What is the management and treatment for ovarian torsion?

Management and Treatment of Ovarian Torsion

Ovarian torsion requires immediate surgical intervention with laparoscopic detorsion as the standard of care to preserve ovarian function, regardless of the macroscopic appearance of the ovary. 1, 2

Clinical Presentation and Diagnosis

• Ovarian torsion typically presents as severe, constant pain that may fluctuate in intensity but rarely completely resolves without intervention 1
• Common associated symptoms include nausea and vomiting (present in approximately 70% of cases) 3
• Ultrasound is the first-line imaging modality with key findings including:
  • Unilaterally enlarged ovary (>4 cm or volume >20 cm³)
  • Peripheral follicles (found in up to 74% of cases)
  • Abnormal or absent venous flow (100% sensitivity, 97% specificity)
  • Whirlpool sign (90% sensitivity in confirmed cases) 1
• Important diagnostic pitfall: Normal arterial blood flow does not rule out ovarian torsion, as torsion can be intermittent or partial 1
• When ultrasound findings are inconclusive but clinical suspicion remains high, MRI (80-85% sensitivity) or CT may be utilized 1

Surgical Management Algorithm

1. Immediate Surgical Intervention

   • Emergency surgical intervention should be performed as soon as ovarian torsion is suspected 1, 4
   • Laparoscopy is both diagnostic and therapeutic 5, 2

2. Fertility-Preserving Approach

   • Detorsion (untwisting) of the affected ovary is the standard first step, regardless of the macroscopic appearance of the ovary 2, 6
   • Even with a blue/black ischemic appearance, the ovary should be preserved as macroscopic appearance does not reliably predict viability 2, 6
   • After detorsion, warm saline irrigation and waiting 10 minutes can help assess potential viability 6

3. Management of Associated Pathology

   • If an ovarian mass or cyst is present (a common risk factor), cystectomy should be performed after detorsion 2
   • Oophoropexy (fixation of the ovary to the pelvic sidewall or utero-ovarian ligament) may be considered to prevent recurrence 2

4. Indications for Oophorectomy

   • Oophorectomy should be avoided in young women whenever possible 2
   • Consider oophorectomy only in cases of:
     • Definitive necrosis with no signs of recovery after detorsion
     • Large malignant masses
     • Postmenopausal women 7, 2

Post-Operative Management

• Post-operative follow-up should include Doppler ultrasound within 1-2 weeks to confirm restoration of ovarian blood flow 6
• Monitor for symptom resolution and normalization of ovarian size and morphology 2
• Regular ultrasound surveillance may be necessary to detect potential recurrence 6

Key Clinical Considerations

• Early diagnosis and prompt surgical intervention are crucial to preserve ovarian function and minimize morbidity 4, 3
• Ovarian torsion can mimic other conditions such as appendicitis, renal colic, or urinary tract infection, leading to diagnostic delays 1, 4
• Ovarian torsion can occur in all age groups, including premenarchal girls, pregnant women, and postmenopausal women 3
• The presence of an ovarian mass or cyst is the most significant risk factor 3, 5
• Conservative management with ovarian preservation should be the standard approach in young women, regardless of the duration of symptoms or macroscopic appearance of the ovary 2, 6