What is the management approach for suspected ovarian torsion?

Management of Suspected Ovarian Torsion

Prompt surgical intervention is the mainstay of treatment for suspected ovarian torsion and should be performed immediately to preserve ovarian function and prevent necrosis. 1

Clinical Presentation and Diagnosis

• Key symptoms:

  • Acute onset of unilateral pelvic/abdominal pain (most common)
  • Nausea and vomiting
  • Anorexia
  • Pain may be intermittent or constant 2, 3

• Physical examination findings:

  • Unilateral abdominal tenderness
  • Palpable adnexal mass (when present)
  • Signs of peritoneal irritation

• Diagnostic imaging:

  • Transvaginal ultrasound combined with transabdominal ultrasound is the first-line imaging modality 1
  • Key ultrasound findings suggestive of torsion:
    • Unilaterally enlarged ovary
    • Central afollicular stroma with peripheral follicles
    • Abnormal or absent Doppler flow patterns
    • Whirlpool sign (90% specific for torsion)
    • Free fluid in pelvis 1

CAUTION: Normal arterial blood flow on Doppler ultrasound does not rule out ovarian torsion. Relying solely on Doppler flow can lead to missed diagnoses 1, 3

Management Algorithm

1. Initial Assessment:

   • Obtain focused history of pain characteristics and associated symptoms
   • Perform physical examination focusing on abdominal/pelvic findings
   • Order immediate pelvic ultrasound with Doppler flow assessment

2. If torsion is suspected based on clinical presentation (regardless of imaging findings):

   • Immediate gynecologic consultation 3
   • Prompt surgical intervention 1, 2

3. Surgical Management:

   • Laparoscopic approach is preferred when feasible 1
   • Primary surgical options:
     • Detorsion (preferred to preserve ovarian function) 1, 4
     • Cystectomy if ovarian mass is present (can be performed even on ischemic ovary) 4
     • Oophoropexy (fixation of ovary) to prevent recurrence 4
     • Oophorectomy only if ovary appears necrotic or in postmenopausal women 1

4. Post-operative Management:

   • Monitor for symptom resolution
   • Follow-up ultrasound to assess normalization of ovarian size and morphology 4

Special Considerations

• Pregnancy: Ovarian torsion risk increases during pregnancy, especially with ovarian stimulation. Early diagnosis and laparoscopic management correlate with favorable maternal and fetal outcomes 5

• Delayed presentation: Surgery should still be considered even with prolonged symptoms, as ovarian salvage may still be possible 3

• Diagnostic challenges: Ovarian torsion can mimic other conditions (renal colic, appendicitis, pyelonephritis), leading to diagnostic delays 6, 3

• Age considerations: Can affect females of all ages, including children and postmenopausal women 2, 3

The key to successful management of ovarian torsion is maintaining a high index of clinical suspicion, prompt imaging, and immediate surgical intervention when torsion is suspected, even if imaging findings are equivocal. Conservative surgical management with detorsion should be attempted whenever possible to preserve ovarian function and fertility.