European Journal of Obstetrics & Gynecology and Reproductive Biology 251 (2020) 20–22

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European Journal of Obstetrics & Gynecology and

Reproductive Biology
journal homepage: www.elsevier.com/locate/ejogrb

Full length article

Dermoid cysts causing adnexal torsion: What are the risk factors?
Ira Rabinovich, Marina Pekar-Zlotin, Yael Bliman-Tal, Yaakov Melcer, Zvi Vaknin,
Noam Smorgick*
Department of Obstetrics and Gynecology, Shamir (Assaf Harofe) Medical Center, Affiliated With the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv,
Israel

A R T I C L E I N F O A B S T R A C T

Article history: Objective: Dermoid cysts (benign mature cystic teratoma) are a relatively common cause of adnexal
Received 15 February 2020 torsion. We aimed to identify the clinical and surgical characteristics associated with adnexal torsion
Received in revised form 12 May 2020 involving dermoid cysts.
Accepted 15 May 2020
Study design: Retrospective review of all cases of ovarian dermoid cysts (as diagnosed by pathology
Available online xxx
evaluation) operated in our department between 2008 2019. We collected information on demographic
characteristics, clinical presentation, and surgical findings and compared those parameters among
Keywords:
women with and without adnexal torsion.
Ovarian dermoid cyst
Benign mature cystic teratoma
Results: The study cohort included 231 patients who were operated for ovarian dermoid cysts. Of these,
Adnexal torsion the surgery was performed urgently for suspected adnexal torsion in 77 (33.3%) cases, while adnexal
torsion was surgically diagnosed in 51 (22.1%) cases. Diagnosis of torsion was significantly associated
with younger mean age (28.8  14.4 years in torsion cases versus 34.5  14.8 years in non-torsion cases, p
= 0.01), but not with the mean cyst diameter (81.9  26.3 mm in the torsion group versus 74.7  35.9 mm
in the non-torsion group, p = 0.1). Regarding cyst size, torsion was found in women with cyst diameter 
55 mm (9 cases, 17.7% of torsion cases), 60 90 mm (30 cases, 58.8%), and  100 mm (12 cases, 23.5%) (p =
0.1 for comparison between all groups and p = 0.05 for comparison between the small diameter group
versus the intermediate/large diameter groups). Although abdominal pain was reported in most women
with and without torsion, patients with adnexal torsion were significantly more likely to present with
nausea and/or vomiting (24 cases [47.1%], versus 14 cases [7.8%], respectively, p < 0.001).
Conclusion: Torsion of dermoid cysts is associated with younger age, but not with the mean cyst’s
diameter. Surgical removal of dermoid cysts should be considered in pre-menarchal girls, adolescents
and young women to prevent adnexal torsion.
© 2020 Elsevier B.V. All rights reserved.

Introduction dermoid cysts with various demographic and surgical character-

Ovarian dermoid cysts (also known as benign mature cystic
teratoma) are relatively common neoplasms, consisting up to 20%
of benign ovarian tumors in young women [1,2]. These cysts may
be diagnosed as asymptomatic findings on ultrasound exam, or in
women evaluated for pelvic pain [3]. Adnexal torsion involving
dermoid cysts may cause acute abdominal pain, necessitating
urgent surgery for de-torsion and cyst removal in order to avoid
ischemic damage to the ovary, especially in adolescents and young
women [4]. Thus, in order to prevent adnexal torsion, elective
surgery for removal of dermoid cysts has been recommended in
young women and adolescents [5]. However, there is limited
information on the association of adnexal torsion involving
* Corresponding author.
E-mail address: nsmorgik@shamir.gov.il (N. Smorgick).
istics, and these recommendations are largely based on expert
opinion [6,7].
The aim of this study is to describe the demographic, clinical
and surgical characteristics of dermoid cysts causing adnexal
torsion, and to compare those parameters in women with and
without torsion of dermoid cysts.
Materials and methods
We retrospectively identified all cases of pathology-confirmed
ovarian dermoid cysts operated in our institution from 2008 to
2019 by searching the database of our pathology department. We
subsequently reviewed the patients’ medical records for their
demographic information, obstetrical and gynecological history,
clinical presentation at time of surgery for dermoid cysts
(abdominal pain, complaints of nausea/vomiting, or asymptomat-
ic), surgical findings (i.e., surgical diagnosis of adnexal torsion),

