Ovarian and fallopian tube torsion

Author
Marc R Laufer, MD
Section Editors
Howard T Sharp, MD
Deborah Levine, MD
Deputy Editor
Sandy J Falk, MD, FACOG
Contributor disclosures

All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Jul 2016. | This topic last updated: Nov 20, 2015.

INTRODUCTION — Ovarian torsion refers to the complete or partial rotation of the ovary on its
ligamentous supports, often resulting in impedance of its blood supply. It is one of the most common
gynecologic emergencies and may affect females of all ages [1]. The fallopian tube often twists along with
the ovary; when this occurs, it is referred to as adnexal torsion. Prompt diagnosis is important to preserve
ovarian and/or tubal function and to prevent other associated morbidity. However, making the diagnosis
can be challenging because the symptoms are relatively nonspecific.

Isolated torsion of the fallopian tube is less common, but may also occur and adversely impact tubal
function [2]. Tubal torsion may occur either in the mid-portion of the tube itself or around the ligamentous
supports of the tube.

Torsion of paratubal or paraovarian cysts may also occur [3,4].

This topic will focus mainly on ovarian torsion, but isolated fallopian tube torsion and torsion of paratubal
or paraovarian cysts will also be reviewed. An overview of the approach to an adnexal mass and to acute
pelvic pain is discussed separately. (See "Approach to the patient with an adnexal mass" and "Evaluation
of acute pelvic pain in women".)

RELEVANT ANATOMY — The ovary is suspended by the infundibulopelvic ligament (also referred to as
the suspensory ligament of the ovary), and is not fixed, but may be positioned lateral and/or posterior to
the uterus, depending upon the position of the patient. The infundibulopelvic ligament is a fold of the
broad ligament that is attached laterally to the pelvic sidewall. The ovarian vessels, which originate in the
upper abdomen, travel through the infundibulopelvic ligaments. Other support structures of the ovary
include the utero-ovarian ligament, which attaches the ovary to the uterus, and the broad ligament, one
area of which is the mesovarium.

The fallopian tubes are attached to the broad ligaments with a condensation of connective tissue called
the mesosalpinx.

Ovarian and fallopian tube anatomy are discussed in detail separately. (See "Surgical female pelvic
anatomy", section on 'Adnexa'.)

PATHOGENESIS

Mechanism of torsion — When ovarian torsion occurs, the ovary typically rotates around both the
infundibulopelvic ligament and the utero-ovarian ligament. The fallopian tube often twists along with the
ovary; when this occurs, it is referred to as adnexal torsion.
In adults, an ovarian physiologic cyst (functional cyst, corpus luteum) or a neoplasm is the most likely
factor to predispose to ovarian torsion (table 1). The presence of an ovarian mass makes it more likely for
the ovary to rotate on the axis of the infundibulopelvic and utero-ovarian ligaments and to become fixed in
a torsed position. As the size of the mass increases, the risk of torsion increases, until the mass becomes
large enough to be fixed in place in the pelvis. In addition, masses that are fixed in place due to
adhesions (eg, endometrioma, tuboovarian abscess) or malignancy appear to be less likely to torse.
(See 'Ovarian mass' below and 'Size' below and 'Benign versus malignant masses' below.)

Ovarian torsion may also occur in patients with normal ovaries (no mass and not enlarged). The
mechanism of torsion of normal ovaries is unclear. This has been found in patients of all ages, but
particularly in premenarchal girls. The utero-ovarian ligament is normally elongated in the premenarchal
girl and then shortens as girls mature through puberty [5-7]. One hypothesis of the etiology of adnexal
torsion in children with normal ovaries is that the elongated utero-ovarian ligament facilitates ovarian
torsion by permitting excessive ovarian movement, but this has not been proven. (See 'Normal
ovaries' below.)

The right ovary appears to be more likely to torse than the left, possibly because the right utero-ovarian
ligament is longer than the left and/or that the presence of the sigmoid colon in the left side of the colon
may help to prevent torsion [8,9].

Some data suggest that ovarian torsion may occur following strenuous exercise or a sudden increase in
abdominal pressure [10-12].

Mechanism of ovarian or tubal injury — Rotation of the infundibulopelvic ligament causes compression
of the ovarian vessels and impedes lymphatic and venous outflow and arterial inflow. However, the
arterial supply to the ovary is not initially interrupted to the same degree as the venous drainage since the
muscular arteries are less compressible than the thin walls of the veins. Continued arterial perfusion in
the setting of blocked outflow leads to ovarian edema with marked ovarian enlargement and further
vascular compression. Ovarian ischemia then occurs and can result in ovarian necrosis, infarction, and
local hemorrhage.

NATURAL HISTORY — Complete occlusion of the ovarian blood supply will ultimately result in loss of
ovarian function and necrosis of the torsed tissues. Additional potential adverse effects are hemorrhage
or peritonitis [13-16]. However, hemorrhage requiring blood transfusion or sepsis have rarely been
reported [17-21]. The necrotic tissue will involute over time, but there may be pelvic adhesion formation,
which can result in pelvic pain or infertility.

Unrecognized tubal torsion will result in loss of tubal function, and likely hydrosalpinx or necrosis with
eventual resorption of the damaged tissue.

Intermittent adnexal torsion may occur, and may have few, if any, adverse effects if perfusion is not
persistently compromised and, in the case of isolated tubal torsion, the tube is not damaged.

