
- Fertility treatments
- Ovarian cysts (usually > 4 cm) and neoplasms account for 94% of cases in adults[1]
- Torsion more common on the right, as the sigmoid colon tends to stabilize the left
- In children, hypermobility of the ovary many be the primary cause of torsion
- Dual blood supply from ovarian and uterine arteries
Pathophysiology
Torsion occurs from either of two causes:
- Hypermobility of the ovary
- Adnexal mass
- Cysts greater than 4 cm are more likely to torse[2]
- Absence of ovarian Doppler flow is highly specific for torsion, but normal Doppler flow does not completely exclude torsion
Clinical Features
- Nausea/vomiting (70%)
- Sudden and sharp pain in the lower abdomen (50%)[3]
- Up to 30% have no tenderness on bimanual exam[6]
- Most adults with ovarian torsion have abnormal or enlarged ovaries that serves as lead point for torsion, but torsion is more likely to occur in normal sized ovaries in pediatrics[7]
- More than 50% of cases have no palpable adnexal mass[8]
- Fever (<2%)
- Up to 20% of cases seen in pregnant women, with most in the 1st trimester and/or received fertility treatments[9]
Differential Diagnosis
Acute Pelvic Pain
Gynecologic/Obstetric
- Normal variants may be noted on exam but generally do not cause pain or other symptoms
- Nabothian cysts: Epithelial cells within mucous glans that appear as yellow inclusions on the cervix
- Cervial Ectropion: Edothelial cells on the exterior of the cervix
- Parous cervix: The is no longer round but may have multiple shapes after birth
- Pregnancy-related
- Ectopic pregnancy
- Spontaneous abortion, threatened or incomplete
- Septic abortion
- Pelvic organ prolapse
- Acute Infections
- Vulvovaginitis
- Adnexal Disorders
- Hemorrhage/rupture of ovarian cyst
- Ovarian torsion
- Twisted paraovarian cyst
- Other
- Myoma (degenerating)
- Genitourinary trauma
- Ovarian hyperstimulation syndrome
- Sexual assault
- Recurrent
- Mittelschmerz
- Primary/Secondary Dysmenorrhea
- Pelvic Congestion Syndrome
- Endometriosis
Genitourinary
Gastrointestinal
- Gastroenteritis
- Appendicitis
- Bowel obstruction
- Perirectal abscess
- Diverticulitis
- Inflammatory bowel disease
- Irritable bowel syndrome
- Mesenteric adenitis
Musculoskeletal
- Abdominal wall hematoma
- Psoas hematoma, psoas abscess
- Hernia
Vascular
- Pelvic thrombophlebitis
- Abdominal aortic aneurysm
- Ischemic bowel (Mesenteric Ischemia)
RLQ Pain
- GI
- Appendicitis
- Perforated appendicitis
- Peritonitis
- Crohn's disease (terminal ileitis)
- Diverticulitis (cecal, Asian patients)
- Inguinal hernia
- Mesenteric ischemia
- Ischemic colitis
- Meckel's diverticulum
- Neutropenic enterocolitis (typhlitis)
- Appendicitis
- GU
- Other
LLQ Pain
- Diverticulitis
- Kidney stone
- UTI
- Pyelonephritis
- Ectopic pregnancy
- Infectious colitis
- Inflammatory bowel disease (Crohn's Disease, Ulcerative Colitis)
- Inguinal hernia
- Mesenteric ischemia
- Epiploic appendagitis
- Mittelschmerz
- Ovarian cyst
- Ovarian torsion
- PID
- Psoas abscess
- Testicular torsion
- Appendicitis
- Abdominal aortic aneurysm
- Herpes zoster
- Endometriosis
- Colon cancer
- Irritable bowel syndrome
- Small bowel obstruction
Evaluation

Contrast-enhanced CT axial image shows thickened right adnexa (thick arrow) interposed between the cystic lesion (thin arrow) and uterus (Ut) which raised suspicion of adnexal torsion.[11]

