Ovarian Torsion

Table of Contents

  1. Overview and Epidemiology
  2. Anatomy and Mechanism
  3. Risk Factors
  4. Clinical Presentation
  5. Diagnosis and Imaging
  6. Surgical Treatment
  7. Fertility and Long-Term Outcomes
  8. Special Populations
  9. Recurrence and Prevention
  10. References and Research
  11. Connections
  12. Featured Videos

1. Overview and Epidemiology

Ovarian torsion is the partial or complete rotation of the ovary—and most often the fallopian tube—on its vascular pedicle. This twisting compresses the blood vessels that supply the ovary, cutting off first venous drainage, then arterial flow, ultimately leading to ischemia and, if untreated, irreversible infarction and permanent loss of the ovary.

Ovarian torsion accounts for roughly 2.7–7.4% of gynecological emergencies presenting to the emergency department. It is the fifth most common gynecological surgical emergency. Despite its relatively low overall incidence (approximately 5.9 per 100,000 women per year in population studies), the time-sensitive nature of the condition means that delayed recognition carries severe consequences: permanent ovarian damage or loss, affecting future fertility.

Torsion can occur at any age—from infancy through postmenopause—but peaks during the reproductive years. A second notable peak occurs in prepubertal and adolescent girls, in whom torsion of a morphologically normal ovary (without a mass) is proportionally more common than in adults. Prompt recognition and surgical management within hours of symptom onset is the decisive factor in ovarian salvage.

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2. Anatomy and Mechanism

The ovary is suspended in the pelvis by three ligamentous structures: the infundibulopelvic (IP) ligament (which carries the ovarian artery and vein superiorly toward the aorta and inferior vena cava), the utero-ovarian ligament (medially to the uterine cornu), and the mesovarium (the peritoneal fold connecting ovary to broad ligament). The fallopian tube shares the utero-ovarian pedicle and therefore rotates with the ovary in most torsion events—producing the commonly described adnexal torsion.

Torsion progresses in stages:

  1. Venous obstruction: the lower-pressure venous system is compressed first, causing ovarian engorgement and edema—the ovary enlarges, often appearing as a large, echogenic mass on ultrasound even when the underlying pathology was a small cyst.
  2. Arterial compromise: as twisting tightens, arterial inflow decreases. Intermittent torsion (wrapping and spontaneously unwrapping) may cause episodic pain with temporary resolution.
  3. Infarction: sustained arterial occlusion leads to ischemic necrosis. The ovary turns hemorrhagic and dark blue-black at laparoscopy.

A critical anatomical asymmetry explains why the right ovary torts more frequently than the left (roughly 60% of cases). The sigmoid colon occupies the left pelvic space and physically limits leftward adnexal mobility, while the right side is adjacent to the more mobile cecum and has a longer utero-ovarian ligament on average.

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3. Risk Factors

Any condition that increases ovarian mass or alters adnexal mobility raises torsion risk. The single most important risk factor is an ovarian or adnexal mass larger than 5 cm, which acts as a fulcrum around which the ovary spins.

Ovarian Masses

Ovulation Induction and Assisted Reproduction

Women undergoing controlled ovarian hyperstimulation for IUI or IVF develop multiple enlarged follicles, dramatically increasing the size and weight of both ovaries. The risk of torsion during and immediately after stimulation is substantially elevated compared with the general population. Ovarian hyperstimulation syndrome (OHSS) compounds the risk by causing further ovarian enlargement and ascites.

Pregnancy

The first trimester of pregnancy is a vulnerable period: the corpus luteum cyst of pregnancy can reach 6–8 cm, and the enlarging uterus displaces adnexal structures, increasing rotational leverage. Torsion complicates approximately 1 in 5,000 pregnancies.

Prior Torsion

Women with a history of unilateral torsion have a significantly elevated risk of contralateral torsion, particularly if the underlying predisposing condition (e.g., elongated infundibulopelvic ligament, dermoid) was not corrected. Recurrence risk on the same side after detorsion without oophoropexy is estimated at 10–15%.

Normal-Ovary Torsion

In prepubertal girls and adolescents, torsion frequently occurs without any identifiable ovarian pathology. An abnormally long utero-ovarian ligament is thought to be the anatomical predisposing factor, allowing the ovary to swing freely and rotate on its pedicle. This population is frequently misdiagnosed because clinicians may not consider torsion without an ovarian cyst on imaging.

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4. Clinical Presentation

The hallmark symptom of ovarian torsion is sudden onset, severe, unilateral lower abdominal or pelvic pain, present in approximately 96% of confirmed cases. The pain is typically localized to one side and may radiate to the flank, groin, or inner thigh. Its abrupt onset reflects the acute vascular compromise that triggers peritoneal irritation and visceral pain.

Associated Symptoms

Intermittent and Atypical Presentations

Partial torsion, where the adnexa wraps partially and then spontaneously unwinds, causes episodic or intermittent pain that may partially or fully resolve between episodes. Patients with intermittent torsion may present multiple times to the emergency department with “recurrent pelvic pain” before a definitive diagnosis is made. This pattern is particularly deceptive and can lead to significant diagnostic delay. The pain-free intervals occur when venous flow is transiently restored after spontaneous detorsion—but each episode causes incremental ischemic damage.