EPIDEMIOLOGY AND RISK FACTORS — The incidence of adnexal torsion is unknown. There are some
data regarding the rate of torsion among patients presenting for gynecologic care to an acute care setting.
In a classic report of a 10-year review of patients at a women's hospital, ovarian torsion accounted for 2.7
percent of emergency surgeries [22]. Torsion was the fifth most common surgical emergency, preceded
by (in descending order) ectopic pregnancy, corpus luteum rupture with hemorrhage, pelvic inflammatory
disease, and appendicitis. In a 10-year review of surgically treated adnexal masses, torsion accounted for
15 percent of cases [23].

The primary risk factor for ovarian torsion is an ovarian mass, particularly a mass that is 5 cm in diameter
or larger [24-27]. Many of the risk factors for ovarian torsion, therefore, are related to the likelihood of
developing an ovarian cyst or neoplasm. Since many of these masses are associated with the
reproductive cycle or reproductive hormones (eg, corpus luteum, ovulation induction), the risk of torsion is
increased in women of reproductive age, during pregnancy, and in women undergoing ovulation induction
for treatment of infertility.

Ovarian mass — An ovarian mass (physiologic cyst or neoplasm) is the primary risk factor for ovarian
torsion. In three case series, each with 80 or more patients with ovarian torsion, 86 to 95 percent had an
ovarian mass [24,27,28].

Torsion usually occurs infrequently in premenarchal girls, but when an ovarian mass is present, torsion is
a common complication. Torsion accounts for 20 to 30 percent of ovarian surgeries in the pediatric
population [25,29]. As an example, in a 15-year retrospective series of girls age 19 years or younger
(average age of 9 years), torsion was the indication for 97 of 328 (30 percent) of ovarian surgical
procedures [25].

Similarly, when an ovarian mass is present in a fetus or neonate, there is an increased risk of ovarian
torsion [30]. As an example, a series of 12 of 66 fetuses with ovarian cysts followed with serial ultrasound
examinations developed sonographic changes consistent with torsion while still in-utero [31]. In addition,
a series of 30 neonates with prenatally diagnosed ovarian cysts that persisted after birth found that 30 to
40 percent required surgical intervention due to torsion in the first weeks after birth [32].

Size — In general, torsion is most likely to occur when the ovary is 5 cm in diameter or larger. In three
case series, each with 80 or more patients, 83 to 93 percent of torsed ovaries were 5 cm or larger
[24,25,27]. This represents an average; however, torsion may occur with a mass of any size. Although it
has been postulated that very large ovaries are less likely to torse because the size impedes movement
within the pelvis, the upper limit of size has not been defined. The wide range of sizes of ovarian masses
that are in cases of torsion was illustrated in a series of 87 cases of torsion, in which ovarian size ranged
from 1 to 30 cm (mean 9.5 cm) [27]. (See'Mechanism of torsion' above.)

Benign versus malignant masses — Torsion is more likely to occur with benign cysts or neoplasms
rather than malignant lesions, possibly because malignant masses are more likely to be fixed in place.
Case series have reported malignancy in 2 percent or fewer of cases of torsion [25,28,33]. However, the
rate of malignancy in a torsed ovary is higher among postmenopausal women (20 to 25 percent in two
series), since the overall rate of a malignant adnexal mass is highest in this population [34,35].

Normal ovaries — It is important to note that torsion may occur in the presence of normal ovaries,
particularly in the pediatric population [36]. In children under the age of 15 years, normal ovaries have
been demonstrated in over 50 percent of patients with ovarian torsion [37,38]. As an example, one large
series of patients with adnexal torsion reported that 23 of 103 patients (22 percent) had no identifiable
adnexal lesion [24]. In another study, 12 of 22 patients under the age of 15 years with adnexal torsion had
normal ovaries visualized at laparoscopy [37]. Asynchronous bilateral torsion of normal ovaries has also
been reported [39,40].
Reproductive age — The majority of cases of ovarian torsion occur in women of reproductive age
[24,27,28]. For example, in 10- to 15-year retrospective series at single institutions, the average age of a
patient with torsion was in the late-20s to mid-30s and the majority of cases occurred between the ages of
20 and 50 years [27,28,33].

Ovarian torsion may occur in females of all ages, even fetuses and neonates, particularly if an ovarian
mass is present, as noted above [25,31,32]. As an example, in a series of 216 cases of torsion, the age
range was 3 months to 77 years (mean 29 years) [33]. There are no data to establish the incidence of
torsion in premenarchal girls. (See 'Ovarian mass' above and "Ovarian cysts and neoplasms in infants,
children, and adolescents".)

Similarly, torsion appears to occur infrequently in postmenopausal women. As an example, in a series of

301 postmenopausal women with ovarian neoplasms, 19 (6 percent) had ovarian torsion [41].

Pregnancy — Pregnancy is associated with an increased risk of ovarian torsion, accounting for 10 to 22
percent of cases of torsion in series of 80 or more patients (image 1) [27,28,33].

The incidence of torsion during pregnancy is uncertain; one five-year retrospective study reported 7 cases
out of 4274 deliveries (0.2 percent) [42]. In a series of 174 pregnant women with a persistent adnexal
mass ≥4 cm, the incidence of torsion was 15 percent [43]. Torsion was most likely between 10 and 17
weeks of gestation, but occurred through term and the postpartum period. Ovarian masses 6 to 8 cm in
diameter were more likely to undergo torsion than larger masses, although torsion occurred in women
with masses that were 10 to 20 cm. Other series in pregnant women with an adnexal mass have reported
a much lower incidence of torsion (1 to 6 percent) [44,45].

