a detailed, updated review on ovarian torsion, its clinical presentation and management according to recent guidelines.

1. Ovarian
torsion
Ovarian torsion refers to the complete or
partial rotation of the ovary vascular
pedicle, which in turn impedes the ovarian
blood supply.

2. Introduction
 Torsion of the ovary, tube or both is responsible for
between 2.7% and 7.4% of all gynaecological
emergencies .
 It most commonly occurs in women of reproductive
age (including during pregnancy) however, pre-
pubertal girls and postmenopausal women can also be
affected.
 Delay or misdiagnosis can result in the loss of the
affected ovary and subsequent reduced reproductive
capacity.
 However, diagnosis can be difficult, particularly in
intermittent torsion and the differential diagnosis can
include several other gynecological and surgical
emergencies.

3. Contd.
 The right ovary appears to be more likely to torse than
the left because the right utero-ovarian ligament is
longer than the left and is the most vulnerable to
become twisted.
 Additionally, structural constraints from the sigmoid
colon on the left side of the colon may help to prevent
torsion of the left ovary.
 Failure to correct the torsion and restore ovarian blood
supply may result in ischemia and loss of ovarian
function.
 Additional potential adverse effects are hemorrhage,
abscess, or peritonitis.

6. Right engorged,
markedly
enlarged
thrombosed
fallopian tube
Right enlarged,
edematous
ovary
Right
ovarian cyst

7. Diagnosis
detailed clinical history
ultrasound findings
scoring systems

8.  Acute sudden onset pelvic pain
 Nausea and vomiting- 80% of cases of torsion
 Low grade pyrexia
 Sinus tachycardia
 Acute -on - chronic condition if hx of ovarian cyst, particularly a
dermoid or Polycystic ovary syndrome ( PCOS ) assoc. with the
enlarged ovary
 Torsion is more likely to occur in a cyst > 5cm or larger

9. Clinical history

10. Differential
diagnosis

11.  Appendicitis- poorly localized colicky central abdominal pain associated with anorexia and
vomiting
 Peritonitis- localized pain in RIF with localized guarding and tenderness
 Functional ovarian cyst- occurs in women using COCPs/ Depo-Provera or GnRH analogues
 Pain from hemorrhage into a cyst should resolve over a next few days
 OHSS- OI with clomiphene or gonadotrophins

12.  Fibroids- degeneration usually occurs in pregnancy
 Torsion of pedunculated fibroids should also be considered in
women with a hx of fibroids
 Rupture of a surface vessel over a fibroid is also a known but rare
cause of acute abdominal pain and hemorrhage
 Renal colic- same presentation as torsion
 Associated microscopic hematuria

13.  Endometriomas and malignancies are less likely to undergo
torsion due to adhesions formation
 In prepubescent girls, torsion is not associated with adnexal
pathology
 Malignancy rate is low at 0.5-1.8%
 Acute pelvic pain in extreme age groups i-e prepubescent and
postmenopausal women- more likely to be due to torsion
 In reproductive age groups- functional ovarian cysts

14. Ultrasound
 USG appearance of torsion of a normal ovary is highly variable
 It is essential to be aware of the different possible USG
appearances
 In any case of suspected ovarian torsion, comparison with the
contralateral ovary will show a distinct difference in the
appearances of the two ovaries (Figures 1–3).
 There is often hemorrhagic fluid in the pouch of Douglas but this is
not invariable
 Anechoic fluid in the pelvis may be a normal finding, so cannot be
used as a marker of torsion.

15. Usually
described as
“ Unilateral ovarian
enlargement and
oedema with
peripherally arranged
follicles”
The latter sign being
more common in
prepubescent girls
It is the most consistent
USG finding in the
literature

16. The affected ovary
may appear as a solid
mass with hypo- and
hyperechoic areas in
keeping with
hemorrhage and
necrosis
The twisted pedicle
may be seen as a
‘whirlpool’, visible in
both greyscale and
colour doppler (Fig 2)

17. in the presence of a
simple ovarian cyst, the
cyst tends to become
hemorrhagic as the
ovary undergoes venous
congestion, so the fluid
within it becomes more
echogenic
Normal ovarian tissue
adjacent to the cyst also
becomes oedematous
and the borders of the
ovary less well defined (
Fig 3)

18. The tube may
also be involved
and filled with
hemorrhagic
fluid

19.  Abnormal Doppler signals in the ovarian vessels have been
identified in up to 100% of cases of adnexal torsion
 however, a complete absence of perfusion may be a relatively late
event, so the presence of flow within the ovary does not exclude
the diagnosis of torsion.

20. Coiling of the
ovarian vessels
may be seen in
early or
subacute cases

21. Ovarian cysts
and torsion is
assisted
reproduction
and pregnancy
 An ovarian cyst ( > 25 mm simple or complex cyst) can be found in
up to 5% of pregnancies with a 1–3% torsion rate.
 The risk of torsion appears to decrease with increasing gestation,
is unusual after 20 weeks and becomes harder to diagnose.
 The use of laparoscopy in pregnancy has been shown to be safe in
any trimester, providing the appropriate surgical expertise is
available.
 The risk of perinatal morbidity is no greater than when compared
with open surgery, although it is generally high in both due to the
emergency nature of the procedure.

22.  The use of assisted reproductive technology (ART) is associated
with an 11-fold increased risk of ovarian torsion.
 In one recent study of ovarian torsion in pregnancy, 48.5% of cases
were associated with ovulation induction or in vitro fertilisation
(IVF), of the 36% of cases that had multicystic ovaries; 86% had
conceived by ART, leading them to conclude that it is a major risk
factor for ovarian torsion in pregnancy.

