DOI: 10.1111/j.1744-4667.2012.00131.

x 2012;14:229–36
The Obstetrician & Gynaecologist
Review
http://onlinetog.org

An update on the diagnosis and management of ovarian

torsion
a b, c
Emmanuel Damigos Ptychio latrikes [MBBS], Jemma Johns MBBS MD MRCOG, * Jackie Ross MBBS FRCOG
a
ST5 in Obstetrics and Gynaecology, Friarage Hospital, South Tees Hospitals Trust, Northallerton, North Yorkshire DL6 1JG, UK
b
Consultant Gynaecologist, King’s College Hospital, Denmark Hill, London SE5 9RS, UK
c
Consultant Obstetrician and Gynaecologist, King’s College Hospital, Denmark Hill, London SE5 9RS, UK
*Correspondence: Jemma Johns. Email: jemma.johns@nhs.net

Key content Learning objectives

 Torsion of the ovary, tube or both is estimated to be responsible  To understand the clinical presentation and ultrasound
for only a small number of all gynaecological emergencies, but is a characteristics associated with ovarian torsion.
common diagnostic challenge in the emergency setting.  To review the literature on the available surgical options.
 Diagnosis can be difficult and is mainly based on clinical
Ethical issues
symptoms and imaging techniques such as ultrasound and MRI. 
 A normal ultrasound scan does not exclude adnexal torsion and
Oophorectomy is commonly performed for adnexal torsion
with a possible negative impact on fertility in women of
the decision to operate should be made on clinical grounds if
reproductive age. De-torsion is a more conservative surgical
symptoms are severe.
 Treatment is traditionally surgical removal of the ovary or
approach that should be considered in all younger women with
ovarian torsion.
adnexum, however, there is increasing evidence for conservative
surgery, such as de-torsion and oophoropexy, particularly in Key words: de-torsion / oophorectomy / oophoropexy / ovarian
younger women. cyst / ovarian torsion
 This article provides an overview of the symptomatology,
ultrasound diagnosis and classification, as well as treatment
options for ovarian torsion.

Please cite this paper as: Damigos E, Johns J, Ross J. An update on the diagnosis and management of ovarian torsion. The Obstetrician & Gynaecologist
2012;14:229–36.

De-torsion and oophoropexy, rather than oophorectomy,

Introduction
Torsion of the ovary, tube or both is responsible for between
2.7% and 7.4%1,2 of all gynaecological emergencies but is a
common diagnostic challenge in the emergency setting. 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
gynaecological and surgical emergencies.
Familiarity with the common presenting symptoms of
torsion, in combination with ultrasound and other imaging
modalities is important for maintaining a high index of
suspicion among emergency staff, to enable swift and
accurate diagnosis and an appropriate management strategy.
The risk of surgical intervention needs to be balanced
against the potential dangers of conservative management
and ovarian torsion is rarely managed expectantly.
are surgical techniques that are increasing in popularity.
Newer techniques to prevent recurrence, such as shortening
of the utero-ovarian ligament are also being performed but
require further appraisal.
Diagnosis
Ovarian torsion is far less common than other causes of acute
pelvic pain such as pelvic inflammatory disease (PID),
ovarian cyst haemorrhage and appendicitis.1 Diagnosis
usually relies on a combination of detailed clinical history
and ultrasound findings, with a high index of suspicion for
torsion. Attempts have been made to create scoring systems
for the prediction of torsion, using clinical history and
imaging findings. A recently published scoring system
identified five criteria that were independently associated
with adnexal torsion (Table 1) and allowed cases to be
placed into low- and high-risk groups.3 Interestingly, while
large ovarian cysts (5 cm) had a strong association with
torsion, other ultrasound features were not particularly