Ovulation induction — Ovulation induction for treatment of infertility results in the formation of large
ovarian follicular cysts and, in some patients, massive ovarian enlargement due to hyperstimulation. As
an example, among women with ovarian hyperstimulation syndrome, the incidence of torsion was 8
percent in one series [46]. (See "Overview of ovulation induction".)

Prior ovarian torsion — Recurrent torsion occurs in some patients, but the rate is not known. In one
series, 23 of 216 cases (11 percent) of torsion were recurrent [33].

Some data suggest that patients with normal ovaries are at higher risk of recurrent torsion than those with
abnormal ovaries. In one study, for example, torsion recurred in 7 of 11 patients (64 percent) with normal
adnexa compared with 4 of 46 patients (9 percent) with abnormal adnexa [26].

Prevention of recurrent torsion is discussed below. (See 'Prevention of recurrence' below.)

Other risk factors — Some data suggest that tubal ligation is associated with an increased risk of
ovarian torsion, but the degree of this risk is uncertain [27,33].

There are a few case reports of ovarian torsion associated with enlarged ovaries in the setting of
polycystic ovarian syndrome [47,48].

CLINICAL PRESENTATION — The classic presentation of ovarian torsion is the acute onset of moderate
to severe pelvic pain, often with nausea and possibly vomiting, in a woman with an adnexal mass
[13,25,49]. However, the presentation may vary and many symptoms and signs that accompany torsion
are also associated with other conditions. In addition, torsion may also occur in the absence of an
adnexal mass. Thus, a high index of suspicion is required to make the diagnosis. This is of particular
importance since torsion may result in the loss of ovarian function or other adverse sequelae.
(See 'Differential diagnosis' below and 'Normal ovaries' above and 'Natural history' above.)

The frequency of presenting symptoms and findings of ovarian torsion were as follows in series of 50 or
more patients [27,28,33,50]:

●Pelvic pain (90 percent)

●Adnexal mass (86 to 95 percent)
●Nausea and vomiting (47 to 70 percent)
●Fever (2 to 20 percent)
●Abnormal genital tract bleeding (4 percent)

Fever may be a marker of adnexal necrosis, particularly in the setting of leukocytosis. (See 'Laboratory
evaluation' below.)

Infants with ovarian torsion present with feeding intolerance, vomiting, abdominal distension,
and fussiness/irritability [13,51-54]. In most instances, ovarian cysts in this patient population have
already been visualized on a prenatal ultrasound and are being followed with serial sonography to track
growth of the cyst or presence of hemorrhage [32]. Parents or other caregivers should be made aware of
the signs and symptoms of torsion so they can contact the child's clinician without delay.

In premenarchal patients, the clinical presentation may differ from other patients. This was suggested by
a retrospective study (41 premenarchal girls, 208 postmenarchal patients) that found that premenarchal
girls had a longer duration of symptoms before presentation and treatment and were more likely to
present with diffuse pain, fever, restlessness, and a palpable pelvic mass than other patients [55]. In this
study, premenarchal patients were more likely to have a finding of a bluish black ovary at surgery (61
versus 41 percent).

Pregnant women with torsion present in a similar fashion with lower abdominal pain, nausea, vomiting,
and possibly a low grade fever, leukocytosis, or a palpable mass [56].

Pelvic pain — Pelvic pain is the most common presenting symptom of ovarian torsion. The pain is
typically of sudden onset (59 percent) and most patients present for evaluation within one to three days of
the onset of the pain [27,28]. There are rare reports of torsion associated with pelvic pain that was
present for up to 210 days, and these are thought to possibly represent intermittent torsion [57]. The pain
is usually moderate to severe (82 percent). The character of the pain may be sharp, stabbing, colicky, or
crampy, and may radiate to the flank, back, or groin. Premenarchal patients may be more likely than other
patients to present with diffuse rather than localized pain [55].

Adnexal mass — An adnexal mass is present in most patients with ovarian torsion. The mass is typically
an ovarian cyst or neoplasm, but the ovary may be diffusely enlarged (eg, ovarian hyperstimulation
syndrome, polycystic ovarian syndrome). The likelihood of torsion is higher if the mass is 5 cm in diameter
or larger. A paraovarian cyst may be associated with ovarian or tubal torsion or a paratubal cyst may
torse around its own pedicle. The size and other characteristics of ovarian masses associated with torsion
are described above. (See 'Ovarian mass' above.)

Nausea and vomiting — Patients with adnexal torsion often experience waves of nausea with or without
vomiting [27,28,33,50]. In our experience, the onset of nausea typically coincides with the onset of pelvic
pain.
Fever — Fever is present in some patients with ovarian torsion, and is typically low grade [27,28,33,50].

EVALUATION OF PATIENTS WITH SUSPECTED TORSION

Medical history — The medical history should include questions regarding symptoms associated with
ovarian torsion, including pelvic pain and nausea. The patient should be asked regarding a history, or
recent diagnosis, of an adnexal mass. (See 'Clinical presentation' above.)

A history of recent vigorous activity may be an inciting event and should prompt the clinician to consider
the diagnosis of torsion in patients with other suggestive symptoms or findings. (See 'Mechanism of
torsion' above.)

Physical examination — A low grade fever is present in some patients with torsion. Some patients with
torsion present with a slightly elevated heart rate or blood pressure, typically in association with severe
pelvic pain. (See 'Fever' above.)