https://doi.org/10.1016/j.ejogrb.2020.05.033
0301-2115/© 2020 Elsevier B.V. All rights reserved.
 I. Rabinovich et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 251 (2020) 20–22
cyst side (right, left or bilateral), surgical procedure (cystectomy or
oophorectomy), and surgical approach (laparoscopy/robotic
assisted laparoscopy, or laparotomy). Cases with malignant cysts
(i.e., immature teratoma) were excluded from the study.
The cyst diameter was retrospectively retrieved from the pre-
operative ultrasound report and from the surgical report (based on
the intra-operative assessment).
All patients were operated under general anesthesia using
endotracheal ventilation. The decision regarding surgical approach
(i.e., laparoscopy or laparotomy) was determined according to the
patient’s age, surgical history, cyst size and suspicion of
malignancy, and need for concomitant gynecologic procedures
(i.e., hysterectomy or myomectomy), at the discretion of the
attending surgeon.
The statistical analysis was performed with the SPSS software
(Version 25, IBM Corp.). Descriptive variables are presented as
mean  standard deviation or as median (range). Frequencies were
compared with the Chi-square test or with the Fisher’s exact test.
Means and medians were compared with the Student t-test or with
the ANOVA test as appropriate.
The study was approved by the Institutional Review Boards
(#0244-18-ASF). The participants’ informed consent was not
required.
Results
During the study period, 231 patients were operated for
pathologically confirmed ovarian dermoid cysts. Their demo-
graphic and clinical characteristics are shown in Table 1. Most
patients were post-menarchal, reproductive-age women. The most
common complaint on admission was abdominal pain of short or
long duration. In 77 (33.3%) cases, the surgery was performed
urgently for suspected adnexal torsion (Table 1).
The surgical characteristics of the study cohort are shown in
Table 2. Adnexal torsion was surgically diagnosed in 51 (22.1%)
cases. The dermoid cysts were evenly distributed on the right and
left side while 23 (9.9%) patients were diagnosed with bilateral
dermoid cysts. The mean cyst diameter as assessed surgically was
76.3  34.1 mm (Table 2).
We compared the demographic and clinical characteristics of
patients with and without torsion of dermoid cysts (Table 3).
Patients with adnexal torsion involving dermoid cysts were
significantly younger than those without torsion and more likely
to be pre-menarchal girls or adolescents. Torsion was significantly
less common in menopausal women. Although abdominal pain
was common in both groups, patients with adnexal torsion were
significantly more likely to present with nausea and/or vomiting
(24 cases [47.1%], versus 14 cases [7.8%], respectively, p < 0.001).
Table 1
The demographic, clinical and surgical characteristics of patients operated for
dermoid cysts.
Parameter Result
Age (years) 33.3  14.9
Menarchal status
Pre-menarche 12 (5.2)
Post-menarche 192 (84.0)
Menopausal 25 (10.8)
Parity 1 (0 7)
Operated during pregnancy 9 (3.9)
Abdominal pain 206 (89.2)
Nausea and/or vomiting 38 (16.5)
Previous surgery for dermoid cyst 21 (9.1)
Type of surgery
Elective 154 (66.7)
Urgent 77 (33.3)
Data is expressed as mean  standard deviation, median (range) or number (%).
21
Table 2
The surgical characteristics of patients operated for dermoid cysts.
Parameter Result
Cyst diameter (mm) 76.3  34.1
Cyst diameter group
 50 mm 65 (28.1)
60 90 mm 113 (48.9)
 100 mm 53 (22.9)
Surgical procedure
Cystectomy 156 (67.5)
Unilateral salpingo-oophorectomy 58 (25.1)
Bilateral salpingo-oophorectomy 17 (7.4)
Surgical diagnosis of adnexal torsion 51 (22.1)
Cyst side
Right 108 (46.8)
Left 100 (43.3)
Bilateral 23 (9.9)
Surgical approach
Laparoscopy/robotic assisted 200 (86.6)
Laparotomy 31 (13.4)
Data is expressed as mean  standard deviation or number (%).
The surgical characteristics of women with and without surgical
diagnosis of torsion involving dermoid cysts is shown in Table 4. The
mean cyst diameter was not different between groups. Following
classification of the cysts’ diameters into small ( 55 mm),
intermediate (60 90 mm) and large ( 100 mm) diameters, there
was no significant difference in the torsion rate between the three
groups. However, while comparing the torsion rates between the
small diameter group and the intermediate/large diameter groups,
there was a trend toward statistical significance (p = 0.05). The
torsion rates were similar in women with cysts on the right ovary, left
ovary or bilateral cysts (p = 0.07). However, when looking at the
torsion rates in women with unilateral cysts, torsion rates were
significantly higher for right sided cyst (p = 0.04).
Discussion
Dermoid cysts are considered a relatively common cause of
adnexal torsion, reported in up to 25% of torsion cases [1]. The
pathophysiology of dermoid cysts causing adnexal torsion is
hypothesized to be the fatty content of the cyst, leading to its
“floatation” outside the pelvis [6]. Previous series reported a
torsion prevalence of 5%–21% among women operated for dermoid
cysts [3,8,9]. We found a relatively high torsion prevalence of 22%,
possibly related to the younger population and inclusion of pre-
memarchal girls and adolescents in our study compared to
previous series.
The size of the dermoid cyst has been previously hypothesized
to be a risk factor for torsion. The highest risk for torsion was
presumed to be for cysts with an “intermediate” diameter (i.e.,
between 60 mm and 90 mm), while cysts with a diameter of less
than 50 mm were considered less likely to cause torsion. On the
other hand, very large cysts with a diameter of > 100 mm were also
considered less likely to cause torsion, because their large mass
would restrict their movement in the pelvis [4]. In accordance with
those hypotheses, some authors recommended removal of
dermoid cysts with a diameter of > 50 mm in young women
and adolescents in order to prevent torsion, while ACOG suggested
removal of “large” dermoid cyst without specifying their actual
size [5,6]. However, our review of the literature revealed that
previous studies did not provide conclusive information on the risk
of torsion relative to the dermoid cyst’s size [3,7–11]. Thus, the
above hypotheses and recommendations are based on “expert
opinion” rather than on “evidence-based” studies.
We found that adnexal torsion occurred with dermoid cysts
considered small (i.e.,  55 mm), intermediate size (60 90 mm)
22 I. Rabinovich et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 251 (2020) 20–22