23.  OHSS presents with enlarged ovaries containing multiple
luteinised cysts or corpora lutea in association with ascites.
 If torsion occurs, areas of swelling, haemorrhage or necrosis can
be seen within the parenchyma of the torted ovary (Figure 6)
 however, the typical features are frequently masked by the large
multicystic ovaries.

26. Other imaging
techniques
 Computed tomography (CT)
 magnetic resonance imaging (MRI)
 Findings include-
 enlargement of the ovarian stroma
 tube thickening
 Ascites
 uterine deviation to the affected side

27. MRI image of
enlarged,
edematous
ovary with
torsion

28. Ct scan image
whirlpool
pattern of
adnexal
torsion

29. disadvantages
 These modalities are expensive
 are less readily available than ultrasound
 rarely provide additional diagnostic information.

30. advantages
 MRI is more useful (and safe) in the second and third trimesters of
pregnancy for diagnosing abdominal pain, where the ovaries and
appendix are more difficult to visualise by ultrasound.
 should be considered early in the investigation of unwell pregnant
women with abdominal pain, not thought to be obstetric in
nature.

31. Serum
markers
 No specific single or combined serum marker
has been identified
 Most commonly used are
 C- Reactive protein ( CRP)
 White cell count
under study
 Ischemia- modified albumin
 Interleukin-6
 Tumor necrosis factor- alpha

34. Management
(surgery)
Determining factors:
 Macroscopic appearance of the adnexum
 Age
 menopausal status
 presence of pre-existing ovarian pathology
 desire to preserve fertility.

35.  Options include:
 partial or complete oophorectomy
 salpingo-oophorectomy
 conservative management with laparoscopic de-torsion
 outcomes from peadiatric cases would support a more
conservative approach to surgical management in the form of de-
torsion with or without oophoropexy

36.  the clinical appearances of torsed adnexae do not
correlate well with the likelihood of residual ovarian
function
 conservative management with laparoscopic de-
torsion in the majority of cases with little short or long-
term associated morbidity even if the ovary appears
dark purple or black.
 The likelihood of preserving viable ovarian tissue with
conservative surgery (de-torsion) decreases over time
 pain for longer than 48 hours is associated with a
significant decrease in successful outcome.

37.  in cases where examination and ultrasound
suggest a high probability of ovarian torsion,
surgery should be performed as quickly as
possible to enable prompt restoration of the
ovarian blood supply before significant damage
occurs
 the same degree of urgency should be afforded
in adnexal torsion as done in testicular torsion
which is dealt as a medical emergency with a
short window of 6 hrs for recovery

38. Follow up
 Follow up of women who have undergone de-torsion,
suggests that in the majority of cases, function appears
to recover (based on the presence of follicular activity
on follow-up ovarian ultrasound, pregnancy rates,
response to ovulation induction or second-look
laparoscopy)

39. Oophoropexy
Whether or not to perform oophoropexy when de-torsion of normal
adnexae is performed is less clear.
In cases where recurrent torsion has occurred, oophoropexy has
been shown to be effective in reducing the recurrence rate.
There are case reports in the literature of fixing the de-torted ovary,
or contralateral ovary, to the back of the uterus, or shortening of
the utero-ovarian ligament.
 Performed mainly in children and adolescents

40. Ovarian cyst +
Torsion
In cases where torsion has occurred in the
presence of a true ovarian cyst, cystectomy at
the time of de-torsion is often risky due to the
friable nature of the tissues, but early elective
cystectomy has been described after an interval
of 2–3 weeks to allow time for the oedema and
congestion to resolve.

41.  Oophorectomy is likely to be used more frequently to avoid the
small but potential risk of repeat torsion during the pregnancy.
 Isolated reports of cyst aspiration to prevent recurrence are
available in the literature but the technique needs further
evaluation.

42. In all cases of adnexal torsion, the laparoscopic
approach would be the preferred route in order to
reduce admission time, postoperative pain and long-
term risk of adhesion formation.

43. conclusion
 Adnexal torsion is frequently suspected in women with acute
pelvic pain, but rarely confirmed.
 It is apparent that prompt diagnosis is dependent on clinical
history and a high index of suspicion.
 Accurate and detailed history taking is highly important, both of
the presenting complaint and of the previous gynaecological and
surgical history.
 Physical examination may elicit an adnexal mass or adnexal
tenderness but can be non-specific.

44.  Transvaginal ultrasound remains the first-line
investigation; however MRI may be more
useful in the second and third trimesters of
pregnancy

45.  Prompt intervention to preserve ovarian
function should be laparoscopic wherever
possible
 De-torsion the treatment of choice in
prepubescent girls and women of reproductive
age whose families are not complete,
regardless of the colour of the ovary at the time
of surgery.

46.  In older and postmenopausal women,
oophorectomy is the treatment of choice to
completely remove the risk of re-torsion.
 In the presence of a non-functional ovarian
cyst, cystectomy or interval cystectomy
should be performed in younger women.

47. Patient education
What is it?
Ovarian torsion is an emergent condition where the ovaries are twisted on its ligaments which hold it. It
can affect the blood supply, ovaries, fallopian tube. It can cause decrease blood flow, edema, bleeding
and a mass.
How do I know if I have ovarian torsion?
Patients will typically experience sudden lower abdominal pain, nausea, vomiting, fever.
How is ovarian torsion diagnosed and treated?
Your provider will order laboratory tests and imaging studies to rule out differentials and make a
definitive diagnosis.You may be given pain medication as well to manage the pain. Depending on the
condition of the the torsion, there are several types of surgery available to untorse the ovary.
What are the complications if left untreated or treatment is delayed?
There can be infection, peritonitis, sepsis, adhesions, chronic pain, and infertility.