Introduction

Ovarian torsion is a process that occurs when the ovary twists over the
ligaments that support it in the adnexa. The fallopian tube often twists with the
ovary and is then referred to as adnexal torsion. The ovary is supported by
multiple structures in the pelvis. One ligament it is suspended by is the
infundibulopelvic ligament, also called the suspensory ligament of the ovary,
which connects the ovary to the pelvic sidewall. This ligament also contains the
main ovarian vessels. The ovary is also connected to the uterus by the utero-
ovarian ligament.[1]

The ovary has dual blood supply from the ovarian arteries and uterine arteries.
Twisting of these ligaments can lead to venous congestion, edema, compression
of arteries, and, eventually, loss of blood supply to the ovary. This can cause a
constellation of symptoms, including severe pain when blood supply is
compromised. This is a true surgical emergency that can lead to necrosis, loss of
ovary, and infertility if not identified promptly.

Etiology

The main risk factor for ovarian torsion is an ovarian mass that is 5 cm in
diameter or larger. The mass increases the chance that the ovary could rotate on
the axis of the two

ligaments holding it in suspension. This torsion impedes venous outflow and

eventually, arterial inflow.

In a study of torsions confirmed by surgery, 46% were associated with

neoplasm, and 48% were associated with cysts. Of these masses, 89% were
benign, and 80% of patients were under age 50. Therefore, reproductive-age
females are at greatest risk of torsion.[2] However, torsion can still occur in
normal ovaries, especially in the pediatric population. Pregnancy, as well as
patients undergoing fertility treatments, are high risk due to enlarged follicles on
the ovary.[1]

Epidemiology

Torsion occurs in females of all ages but is most common in women of

childbearing age. In a 10-year review of surgical emergencies at a women’s
hospital, ovarian torsion was the fifth most common, accounting for 2.7 percent.
Only 20% of patients are premenarchal, and 50% of these will have a normal
ovary. The majority of reproductive-age females with torsion had a benign
ovarian mass.[3] Pregnancy is also an independent risk factor for torsion. In a
retrospective study of patients diagnosed with torsion, 8 to 15% of them were
pregnant.[1]

Pathophysiology

Torsion occurs when the ovary twists over the supporting ligaments, the
infundibulopelvic ligament, and the utero-ovarian ligament. This causes
swelling and obstruction of blood flow. Initially, the venous outflow is
obstructed, and later arterial inflow is also interrupted due to increased swelling,
leading to necrosis of the ovary, infarction, hemorrhage, and possibly
peritonitis. The right side has been seen more commonly than left-sided torsion,
which is thought to be due to increased space in the right pelvis due to the
location of the sigmoid colon in the left.[4]

History and Physical

The patient most commonly will present with lower abdominal pain or pelvic
pain. Pain can be sharp, dull, constant, or intermittent. Pain may radiate to the
abdomen, back, or flank.[5] One study showed that post-menopausal women
commonly presented with dull, constant pain when compared to premenopausal,
who more commonly had sharp stabbing pain. Symptoms may or may not be
intermittent if the ovary is torsing and detorsing.

The patient may also have associated nausea and vomiting. In one study of
children and adolescents with lower abdominal pain, vomiting was found to be
an

independent risk factor for ovarian torsion.[6] The patient may or may not
already have a known adnexal mass, which predisposes them to torsion.

Fever may be present if the ovary is already necrotic. The patient could also
have abnormal vaginal bleeding, or discharge if torsion involves a tubo-ovarian
abscess. Infants with torsion may present with feeding intolerance or
inconsolability.

Physical exam in the patient is variable. The patient may have abdominal
tenderness focally in the lower abdomen, pelvic area, diffusely, or not at all. Up
to one-third of patients were found to have no abdominal tenderness. There
could also be an abdominal mass. If the patient has guarding, rigidity, or
rebound, there may already be necrosis of the ovary. Every patient should also
have a pelvic exam to better evaluate for masses, discharge, and cervical motion
tenderness.

Evaluation

Laboratory testing should include a complete blood count, complete metabolic

panel, and a serum hCG. CBC may show a leukocytosis, or anemia if the
torsion is causing hemorrhage. Hcg is especially important since pregnancy is a
risk factor for torsion. These laboratory abnormalities are non-specific, and
most often, the lab values will be normal in torsion.

The imaging study of choice is ultrasound with doppler. Both a transvaginal

and pelvic ultrasound should be done. The sensitivity of ultrasound for ovarian
torsion is dependent on many factors, including technician skill and patient
anatomy, but is reported to be around 84%.[7] In one study, the most sensitive
findings on ultrasound were ovarian edema, abnormal ovarian blood flow, and
relative enlargement of the ovary.[8] There may also be free fluid or the
whirlpool sign, which is thought to be due to the twisting of the vascular pedicle
in cross-section.[9]

Blood flow should be assessed as compared to the contralateral ovary. Due to

the ovaries having dual blood supply, the complete lack of flow is not necessary
to be symptomatic. The ovary may also not be torsed at the time of ultrasound,
which is why ultrasound alone cannot rule out ovarian torsion. CT and MRI are
not generally used to diagnose ovarian torsion but are commonly done to rule
out other abdominal pathology such as acute appendicitis.