Table 3
Comparison of demographic and clinical characteristics between women with and without surgical diagnosis of adnexal torsion of dermoid cyst.

Parameter Adnexal torsion (N = 51) No torsion (N = 180) P value

Age (years) 28.8  14.4 34.5  14.8 0.01
Menarchal status
Pre-menarchal/adolescents 17 (33.3) 24 (13.3) <0.01
Reproductive age (>18 years) 32 (62.7) 133 (73.9)
Menopausal 2 (3.9) 23 (12.8)
Parity 0 (0 7) 1 (0 7) 0.4
Operated during pregnancy 4 (7.8) 5 (2.8) 0.1
Abdominal pain 51 (100.0) 155 (86.1) 0.005
Nausea and/or vomiting 24 (47.1) 14 (7.8) <0.001
Previous surgery for dermoid cyst 5 (9.8) 16 (8.9) 0.7

Data is expressed as mean  standard deviation, median (range) or number (%).

Table 4 followed conservatively. In addition, the inclusion of surgical cases

Comparison of surgical characteristics between women with and without surgical
probably introduces selection bias towards inclusion of larger cysts,
diagnosis of adnexal torsion of dermoid cyst.
since smaller cysts diagnosed on ultrasound are more likely to be
Parameter Adnexal torsion No torsion (N = 180) P value followed conservatively.
(N = 51)
In conclusion, adnexal torsion is a common complication
Cyst diameter (mm) 81.9  26.3 74.7  35.9 0.1 diagnosed in women undergoing surgery for dermoid cyst,
Cyst diameter group
associated with younger age, but not with the cyst’s diameter. In
 50 mm 9 (13.8) 56 (86.2) 0.1*
60 90 mm 30 (26.5) 83 (73.5) 0.05**
order to prevent torsion, surgical removal of dermoid cysts may
 100 mm 12 (22.6) 41 (77.4) be considered in pre-menarchal girls, adolescents and young
Cyst side women.
Right 29 (56.9) 79 (43.9) 0.07***
Left 15 (29.4) 85 (47.2) 0.04****
Declaration of competing interest
Bilateral 7 (13.7) 16 (8.9)
Surgical approach
Laparoscopy/robotic 45 (88.2) 155 (86.1) 0.6 The authors declare that they have no known competing
assisted financial interests or personal relationships that could have
Laparotomy 6 (11.8) 25 (13.9)
appeared to influence the work reported in this paper.
Data is expressed as mean  standard deviation or number (%).
*
P value – comparison between the three groups (small, intermediate and large
diameters). Appendix A. Supplementary data
**
P value – comparison between the small diameter group ( 50 mm) and the
intermediate (60 90 mm) and large ( 100 mm) diameter groups. Supplementary material related to this article can be found, in the
***
P value – comparison pf torsion rates between the three groups (right, left, and online version, at doi:https://doi.org/10.1016/j.ejogrb.2020.05.033.
bilateral).
****
P value – comparison of the torsion rates between the right and left groups.
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