An abdominal and pelvic examination should be performed. Findings on physical examination are
variable. Most patients exhibit pelvic and/or abdominal tenderness, although tenderness on examination
is absent in as many as one-third of patients [27,28,33]. Tenderness may be localized to the side of an
adnexal mass, if present, or may be diffuse. Similarly, a palpable pelvic mass may or may not be present.
Peritoneal signs are present in a small number of patients, and should raise concern for adnexal necrosis.
(See 'Natural history' above.)

Laboratory evaluation — A serum human chorionic gonadotropin, hematocrit, white blood cell count,
and electrolyte panel should be drawn.

Pregnancy testing with human chorionic gonadotropin is essential, since the risk of torsion is increased in
pregnant women. In addition, ectopic pregnancy must be excluded in pregnant women with acute pelvic
pain. Also, knowledge of pregnancy status helps to guide management to ensure maternal and fetal
safety.

In the setting of ovarian torsion, in rare cases, hemorrhage may result in anemia and adnexal necrosis
may cause infection with associated leukocytosis. Laboratory abnormalities are absent in many patients
and, when present, anemia or leukocytosis are nonspecific and do not contribute to establishing the
diagnosis of torsion. However, if these laboratory findings are present in a patient with suspected torsion,
they raise concern for severe adnexal damage.

There is no serum marker for the diagnosis of adnexal torsion. Small observational studies have found an
association between an increased level of serum interleukin-6 (IL-6) and ovarian torsion [58,59]; further
investigation is needed to evaluate use of serum IL-6 for diagnosis of torsion.

If an adnexal mass is present and malignancy is suspected, serum tumor markers should be drawn.
(See "Approach to the patient with an adnexal mass", section on 'Laboratory studies'.)

Imaging studies — We suggest pelvic ultrasound as the first line imaging study for patients with
suspected ovarian torsion. Pelvic magnetic resonance imaging (MRI) or computed tomography (CT) scan
are not usually ordered for the evaluation for adnexal torsion, but the diagnosis may be made using those
modalities in a patient studied for a different clinical indication.

Ultrasound — Ultrasound is the initial imaging study of choice for patients with suspected ovarian
torsion. Ultrasound is less expensive than CT and MRI, and its diagnostic performance is similar. Both a
transvaginal and transabdominal ultrasound should be obtained in most patients to visualize both
abdominal processes and provide the best images of pelvic structures.

The sonographic findings that are associated with ovarian torsion are listed here and examples are
shown in the images (image 2 and image 3) [60,61]. The presence of these findings varies across
patients:

●An ovary that is rounded and enlarged compared with the contralateral ovary – This is due to
edema and vascular and lymph engorgement.
●An ovarian mass – While the ultrasound is being performed, it is often helpful to note whether the
patient has tenderness associated with the mass. In torsion, the patient will have pain ipsilateral to
the mass, and scanning with the vaginal probe in the region of the mass will elicit pain.
●Heterogenous appearance of the ovarian stroma – This is due to edema and hemorrhage.
●Multiple small peripheral follicles (“string of pearls”) – This is thought to be due to displacement by
edema. This feature is also seen in polycystic ovarian syndrome, although in polycystic ovaries, the
stroma is echogenic centrally, the ovary does not appear edematous, and the patient does not have
acute pain.
●Abnormal ovarian location – The normal location of the ovaries is lateral to the uterus, but in
torsion, they may be located anterior to the uterus.
●Decreased or absent Doppler flow within the ovary – Diminished or absent ovarian vessel flow on
two-dimensional, color, and three-dimensional Doppler ultrasound has been proposed as a test for
ovarian torsion [14,62-65]. Since the ovary has a dual blood supply, flow can be present even in the
presence of torsion. Arterial flow in systole without flow in diastole is evidence for outflow
obstruction. Venous flow in the setting of torsion is associated with ovarian viability. It is helpful
when performing sonography for torsion to ensure that Doppler flow settings are set appropriately by
obtaining flow tracings in the contralateral ovary prior to examining the symptomatic ovary.

In a prospective study of 199 patients with an adnexal mass in the setting of pelvic pain, absence or
impaired ovarian venous flow on Doppler ultrasound was found to have 100 percent sensitivity and
97 percent specificity for a diagnosis of ovarian torsion [66]. In contrast, a retrospective study of 78
patients who underwent laparoscopy for presumed torsion reported that abnormal Doppler flow had
a sensitivity and specificity of 43 and 92 percent [67].
●Doppler grayscale “whirlpool sign” in the ovarian vessels – This is visualized as a round
hyperechoic structure with concentric hypoechoic stripes or a tubular structure with internal
heterogeneous echoes. This sign is thought to represent the twisting of the vascular pedicle. Two
small series of 20 patients with suspected torsion found this sign to have a sensitivity of 90 percent
or higher for the diagnosis of torsion [68,69]. Further study is needed to determine the usefulness of
this sign in patients who present with pelvic pain.

The reported sensitivity of ultrasound for the diagnosis of ovarian torsion ranges from 46 to 75 percent
[61,70]. As an example, in one series of 63 patients with suspected torsion, the most sensitive
sonographic findings were: abnormal ovarian location (sensitivity: 90 percent and specificity: 68 percent);
free fluid around ovary or in posterior cul-de-sac (89 and 54 percent); ovarian cyst/mass (83 and 70
percent); and abnormal ovarian blood flow (80 and 54 percent) [70]. A sensitivity of 100 percent was
achieved by combining two or more findings, although the highest specificity was approximately 70
percent even when findings were combined.
Other imaging studies — MRI may be helpful if findings on ultrasound are equivocal, but the cost and
time required for MRI does not justify its routine use for the evaluation of suspected adnexal torsion [71-
76]. MRI findings consistent with ovarian torsion include an enlarged, edematous ovary in an abnormal
location and, with contrast enhancement, the coiled ovarian vessels may be visualized with the “whirlpool”
sign.