The definitive diagnosis of ovarian torsion is made by direct visualization of a

rotated ovary during surgery. For this reason, if clinical suspicion remains high
with

Ovarian Torsion

Guile SL, Mathai JK.

Publication Details

Continuing Education Activity

Ovarian torsion is caused by twisting of the ligaments that support the adnexa,
cutting off the blood flow to the organ and represents a true surgical emergency.
In order to avoid the high morbidity associated with this condition, it must be
promptly diagnosed and treated. This activity reviews the evaluation and
treatment of ovarian torsion and highlights the role of an interprofessional team
in evaluating and treating patients with this condition.
Objectives:

 Describe the etiology of ovarian torsion.

 Summarize the evaluation steps for ovarian torsion.

 Outline the management options available for ovarian torsion.

Access free multiple choice questions on this topic.

Introduction

Ovarian torsion is a process that occurs when the ovary twists over the
ligaments that support it in the adnexa. The fallopian tube often twists with the
ovary and is then referred to as adnexal torsion. The ovary is supported by
multiple structures in the pelvis. One ligament it is suspended by is the
infundibulopelvic ligament, also called the suspensory ligament of the ovary,
which connects the ovary to the pelvic sidewall. This ligament also contains the
main ovarian vessels. The ovary is also connected to the uterus by the utero-
ovarian ligament.[1]

The ovary has dual blood supply from the ovarian arteries and uterine arteries.
Twisting of these ligaments can lead to venous congestion, edema, compression
of arteries, and, eventually, loss of blood supply to the ovary. This can cause a
constellation of symptoms, including severe pain when blood supply is
compromised. This is a true surgical emergency that can lead to necrosis, loss of
ovary, and infertility if not identified promptly.

Etiology

The main risk factor for ovarian torsion is an ovarian mass that is 5 cm in
diameter or larger. The mass increases the chance that the ovary could rotate on
the axis of the two ligaments holding it in suspension. This torsion impedes
venous outflow and eventually, arterial inflow.

In a study of torsions confirmed by surgery, 46% were associated with

neoplasm, and 48% were associated with cysts. Of these masses, 89% were
benign, and 80% of patients were under age 50. Therefore, reproductive-age
females are at greatest risk of torsion.[2] However, torsion can still occur in
normal ovaries, especially in the pediatric population. Pregnancy, as well as
patients undergoing fertility treatments, are high risk due to enlarged follicles on
the ovary.[1]

Epidemiology

Torsion occurs in females of all ages but is most common in women of

childbearing age. In a 10-year review of surgical emergencies at a women’s
hospital, ovarian torsion was the fifth most common, accounting for 2.7 percent.
Only 20% of patients are premenarchal, and 50% of these will have a normal
ovary. The majority of reproductive-age females with torsion had a benign
ovarian mass.[3] Pregnancy is also an independent risk factor for torsion. In a
retrospective study of patients diagnosed with torsion, 8 to 15% of them were
pregnant.[1]

Pathophysiology

Torsion occurs when the ovary twists over the supporting ligaments, the
infundibulopelvic ligament, and the utero-ovarian ligament. This causes
swelling and obstruction of blood flow. Initially, the venous outflow is
obstructed, and later arterial inflow is also interrupted due to increased swelling,
leading to necrosis of the ovary, infarction, hemorrhage, and possibly
peritonitis. The right side has been seen more commonly than left-sided torsion,
which is thought to be due to increased space in the right pelvis due to the
location of the sigmoid colon in the left.[4]

History and Physical

The patient most commonly will present with lower abdominal pain or pelvic
pain. Pain can be sharp, dull, constant, or intermittent. Pain may radiate to the
abdomen, back, or flank.[5] One study showed that post-menopausal women
commonly presented with dull, constant pain when compared to premenopausal,
who more commonly had sharp stabbing pain. Symptoms may or may not be
intermittent if the ovary is torsing and detorsing.

The patient may also have associated nausea and vomiting. In one study of
children and adolescents with lower abdominal pain, vomiting was found to be
an independent risk factor for ovarian torsion.[6] The patient may or may not
already have a known adnexal mass, which predisposes them to torsion.

Fever may be present if the ovary is already necrotic. The patient could also
have abnormal vaginal bleeding, or discharge if torsion involves a tubo-ovarian
abscess. Infants with torsion may present with feeding intolerance or
inconsolability.