In children, the presentation can be especially misleading: nonspecific abdominal pain, periumbilical or diffuse rather than lateralized, with vomiting dominating the picture. Torsion should be high on the differential for any girl presenting with acute abdominal pain and vomiting.

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5. Diagnosis and Imaging

Ovarian torsion is primarily a clinical diagnosis confirmed at surgery. No single laboratory test or imaging modality reliably rules it out, and a high index of suspicion must be maintained even when initial studies appear reassuring.

Pelvic Ultrasound with Doppler

Transvaginal (or transabdominal in children) pelvic ultrasound with Doppler flow assessment is the first-line imaging study. Findings that raise concern for torsion include:

The Critical Limitation of Doppler

This is the most clinically important point: the presence of normal ovarian blood flow on Doppler does NOT exclude torsion. This cannot be overemphasized. In partial torsion, the arterial supply may remain patent while venous outflow is already compromised. Studies report that Doppler is falsely reassuring in 40–60% of surgically confirmed torsion cases. A normal Doppler study should never be used to discharge a patient with a clinical picture consistent with torsion without further evaluation or surgical consultation.

CT and MRI

Computed tomography (CT) of the abdomen and pelvis is often obtained in the emergency department when the diagnosis is uncertain and appendicitis or other surgical pathologies are on the differential. CT can identify an adnexal mass, ovarian enlargement, and free fluid but lacks the sensitivity of MRI for soft-tissue characterization. MRI provides excellent visualization of the twisted vascular pedicle, the extent of ovarian ischemia, and the composition of any mass, but its use is limited by availability and time in the acute setting.

Diagnosis at Laparoscopy

When clinical suspicion is high despite inconclusive imaging, diagnostic and therapeutic laparoscopy is the appropriate next step. The definitive diagnosis is made intraoperatively when the twisted adnexa is directly visualized. Delay for additional workup is inappropriate when the clinical picture is compelling—the surgeon should proceed to the operating room promptly.

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6. Surgical Treatment

Ovarian torsion is a surgical emergency. The primary goal is to restore blood flow to the ovary as quickly as possible. The overriding principle is that a dark, necrotic-appearing ovary does not necessarily mean irreversible damage—remarkable viability has been demonstrated even in grossly ischemic tissue after prompt detorsion.

Laparoscopic Detorsion

Laparoscopic untwisting (detorsion) of the adnexa is the treatment of choice and should be performed regardless of the ovary’s macroscopic appearance at surgery. Historically, surgeons would perform immediate salpingo-oophorectomy for a visually necrotic ovary out of concern for thromboembolic events from “releasing” the torted pedicle. This practice is no longer supported by evidence:

Concurrent Cystectomy

If an ovarian cyst or mass is identified as the precipitating factor, laparoscopic cystectomy can be performed concurrently at the same operative setting or planned for a second stage once viability is confirmed. Dermoids and simple cysts are safely removed laparoscopically. Complex or suspicious masses may warrant further preoperative evaluation before cystectomy.

When Salpingo-Oophorectomy Is Indicated

Removal of the ovary and tube is reserved for situations where frank gangrene is unequivocal (tissue is friable, frankly necrotic, or fails to demonstrate any perfusion after a brief period of observation post-detorsion), the patient is postmenopausal (ovarian preservation is less critical), or tissue characteristics suggest malignancy requiring complete excision and staging.

Surgical Access: Laparoscopy vs. Laparotomy

Laparoscopy is the standard approach and carries lower morbidity, shorter recovery, and equivalent efficacy compared with open surgery. Laparotomy may be necessary in cases with extensive pelvic adhesions, hemodynamic instability, or inability to safely perform laparoscopy due to body habitus or prior surgeries.

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7. Fertility and Long-Term Outcomes

Early surgical intervention is strongly associated with excellent fertility outcomes. Women who undergo prompt laparoscopic detorsion generally retain normal ovarian function and achieve future pregnancies at rates comparable to women who have not experienced torsion.

Ovarian Function After Detorsion

The majority of studies following women after laparoscopic detorsion demonstrate:

Impact of Salpingo-Oophorectomy

Women who undergo salpingo-oophorectomy for torsion with a necrotic ovary lose the functional reserve of that ovary. In women with a normal contralateral ovary, this typically does not impair natural fertility, as the remaining ovary compensates. However, in women with diminished contralateral reserve or those who later develop contralateral torsion, the loss is clinically significant. This reinforces the case for attempting detorsion and ovarian conservation in all patients.

Timing and Outcomes

Duration of ischemia strongly predicts outcomes:

The practical implication: there is no “safe window” to delay surgery while awaiting more diagnostic certainty. If torsion is suspected, the patient should go to the operating room.

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8. Special Populations

Pediatric and Adolescent Patients

Ovarian torsion in girls under 15 presents unique diagnostic challenges. The pain is often non-specific and may be diffuse or periumbilical rather than lateralized. Vomiting frequently dominates the clinical picture, leading to workups for gastrointestinal pathology (gastroenteritis, appendicitis) and delaying the correct diagnosis.