CT is not typically used for the evaluation of ovarian torsion, but a woman with acute abdominal or pelvic
pain may undergo CT as an initial study (eg, to exclude appendicitis). Similar to MRI, findings on CT that
are consistent with torsion include an enlarged, edematous ovary in an abnormal location, lack of
enhancement of the ovary after administration of intravenous contrast, and coiled ovarian vessels.

DIAGNOSIS — A definitive diagnosis of ovarian torsion is made by direct visualization of a rotated ovary
at the time of surgical evaluation.

The decision to proceed with surgery is based upon a clinical diagnosis made with a combination of
symptoms, signs, and ultrasound findings. A presumptive diagnosis of torsion can be made with a fair
degree of confidence in the presence of acute pelvic pain and an adnexal mass with a sonographic
appearance consistent with torsion and after exclusion of ectopic pregnancy, tuboovarian abscess, and
appendicitis. Additional findings, such as nausea, fever, and pelvic tenderness on examination further
support the diagnosis. (See 'Ultrasound' above and 'Differential diagnosis' below.)

The decision to proceed with surgery, however, must often be made in the absence of some of these
clinical features. It is important to note that the absence of an adnexal mass does not exclude a diagnosis
of torsion. Torsion may occur in patients with ovaries with no underlying lesion, particularly in
premenarchal patients, as noted above. (See 'Normal ovaries' above.)

The difficulty in diagnosis was illustrated in a series of 115 cases of adnexal torsion that revealed that the
correct preoperative diagnosis was made in only 38 percent of patients [77].

DIFFERENTIAL DIAGNOSIS — The differential diagnosis of ovarian torsion includes other conditions
that present in a similar manner.

In a woman with acute pelvic pain and an adnexal mass, ectopic pregnancy, a ruptured ovarian cyst, and
tuboovarian abscess should be excluded. A negative serum human chorionic gonadotropin excludes
ectopic pregnancy.

In pregnant women, sonographic evidence of an intrauterine pregnancy decreases the likelihood of

ectopic pregnancy (but does not exclude heterotopic pregnancy). If it is too early in pregnancy to visualize
an intrauterine gestation, the two conditions are typically differentiated by risk factors, symptoms and
ultrasound findings. Patients with either ectopic pregnancy or ovarian torsion may have pelvic pain, an
adnexal mass, and nausea. However, the onset of the pain is typically followed shortly by nausea in
torsion. In addition, ectopic pregnancy is usually associated with vaginal bleeding, while torsion is usually
not. Either condition requires urgent intervention. (See "Ectopic pregnancy: Clinical manifestations and
diagnosis".)

Rupture of an ovarian cyst is often accompanied by sonographic evidence of hematoperitoneum or free

fluid in the pelvis; free fluid may also be seen with torsion [61]. In addition, the classic history of cyst
rupture is the sudden onset of pelvic pain at midcycle, often following sexual intercourse. Symptom
patterns and ultrasound findings vary for both conditions, and may appear similar. When the patient has
pain with associated fluid, the distinction between a ruptured cyst and torsion may be difficult. If torsion is
suspected, surgical evaluation should be performed. (See "Evaluation and management of ruptured
ovarian cyst".)

Tuboovarian abscess is more likely to have an indolent course and be associated with fever than torsion,
and the characteristic sonographic appearance of an abscess is a complex, multilocular mass, which is
not usually found in torsion. (See "Epidemiology, clinical manifestations, and diagnosis of tubo-ovarian
abscess", section on 'Evaluation of women with suspected toa'.)

Appendicitis is another etiology of pelvic pain, nausea, and fever that may be difficult to differentiate from
adnexal torsion. Currently, these two conditions are differentiated by the patient’s symptoms, physical
examination to localize the pain, and by the presence of characteristic imaging findings [78,79]. Use of
biomarkers has been proposed to differentiate between these two clinical entities. As an example, a
prospective study of over 300 women ages 6 to 21 years with pelvic pain reported that serum IL-6 was
elevated in women who underwent surgery, and that serum CD64 levels were significantly higher in
patients with appendicitis compared to those with ovarian torsion [80]. These results are investigational,
and further study is needed before they can be applied clinically. (See "Acute appendicitis in adults:
Clinical manifestations and differential diagnosis".)

The pattern of pain associated with ovarian torsion is variable, and thus, the differential diagnosis also
includes other conditions that are associated with acute or chronic pelvic pain, including an ovarian cyst
or neoplasm that is not torsed, endometriosis, or a degenerating leiomyoma. (See "Evaluation of acute
pelvic pain in women" and"Causes of chronic pelvic pain in women".)

SURGICAL EVALUATION — The decision to proceed with a surgical evaluation is based upon a clinical
diagnosis of ovarian torsion. (See 'Diagnosis' above.)

The goals of the intraoperative evaluation are to confirm the presence of torsion and evaluate the viability
of the ovary and tube. Most torsed ovaries are considered potentially viable, unless there is a clearly
necrotic appearance.

A laparoscopic approach is typically used, unless there is a suspicion of ovarian or fallopian tubal cancer
[33,81]. Surgical treatment should be performed by a gynecologist, whenever possible, for optimal
evaluation of the ovary. In children, if a gynecologic pediatric surgeon is not available, an intraoperative
consultation from a gynecologist should be obtained [82]. (See "Approach to the patient with an adnexal
mass", section on 'Evaluation for malignancy'.)