Physical exam in the patient is variable. The patient may have abdominal
tenderness focally in the lower abdomen, pelvic area, diffusely, or not at all. Up
to one-third of patients were found to have no abdominal tenderness. There
could also be an abdominal mass. If the patient has guarding, rigidity, or
rebound, there may already be necrosis of the ovary. Every patient should also
have a pelvic exam to better evaluate for masses, discharge, and cervical motion
tenderness.

Evaluation
Laboratory testing should include a complete blood count, complete metabolic
panel, and a serum hCG. CBC may show a leukocytosis, or anemia if the
torsion is causing hemorrhage. Hcg is especially important since pregnancy is a
risk factor for torsion. These laboratory abnormalities are non-specific, and
most often, the lab values will be normal in torsion.

The imaging study of choice is ultrasound with doppler. Both a transvaginal

and pelvic ultrasound should be done. The sensitivity of ultrasound for ovarian
torsion is dependent on many factors, including technician skill and patient
anatomy, but is reported to be around 84%.[7] In one study, the most sensitive
findings on ultrasound were ovarian edema, abnormal ovarian blood flow, and
relative enlargement of the ovary.[8] There may also be free fluid or the
whirlpool sign, which is thought to be due to the twisting of the vascular pedicle
in cross-section.[9]

Blood flow should be assessed as compared to the contralateral ovary. Due to

the ovaries having dual blood supply, the complete lack of flow is not necessary
to be symptomatic. The ovary may also not be torsed at the time of ultrasound,
which is why ultrasound alone cannot rule out ovarian torsion. CT and MRI are
not generally used to diagnose ovarian torsion but are commonly done to rule
out other abdominal pathology such as acute appendicitis.

The definitive diagnosis of ovarian torsion is made by direct visualization of a

rotated ovary during surgery. For this reason, if clinical suspicion remains high
with relatively normal labs and ultrasound imaging, the patient must have
surgical evaluation.

Treatment / Management

The treatment of ovarian torsion is surgical detorsion, preferably by a

gynecologist. In reproductive age females, salvage of the ovary should be
attempted, and the surgeon must evaluate the ovary for viability. Most often, the
approach to surgery should be laparoscopic and involves direct visualization of
a twisted ovary. The evaluation of viability is mostly by visualization. A dark,
enlarged ovary with hemorrhagic lesions may have compromised blood flow
but is often salvageable.[10]

After detorsion, ovaries were found to be functional in greater than 90% of

patients who underwent detorsion. This was assessed by the appearance of the
adnexa on ultrasound, including follicular development on the ovaries.
[11] Therefore, surgery with adnexal sparing is the management of choice.
Rarely, if the ovary appears necrotic and gelatinous beyond possible salvage,
the surgeon may choose to perform a salpingo-oophorectomy. The surgeon may
also perform cystectomy if a benign cyst is present. If the cyst appears to be
malignant, or if the woman is post-menopausal, salpingo-oophorectomy is the
preferred management.

Differential Diagnosis

There are many differentials for abdominal pain in a female. In a patient of

childbearing age, ectopic pregnancy must first be ruled out with a beta hCG. If
the beta hCG is negative, then this can essentially be ruled out. If positive, then
an intrauterine pregnancy on ultrasound dramatically decreases the risk of
ectopic but does not rule out heterotopic pregnancy. A ruptured ovarian cyst can
also present like an ovarian torsion. Both may also have free fluid in the pelvis
on ultrasound. However, cyst rupture typically causes sudden onset of sharp
pain, which commonly occurs during sexual intercourse.

A tubo-ovarian abscess may present with lower pelvic pain, which is usually
more gradual in onset and associated with fever. Appendicitis can present with
right-sided pelvic pain, nausea, vomiting, and fever. Lab values may show
leukocytosis, and CT imaging should aid in differentiating it from ovarian
pathology.[12] Other differentials include pyelonephritis, diverticulitis, and
pelvic inflammatory disease.

Prognosis

Ovarian torsion is not usually life-threatening, but it is organ threatening. In

premenopausal women, surgery with adnexal sparring is now the preferred
treatment, and the majority of women had normal-appearing adnexa on
ultrasound after surgery.[13] Ovarian salvage is increased in patients with less
time from the onset of symptoms to surgical intervention. In postmenopausal
women, salpingo-oophorectomy is done to prevent reoccurrence. This approach
is also used in women with a mass suspicious for malignancy. The majority of
ovarian masses are benign. Some case reports show less than 2% of torsions
involving a malignant lesion. However, the chances of a malignant lesion
involved in torsion are increased in the postmenopausal group.[1]

Complications

The main complication of ovarian torsion is the inability to salvage the ovary
and the need for salpingo-oophorectomy. This may affect fertility in a woman
of childbearing age. Other complications of torsion include abnormal pelvic
anatomy that may contribute to infertility, such as adhesions, or atrophied
ovaries.[14] There may be complications from the surgery itself, such as
infection or venous thromboembolism. The risk of post-operative infection is
increased when necrotic tissue is already present.[15]