ª 2012 Royal College of Obstetricians and Gynaecologists 229

 An update on the diagnosis and management of ovarian torsion

presence of acute pelvic pain in prepubescent and

Table 1. Scoring system for the identification of women with adnexal
torsion3 postmenopausal women is more likely to be caused by
torsion, whereas in the reproductive years, pain associated
Adjusted odds with functional ovarian cysts is much more likely. The
Criteria ratio (95%CI)
differential diagnoses in women presenting with acute lower
1 Unilateral lumbar or abdominal pain 4.1 (1.2–14)
abdominal or pelvic pain are listed in Box 2.
2 Pain duration >8 hours 8.0 (1.7–37.5)
3 Vomiting 7.9 (2.3–27)
4 Absence of leucorrhoea/metrorrhagia 12.6 (2.3–67.6)
Box 2. Differential diagnoses in acute lower
5 Ovarian cyst >5 cm by ultrasound 10.6 (2.9–38.8) abdominal pain

Differential
diagnoses History Clinical features
predictive and the highest scoring features were clinical.
These results are promising but need to be subjected to large PID Sexually active Non-migratory pain,
prospective assessment. bilateral tenderness,
no nausea or
vomiting
Appendicitis Typically <40 Migratory pain,
Clinical history years old anorexia, vomiting
The clinical presentation of adnexal torsion, like other Functional Natural cycles Sudden onset, sharp
ovarian cyst stabbing pain
pathologies, is with acute onset of pelvic pain but can be OHSS History of ovulation Bloating, pelvic pain,
non-specific, frequently presenting diagnostic difficulties. induction nausea and vomiting
Nausea and vomiting are also common presenting features, Fibroid torsion History of fibroids Constant, severe pain
occurring in 85% of cases of ovarian torsion.4 A low-grade Renal colic Generally idiopathic Unilateral loin pain
radiating to groin
pyrexia and sinus tachycardia may also be present. The Adnexal torsion History of ovarian cyst, Intermittent, colicky
clinical features of torsion are described in Box 1. PCOS, ovulation acute pain, nausea,
induction vomiting, pyrexia
Box 1. Clinical features of adnexal torsion OHSS = ovarian hyperstimulation syndrome; PCOS = polycystic ovary
syndrome; PID = pelvic inflammatory disease
Symptoms
General Pelvic or abdominal pain,
fluctuating, radiating to loin or thigh
Nausea
It is obvious from this list that a detailed gynaecological,
Vomiting surgical and medical history is paramount in determining the
Signs most likely cause of the pain. Clinical features that favour the
General Pyrexia diagnosis of PID are non-migratory pain, bilateral pelvic
Tachycardia
Abdominal examination Generalised abdominal tenderness, localised
tenderness and absence of nausea or vomiting. Appendicitis
guarding, rebound typically presents with poorly localised colicky central
Vaginal examination Cervical excitation, adnexal tenderness, abdominal pain associated with anorexia and vomiting. As
adnexal mass the condition worsens, and peritonitis develops, the pain
becomes more localised to the right iliac fossa, with localised
It is key to take a detailed history of any woman presenting guarding and tenderness. A history of sudden-onset,
with acute pelvic pain when ovarian torsion is suspected. stabbing, sharp pain should raise the suspicion of
Torsion may present as an acute-on-chronic condition if there haemorrhage from a functional cyst. Functional ovarian
is a history of an ovarian cyst, particularly a dermoid, or cysts are unlikely to occur in women who are using
polycystic ovary syndrome (PCOS) (associated with the contraceptives or other medications that cause ovarian
enlarged ovary). Data regarding cyst size and risk of torsion suppression (for example, combined oral contraceptives,
are conflicting, with some suggesting that torsion may be more long-acting reversible contraceptive such as depo provera, or
likely in larger cysts (>5 cm),3,5 and others suggesting that GnRH analogues). Pain from haemorrhage into a cyst should
cysts larger than 5 cm in size are less likely to undergo torsion resolve over the next few days.10 Women with ovarian
than smaller ones.6 It has also been suggested that malignancies hyperstimulation syndrome (OHSS) will usually give a
and endometriomas undergo torsion less frequently because of history of recent ovulation induction with gonadotrophins
their association with pelvic adhesions.5 In prepubescent girls, or occasionally clomiphene. Rarely, cases will occur in
torsion frequently occurs in the absence of adnexal pathology7 spontaneous pregnancies.11 The severity at presentation is
and recent data suggest that the malignancy rate is low at 0.5– variable but symptoms include abdominal bloating, pelvic
1.8%, rather than the frequently quoted figure of 10%.8,9 The pain and nausea and vomiting. Determining whether the