Confirm torsion — The diagnosis of torsion is confirmed by direct visualization of the rotated ovary, tube,
or paratubal or paraovarian cyst. Most surgeons document the findings with laparoscopic photographs of
the adnexa.

Assess ovarian viability — There is no highly effective intraoperative approach to determining ovarian
viability in women with ovarian torsion. Ovarian conservation is the preferred approach for
premenopausal women, and most ovaries should be considered viable unless there is a high degree of
certainty that the ovary is not viable due to the presence of necrotic/gelatinous tissue.

The standard approach to determining the viability of a torsed ovary is gross visual inspection. An ovary
that is dark and enlarged likely has vascular and lymphatic congestion and may have hemorrhagic lesions
(picture 1A-B). Traditionally, ovaries with this appearance have been thought to be nonviable, but multiple
studies have found that many women (even those with an ovary that is blue or black) retain ovarian
function following detorsion [81,83-90]. In studies with ultrasound follow-up, the rate of follicular
development after detorsion was 80 percent or higher [75,86,89,90]. As an example, in a study of 40
women with ovarian torsion who had a “bluish-black” appearance of the ovary at surgery and underwent
detorsion, normal follicular development was demonstrated on ultrasound in 35 of 37 patients who were
followed after surgery [86]. A possible explanation of the viability of ovarian tissue, based upon rat data, is
that total arterial occlusion may not be present in the torsed ovary despite venous and lymphatic
congestion [91].

Rarely, ovarian or tubal necrosis are present at time of surgery. The appearance on gross inspection of a
necrotic ovary or tube includes a loss of normal anatomic structure and a gelatinous or friable
consistency.

Other approaches have been proposed to assess whether ovarian perfusion is present, but these are
investigational. One technique is ovarian bivalving, in which the ovary is untwisted and the ovarian cortex
incised. In our practice, we make the incision with a laparoscopic instrument with an electrosurgical “L-
hook” needle tip attachment. This method allows visualization of whether blood flow is present at the
incision. In addition, there is a potential therapeutic effect by relieving the increased pressure exerted by
the lymphatic and venous congestion (picture 2A-C) [92,93]. This approach was reported in one series of
five patients who underwent bivalving, four of whom had normal postoperative follicular development
documented by ultrasound [92]. Another approach that has been reported is intraoperative
intravenousfluorescein injection followed by direct visualization of the affected ovary under ultraviolet light
[94]. However, this approach requires specialized equipment and its efficacy has not been validated.

MANAGEMENT — The mainstay of treatment of ovarian torsion is swift operative evaluation to preserve
ovarian function and prevent other adverse effects (eg, hemorrhage, peritonitis, adhesion formation). For
most premenopausal patients with ovarian torsion, we recommend detorsion and ovarian conservation
rather than salpingo-oophorectomy. Ovarian cystectomy is often performed if a benign mass is present.
Patients with an ovarian mass that is suspicious for malignancy require salpingo-oophorectomy. Ovaries
that are hemorrhagic and/or edematous are most likely viable and, thus, oophorectomy should be
reserved for necrotic/gelatinous/deadtissue. Salpingo-oophorectomy is also reasonable for
postmenopausal women.

Historically, salpingo-oophorectomy on the affected side had been the standard treatment of a torsed
ovary because it was believed that conserving the ovary would leave behind necrotic tissue and restoring
normal anatomy via detorsion could dislodge a clot in the ovarian vein and result in an embolus [95].
However, it appears that detorsion is associated with continued ovarian function in many women, based
upon multiple observational studies, as discussed above [83-87].

The key factor is to perform detorsion as quickly as possible. A study in rats found that necrosis occurred
after occlusion of the ovarian vessels for 36 hours or longer [91]. Consistent with the increasing risk of
ovarian ischemic damage over time, the rate of ovarian conservation reported in studies decreases with
an increasing interval between symptoms to surgery [37,88].

There is also no evidence of an increase of adverse events with detorsion. In the only comparative data,
a retrospective study of 94 women under age 40 years with ovarian torsion, there was no increase in
postoperative complications in those who underwent detorsion with cystectomy compared with salpingo-
oophorectomy [96]. No pulmonary embolic events were identified in either group. In addition, a case
report and review of the literature described 981 cases of torsion in which 309 were managed with
detorsion and 672 with adnexal resection [16]. Two pulmonary embolisms were observed in the adnexal
resection group, and none in the detorsion group.

Premenopausal patients with a viable ovary — In premenopausal patients, the surgical evaluation is
performed. Following detorsion, the adnexa is assessed for the presence of an ovarian cyst or neoplasm.
If a mass is present and there is no suspicion of malignancy, a cystectomy is performed. If malignancy is
suspected, a salpingo-oophorectomy should be performed. (See 'Surgical evaluation' above and 'Patients
with a nonviable ovary, suspected malignancy, or postmenopausal patients'below.)

The evaluation and management of an ovarian cyst or neoplasm is discussed in detail separately.
(See "Approach to the patient with an adnexal mass" and "Management of an adnexal mass".)

Detorsion and ovarian conservation — Detorsion consists of untwisting the torsed ovary and any other
torsed structure. During laparoscopy, this can be accomplished with a blunt probe or an atraumatic
grasper. If laparotomy is performed, the ovary can be untwisted manually.