Sagittal MR image showing "whirlpool appearance" of the right adnexa (thick arrow) suggestive of ovarian torsion. Right ovarian cystic mass is also seen (thin arrow). MRI is not typically first line imaging for ovarian torsion.[12]
Doppler Ultrasound
Findings suggestive of torsion may include:
- Diminished or absent blood flow in the ovarian vessels[13]
- Enlarged ovarian volume
- MC finding
- A maximum ovarian diameter (MOD) < 3cm in a postmenarchal patient is unlikely to represent ovarian torsion[16]
- 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[13]
CT Abd/Pelvis
- CT has a low sensitivity for torsion
- Examine for asymmetric ovarian enlargement, which warrants a pelvic US if concerning symptoms exist[17]
- CT may be used to rule out other possible causes of lower abdominal pain; also exclude presence of pelvic mass
Management
- Emergent OB/GYN consult in ED
- Consider if high suspicion exists even after equivocal US
- Surgical detorsion is required to prevent ovarian necrosis
- If the ovary becomes necrotic, there is a high risk of infection
- Salvage rate may be high even if time is prolonged beyond several hours of symptoms[18]
See Also
External Links
References
- ↑ Amirbekian S et al. Ultrasound Evaluation of Pelvic Pain. Radiol. Clin. North Am. 2014;52 (6): 1215-1235
- ↑ M.L. Brandt et al. Surgical indications in antenatally diagnosed ovarian cysts J Pediatr Surg, 26 (1991), pp. 276–282
- ↑ Houry, D. and Abbott, J.T. Ovarian torsion: a fifteen-year review. Ann Emerg Med. 2001; 38: 156–159.
- ↑ Damigos, E., Johns, J., and Ross, J. An update on the diagnosis and management of ovarian torsion. Obstet Gynaecol. 2012; 14: 229–236.
- ↑ Sasaki, K.J. and Miller, C.E. Adnexal torsion: review of the literature. J Minim Invasive Gynecol. 2014; 21: 196–202.
- ↑ Houry, D. and Abbott, J.T. Ovarian torsion: a fifteen-year review. Ann Emerg Med. 2001; 38: 156–159.
- ↑ Anders, J.F. and Powell, E.C. Urgency and evaluation and outcome of acute ovarian torsion in pediatric patients. Arch Pediatr Adolesc Med. 2005; 159: 532–535.
- ↑ Houry, D. and Abbott, J.T. Ovarian torsion: a fifteen-year review. Ann Emerg Med. 2001; 38: 156–159.
- ↑ Albayram, F. and Hamper, U.M. Ovarian and adnexal torsion: spectrum of sonographic findings with pathologic correlation. J Ultrasound Med. 2001; 20: 1083–1089.
- ↑ Norris DL, Young JD. UTI. EM Clin N Am. 2008; 26:413-30.
- ↑ Ghonge NP, Lall C, Aggarwal B, Bhargava P - Radiology case reports (2015). The MRI whirlpool sign in the diagnosis of ovarian torsion.
- ↑ Ghonge NP, Lall C, Aggarwal B, Bhargava P - Radiology case reports (2015). The MRI whirlpool sign in the diagnosis of ovarian torsion.
- ↑ 13.0 13.1 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.
- ↑ Cicchiello, L.A., Hamper, U.M., and Scoutt, L.M. Ultrasound evaluation of gynecologic causes of pelvic pain. Ultrasound Clin. 2010; 38: 85–114.
- ↑ Cicchiello, L.A., Hamper, U.M., and Scoutt, L.M. Ultrasound evaluation of gynecologic causes of pelvic pain. Ultrasound Clin. 2010; 38: 85–114.
- ↑ Budhram G, Elia T, Dan J, et al. A Case-Control Study of Sonographic Maximum Ovarian Diameter as a Predictor of Ovarian Torsion in Emergency Department Females With Pelvic Pain. Acad Emerg Med. 2019;26(2):152-159.
- ↑ Lourenco, A.P., Swenson, D., Tubbs, R.J. et al. Ovarian and tubal torsion: imaging findings on US, CT and MRI. Emerg Radiol. 2014; 21: 179–187.
- ↑ Anders JF, Powell EC. Urgency of evaluation and outcome of acute ovarian torsion in pediatric patients. Arch Pediatr Adolesc Med. 2005;159:532–535