230 ª 2012 Royal College of Obstetricians and Gynaecologists


Figure 1. Top row: polycystic left ovary in a pregnant woman. Bottom row: contralateral torted ovary in same individual
enlarged ovaries are undergoing torsion can be extremely
difficult under these circumstances and the ultrasound
features are discussed further below. Fibroid degeneration
rarely causes pain outside of pregnancy, although torsion of
pedunculated fibroids is not unusual and should be
considered in women known to have fibroids. Rupture of a
surface vessel over a fibroid is also a rare but reported cause
of acute abdominal pain and intraperitoneal
haemorrhage.12,13 Renal colic typically presents with sudden
onset of severe unilateral colicky pain radiating from the loin
to the groin, which comes in waves, very similar to torsion.
There is often associated microscopic haematuria.
Ultrasound
The ultrasound appearance of torsion of a normal ovary can
be highly variable, representing the dynamic nature of the
pathophysiological process. It is therefore essential to be
aware of the different possible ultrasound appearances and
combine these with the clinical picture in order to make a
swift diagnosis of ovarian torsion. It is frequently described
as unilateral ovarian enlargement and oedema with
peripherally arranged follicles (Figure 1),11,14 the latter sign
ª 2012 Royal College of Obstetricians and Gynaecologists
Damigos et al.
being more common in pre-pubescent ovaries.15 The affected
ovary may appear as a solid mass with hypo- and
hyperechoic areas14 in keeping with haemorrhage and
necrosis (Figure 2). The pedicle that is twisted may be seen
as a ‘whirlpool’ that is visible both in grey scale and on
colour Doppler16 and has been shown to increase the
diagnostic sensitivity for torsion.17 Of the above appearances,
unilateral ovarian enlargement and oedema appears to be the
most consistent finding in the literature. If there is a simple
cyst within the ovary, the cyst tends to become haemorrhagic
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 (Figure 3). The tube
may also be involved and may fill with haemorrhagic
fluid (Figure 4).
Abnormal Doppler signals in the ovarian vessels have been
identified in up to 100% of cases of adnexal torsion17;
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.11 Coiling of the ovarian
vessels may be seen in early or subacute cases (Figure 5).18
Attempts have been made to classify the severity of torsion in
231
 An update on the diagnosis and management of ovarian torsion
Figure 2. Top left: normal ovary. Top right and bottom row: enlarged, haemorrhagic, torted contralateral ovary
the presence of coiling of the ovarian vessels, but this has yet
to be confirmed in larger studies. 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 haemorrhagic fluid in
the pouch of Douglas15 but this is not invariable. Anechoic
fluid in the pelvis may be a normal finding, so cannot be used
as a marker of torsion.
Ovarian cysts and torsion in assisted
reproduction and pregnancy
An ovarian cyst (  25 mm simple or complex cyst) can be
found in up to 5% of pregnancies,19 with a 1–3% torsion
rate.19–21 The risk of torsion appears to decrease with
increasing gestation,21 is unusual after 20 weeks22 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.23
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.24
Oophorectomy is likely to be used more frequently to avoid
232
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.25,26
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. The use of assisted
reproductive technology (ART) is associated with an 11-fold
increased risk of ovarian torsion.27 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,28 leading them to conclude that it is a major risk
factor for ovarian torsion in pregnancy.
Other imaging techniques
Computed tomography (CT) and magnetic resonance
imaging (MRI) have been shown to be useful in the
diagnosis of adnexal torsion and findings include
ª 2012 Royal College of Obstetricians and Gynaecologists
 Damigos et al.