While the benefits of conservative surgery appear to outweigh the theoretical surgical risks of detorsion,
irreversible ischemic damage to the adnexa can occur and may lead to infection if a necrotic ovary is
retained. Postoperative care and instructions following detorsion should include observation for signs of
peritonitis or sepsis (fever, abdominal pain, peritoneal signs, hemodynamic instability). This rare
complication was reported in a pregnant patient who underwent laparotomy and detorsion of a
hyperstimulated ovary with reperfusion of the torsed adnexa observed intraoperatively [21]. Reexploration
because of peritonitis two days postoperatively revealed clear evidence of a necrotic ovary. (See 'Natural
history' above.)

Patients with a nonviable ovary, suspected malignancy, or postmenopausal patients

Salpingo-oophorectomy — Patients with an ovary that is apparently necrotic (black color combined with
loss of normal anatomic structure and a diminished size) during intraoperative evaluation should undergo
salpingo-oophorectomy.

Salpingo-oophorectomy is required if ovarian or fallopian tubal cancer is suspected. Ovarian torsion is

rare in postmenopausal women, but when it occurs, salpingo-oophorectomy is reasonable to prevent
recurrence. In addition, if an ovarian mass is present, removal of the adnexa is the standard in this patient
population due to the risk of malignancy.

Evaluation for malignancy typically depends in part on measurement of serum tumor markers and often
on serial pelvic sonography. These results are often not available for patients who require urgent surgery,
so decisions regarding salpingo-oophorectomy should be made based upon the available information. In
a premenopausal patient, the ovary should be preserved unless there is a high clinical suspicion of
malignancy. In contrast, in the rare postmenopausal woman with an ovarian mass, salpingo-
oophorectomy is the preferred approach.

Intraoperatively, the adnexa should be detorsed to better visualize the mass. In addition, this allows better
delineation of the infundibulopelvic ligament and location of the ureter to avoid surgical complications.
The adnexa is then removed in the usual fashion. (See "Oophorectomy and ovarian cystectomy".)

The evaluation and management of an adnexal mass if malignancy is suspected is discussed in detail
separately. (See "Approach to the patient with an adnexal mass", section on 'Evaluation for
malignancy' and "Management of an adnexal mass".)
Pregnant women — Management of torsion in pregnancy is similar to that in nonpregnant patients, but
may be technically more difficult given the size of the gravid uterus. One review examined 47 patients (17
in the first trimester, 27 in the second trimester, 4 in the third trimester) who underwent laparoscopic
management of ovarian cysts (n = 36), torsion (n = 8), and pelvic mass (n = 3 [97]). One pregnancy loss
occurred four days after the procedure, suggesting that the laparoscopic approach remains a safe option
even in pregnancy [97]. Other reviews have confirmed the safety and effectiveness of laparoscopic
management of torsion in pregnant women [98-100]. (See "Laparoscopic surgery in pregnancy".)

Fetuses and neonates — Ovarian masses in a fetus are occasionally detected on prenatal ultrasound
and are followed with serial sonography. In-utero ovarian torsion may occur, in which case, the ovary may
undergo necrosis and develop into a calcified persistent mass or resorb. Prenatal puncture of ovarian
cysts thought to be at risk for torsion has been described, but is investigational [101]. Consultation with a
maternal-fetal medicine specialist is advised.

Ovarian masses may also be found in neonates; these are typically first noted prenatally. In a neonate
with an ovarian mass, if there is suspicion of torsion based upon irritability, pelvic/abdominal tenderness,
and suggestive ultrasound findings, the patient should be evaluated surgically and managed in the same
fashion as other patients [53,102,103]. A laparoscopic approach is appropriate, if a surgeon with
expertise in pediatric laparoscopy is available [104]. (See "Overview of laparoscopy in children and
adolescents".)

Management of ovarian masses in the pediatric population is discussed in detail separately.

(See "Ovarian cysts and neoplasms in infants, children, and adolescents".)

PREVENTION OF RECURRENCE — Ovarian torsion may recur, although the incidence of and risk
factors for recurrence are unknown [6,26,105-107]. (See 'Prior ovarian torsion' above.)

There are several options to decrease the risk of recurrence:

●Suppression of ovarian cysts – Use of high dose oral contraceptives (≥50 mcg estrogen) results in
fewer ovulations and cysts [108-111]; however, prolonged use of these is associated with thrombotic
risks and it has not been shown that this therapy decreases the risk of recurrent ovarian torsion.
Low dose estrogen-progestin contraceptives may not prevent development of ovarian cysts [112].
(See "Management of an adnexal mass", section on 'Clinical scenarios for ovarian
masses' and"Risks and side effects associated with estrogen-progestin contraceptives".)
●Oophoropexy – Unilateral or bilateral oophoropexy following ovarian detorsion has also been used
to prevent recurrence, although there are no high quality data regarding the efficacy of this approach
[98,113,114]. Some experts advise this procedure be performed in every case of childhood torsion,
especially if one ovary is removed [8,115], but others are concerned about the routine use of
oophoropexy, since long-term follow-up fertility studies have not been performed [13].