A critical point in pediatric torsion is the high prevalence of torsion occurring in morphologically normal ovaries (without a mass). Ultrasound may show an enlarged, edematous ovary without an obvious cyst or tumor. Because clinicians often associate torsion with an ovarian mass, normal-appearing ovaries on imaging are frequently dismissed, and the diagnosis is delayed. In pediatric patients with classic symptoms, the absence of an ovarian cyst should not be used to exclude torsion.

Ovarian preservation is especially important in children and adolescents, given the decades of reproductive function that remain. Aggressive surgical conservatism (detorsion even of grossly ischemic ovaries) is strongly advocated in this age group.

Pregnancy

Ovarian torsion during pregnancy is challenging to manage because concern for fetal exposure to anesthesia and surgical stress adds complexity. However, the risk of leaving torsion untreated (maternal ischemic injury, peritonitis, preterm labor from intraperitoneal inflammation) outweighs the procedural risk. Laparoscopic detorsion is safe throughout pregnancy, with the lowest risk in the second trimester. Obstetricians and gynecologic surgeons should collaborate on management. The corpus luteum (a frequent precipitant in the first trimester) can typically be preserved during cystectomy using careful hemostasis.

Postmenopausal Women

Torsion is less common after menopause because ovarian mass lesions are less frequent and the pelvic floor is less mobile. When it occurs, the differential diagnosis must include ovarian malignancy (which rises sharply in prevalence after menopause). Any adnexal torsion in a postmenopausal woman warrants complete surgical staging evaluation if the removed tissue is suspicious for malignancy on frozen section.

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9. Recurrence and Prevention

The risk of recurrent ipsilateral torsion after detorsion alone (without fixation) is approximately 10–15%, though estimates vary widely across studies. Contralateral torsion is also elevated in women with prior torsion, particularly when the predisposing anatomical factor (elongated ligament, dermoid) is bilateral or when the contralateral ovary is enlarged.

Oophoropexy

Oophoropexy—surgical fixation of the ovary to the pelvic sidewall, utero-ovarian ligament, or posterior broad ligament—is performed to prevent recurrence. Indications and technique are debated:

Cyst Management

Addressing the underlying precipitating mass—whether dermoid, follicular cyst, or other benign tumor—reduces recurrence risk. Concurrent cystectomy during detorsion is preferred when technically feasible and safe. For dermoids, the contralateral ovary should also be evaluated at the time of surgery, given the 10–15% bilateral incidence of dermoid cysts.

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10. References and Research

Key Research Papers

  1. Houry D, Abbott JT. Ovarian torsion: a fifteen-year review. Annals of Emergency Medicine. 2001;38(2):156–159. PMID: 11468611
  2. Shalev E, Bustan M, Yarom I, Peleg D. Recovery of ovarian function after laparoscopic detorsion. Human Reproduction. 1995;10(11):2965–2966. PMID: 8747071
  3. Oelsner G, Cohen SB, Soriano D, et al. Minimal surgery for the twisted ischaemic adnexa can preserve ovarian function. Human Reproduction. 2003;18(12):2599–2602. PMID: 14645179
  4. Cohen SB, Wattiez A, Seidman DS, et al. Laparoscopy versus laparotomy for detorsion and sparing of twisted ischemic adnexa. JSLS. 2003;7(4):295–299. PMID: 14626394
  5. Nizar K, Deutsch M, Filmer S, et al. Doppler studies of the ovarian venous blood flow in the diagnosis of adnexal torsion. Journal of Clinical Ultrasound. 2009;37(8):436–439. PMID: 19415706
  6. Chang HC, Bhatt S, Dogra VS. Pearls and pitfalls in diagnosis of ovarian torsion. Radiographics. 2008;28(5):1355–1368. PMID: 18794312
  7. Guthrie BD, Adler MD, Powell EC. Incidence and trends of pediatric ovarian torsion hospitalizations in the United States, 2000–2006. Pediatrics. 2010;125(3):532–538. PMID: 20142283
  8. Huchon C, Fauconnier A. Adnexal torsion: a literature review. European Journal of Obstetrics and Gynecology and Reproductive Biology. 2010;150(1):8–12. PMID: 20122803
  9. Schmeler KM, Mayo-Smith WW, Peipert JF, et al. Adnexal masses in pregnancy: surgery compared with observation. Obstetrics and Gynecology. 2005;105(5):1098–1103. PMID: 15863550
  10. Spinelli C, Buti I, Pucci V, et al. Adnexal torsion in children and adolescents: new trends to conservative surgical approach — our experience and review of literature. Gynecological Endocrinology. 2013;29(1):54–58. PMID: 23033869
  11. Mashiach R, Melamed N, Gilad N, et al. Sonographic diagnosis of ovarian torsion: accuracy and predictive factors. Journal of Ultrasound in Medicine. 2011;30(9):1205–1210. PMID: 21876098
  12. Hibbard LT. Adnexal torsion. American Journal of Obstetrics and Gynecology. 1985;152(4):456–461. PMID: 4014258

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11. Connections

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