Figure 3. Two cases of adnexal torsion associated with simple ovarian cysts. Contralateral ovaries are normal (left). Torted ovaries are enlarged,
oedematous and less well defined (right)

Figure 4. Grossly distended fallopian tube filled with haemorrhagic Figure 5. Coiling of the ovarian vessels in a case of subacute torsion
fluid in association with an ovarian torsion

enlargement of the ovarian stroma, tube thickening, ascites provide additional diagnostic information. MRI is more
and uterine deviation to the affected side,29–31 with a good useful (and safe)32 in the second and third trimesters of
negative predictive value.31 These modalities are expensive pregnancy for diagnosing abdominal pain, where the ovaries
however, are less readily available than ultrasound and rarely and appendix are more difficult to visualise by ultrasound

ª 2012 Royal College of Obstetricians and Gynaecologists 233

 An update on the diagnosis and management of ovarian torsion
Figure 6. Two cases of ovarian torsion after ART. Top: hyperstimulated ovary with areas of haemorrhage and necrosis (arrows). Bottom:
multicystic ovaries with areas of haemorrhage
and should be considered early in the investigation of unwell
pregnant women with abdominal pain, not thought to be
obstetric in nature.
Serum markers
Blood is routinely taken from women presenting to the
emergency department (ED) with acute pelvic pain, to detect
evidence of infection, anaemia and inflammation. No single
or combined markers have been identified that improve
diagnostic accuracy in adnexal torsion. Torsion results in an
ischaemic insult to the ovary, which is either intermittent or
complete, and markers of ischaemia or ischaemia-reperfusion
injury could theoretically be raised in the serum of women
with torsion. The commonest and easiest marker to examine
is C-reactive protein, an acute phase protein that is raised in
the presence of inflammation; the white cell count is also
often measured and is raised in approximately 50% of women
with adnexal torsion.11 Unfortunately, neither of these
markers has been found to be useful in the diagnosis of
torsion because of low sensitivity and specificity. Several other
pro-inflammatory markers (such as interleukin-6 and tumour
necrosis factor-a33) have been assessed, but again, none have
234
proved to have sufficient diagnostic accuracy to enter into
routine use. Recently, ischaemia-modified albumin has been
shown in animal models to be raised in cases of ovarian
torsion; however this has yet to be assessed in humans.34
Management
The surgical management of adnexal torsion is clearly
determined by many factors in addition to the macroscopic
appearance of the adnexum; including age, menopausal
status, presence of pre-existing ovarian pathology and desire
to preserve fertility. Due to the relatively low incidence of the
disease, studies examining long-term outcomes are usually
retrospective and involve small numbers. Traditionally,
surgery has involved partial or complete oophorectomy or
salpingo-oophorectomy. There is evidence to suggest that the
clinical appearances of torsed adnexae do not correlate well
with the likelihood of residual ovarian function and
recovery35–39 and there are good outcome data to support
conservative management with laparoscopic de-torsion in the
majority of cases with little short or long-term associated
morbidity,36,38–41 even if the ovary appears dark purple or
black. In addition, outcomes from paediatric cases of torsion
ª 2012 Royal College of Obstetricians and Gynaecologists

would support a more conservative approach to surgical
management in the form of de-torsion with or without
oophoropexy.42,43 The likelihood of preserving viable ovarian
tissue with conservative surgery (de-torsion) decreases over
time, with some evidence that pain for longer than 48 hours
is associated with a significant decrease in successful
outcome.44 Clearly, 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. Cases of testicular torsion are
managed as a surgical emergency, as testicular torsion of
greater than 6 hours is thought unlikely to be accompanied
by testicular recovery. While there may be less time pressure
with ovarian torsion, the diagnosis is less obvious and the
process may be more lengthy, so once the decision for
laparoscopy has been made, the same degree of urgency
should be afforded in adnexal torsion.45
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).4,35,40,41,46
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.47 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. These reports are mainly in
children and adolescents, however, long-term outcomes in
these cases are unclear.43 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.4 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. As always, however, the route
should be determined by the clinical expertise of the
operator, and based on the patients’ suitability for
laparoscopic surgery.
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
ª 2012 Royal College of Obstetricians and Gynaecologists
Damigos et al.
tenderness but can be non-specific. Transvaginal ultrasound
remains the first-line investigation; however MRI may be
more useful in the second and third trimesters of pregnancy.
The absence of radiological evidence suggestive of torsion
does not necessarily exclude it and the decision to operate
should be on clinical grounds if symptoms are severe.
Prompt intervention to preserve ovarian function should
be laparoscopic wherever possible and 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. 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.
Conflict of interest
None declared.
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ª 2012 Royal College of Obstetricians and Gynaecologists