In our practice, we perform oophoropexy on children with ovarian torsion who do not have an
ovarian mass, but not in those with an ovarian mass present at the time of torsion. We also offer
oophoropexy for girls and young women who have previously undergone an oophorectomy for prior
ovarian torsion. The procedure can be performed laparoscopically and we typically shorten the
utero-ovarian ligament or, if the ovary is greatly enlarged without a discrete mass, then it can be
sutured to the uterosacral ligament (picture 3) [116], and has been done in pregnant women [98].
(See "Ovarian transposition before pelvic radiation".)
TORSION OF OTHER ADNEXAL STRUCTURES

Isolated fallopian tube torsion — Torsion of the fallopian tube without ovarian torsion is a rare, but
noteworthy, cause of lower abdominal pain in reproductive age women (picture 4) [117]. Torsion of the
midportion of the fallopian tube causes compression of the tissue and may result in ischemic or traumatic
tubal injury. Tubal injury caused by torsion, similar to injury resulting from infection or adhesive disease,
may result in an adverse effect on fertility. (See "Causes of female infertility", section on 'Fallopian tube
abnormalities/pelvic adhesions'.)

Possible risk factors for tubal torsion include tubal pathology (eg, hydrosalpinx, paratubal cyst, neoplasm,
tubal ligation device, ectopic pregnancy, congenital anomaly), ovarian mass, infection, ectopic pregnancy,
altered tubal function (eg, abnormal peristalsis, spasm), or extrinsic lesions (eg, adhesions,
endometriosis) [118]. In the largest retrospective review of patients with tubal torsion, 24 percent had
normal-appearing tubes, 18 percent had hydrosalpinx, and 13 percent had infection; 12 percent of
torsions were diagnosed during pregnancy [117].

The presenting symptoms and physical examination findings for tubal torsion are similar to those for
ovarian torsion, including pain, nausea and, occasionally, fever [119,120]. Radiologic diagnosis is limited.
In one case series, the most consistent finding on either pelvic ultrasound or computed tomography was a
midline cystic mass (either in the posterior cul-de-sac or superior to the uterus) associated with a normal
ipsilateral ovary [119]. Ultimately, the diagnosis is generally made at time of surgical exploration. As with
ovarian torsion, prompt consideration of this diagnosis and surgical detorsion may prevent irreversible
ischemic damage. (See 'Clinical presentation'above and 'Management' above.)

Paratubal or paraovarian cyst torsion — Paratubal cysts are often connected with the mesosalpinx
with a stalk, around which torsion may occur [3,121]. The incidence of torsion of paratubal cysts is
uncertain, but should be suspected in a patient with acute or intermittent pelvic pain who has a paratubal
cyst identified on pelvic ultrasound. The diagnosis of torsion can be made only with surgical evaluation.
These cysts can easily be removed at time of surgery without compromise of the ovary or fallopian tube.
(See "Differential diagnosis of the adnexal mass", section on 'Paraovarian/paratubal cysts and tubal and
broad ligament neoplasms'.)

Paraovarian cysts are often incorporated in the broad ligament close to the fallopian tube and may
increase the risk of tubal torsion [4,122,123]. In such cases, the fallopian tube is often distended, and if
torsion occurs, the cyst must be removed with great care to avoid compromise of tubal function.

SUMMARY AND RECOMMENDATIONS

●Ovarian torsion refers to the complete or partial rotation of the ovary on its ligamentous supports,
often resulting in ischemia. It is one of the most common gynecologic emergencies. The fallopian
tube often twists along with the ovary; when this occurs, it is referred to as adnexal torsion.
(See 'Introduction' above.)
●Ovarian torsion occurs in all age groups, but the majority of cases occur in women of reproductive
age. (See 'Epidemiology and risk factors' above.)
●The primary risk factor for ovarian torsion is an ovarian mass and is most common if the ovary is 5
cm or larger. However, torsion may also occur without an underlying lesion, particularly in the
pediatric population. (See 'Ovarian mass' above.)
 ●The classic presentation of ovarian torsion is the acute onset of pelvic pain, often with nausea and
possibly vomiting, in a woman with an adnexal mass. The presentation is variable (eg, the pain may
be chronic, some patients present without an adnexal mass, a low grade fever may be occasionally
present). (See 'Clinical presentation' above.)
●Pelvic ultrasound is the first line imaging study for patients with suspected ovarian torsion.
(See 'Imaging studies' above.)
●A definitive diagnosis of ovarian torsion is made by direct visualization of a rotated ovary at the
time of surgical evaluation. The decision to proceed with surgery is based upon a clinical diagnosis,
which is often based upon the presence of acute pelvic pain and an adnexal mass with a
sonographic appearance consistent with torsion, and after exclusion of other conditions.
(See 'Diagnosis' above.)
●The differential diagnosis of ovarian torsion includes ectopic pregnancy, tuboovarian abscess, and
appendicitis, as well as other conditions associated with acute or chronic pelvic pain.
(See 'Differential diagnosis' above.)
●For most premenopausal patients with ovarian torsion, we recommend detorsion and ovarian
conservation rather than salpingo-oophorectomy, even in the case of a darkened, congested ovary
(Grade 1B). Ovarian cystectomy is often performed if a benign mass is present. Patients with an
obviously necrotic ovary or an ovarian mass that is suspicious for malignancy require salpingo-
oophorectomy. Salpingo-oophorectomy is also reasonable for postmenopausal women.
(See 'Management'above and 'Assess ovarian viability' above.)
●Isolated torsion of the fallopian tube is uncommon, but may also occur and may result in an
adverse impact on tubal function. Tubal torsion occurs most commonly in the mid-portion of the tube
itself, but may also occur around the ligamentous supports of the tube. In addition, torsion of
paratubal or paraovarian cysts may occur. (See 'Torsion of other adnexal structures' above.)

ACKNOWLEDGMENT — The editorial staff at UpToDate would like to acknowledge Whitfield Growdon,
MD, FACS, who contributed to an earlier version of this topic review.
Use of UpToDate is subject to the Subscription and License Agreement.

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