What is the management and treatment for ovarian torsion?

Management and Treatment of Ovarian Torsion

The standard approach for managing ovarian torsion is immediate surgical intervention with laparoscopic detorsion to preserve ovarian function, regardless of the macroscopic appearance of the ovary. 1

Clinical Presentation and Diagnosis

• Ovarian torsion typically presents as severe, constant pain that may fluctuate in intensity but rarely completely resolves without intervention 1, 2
• Common associated symptoms include nausea and vomiting (present in approximately 70% of cases) 3
• The condition can mimic other acute abdominal conditions such as appendicitis, renal colic, or urinary tract infection, leading to diagnostic delays 1, 2

Diagnostic Imaging

• Ultrasound is the first-line imaging modality with key diagnostic findings: 1, 2

  • 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)

• Important diagnostic considerations: 2

  • Normal arterial blood flow does not rule out ovarian torsion, as torsion can be intermittent or partial
  • Combined transabdominal and transvaginal ultrasound provides the most comprehensive assessment
  • Doppler ultrasound has a sensitivity of 80% and specificity of 88% for diagnosing ovarian torsion

• When ultrasound findings are inconclusive but clinical suspicion remains high: 1, 2

  • MRI can be utilized (80-85% sensitivity)
  • CT may show an enlarged, featureless, hypoenhancing ovary with swirling of vascular pedicle

Surgical Management Algorithm

1. Immediate surgical intervention is required once ovarian torsion is suspected 1, 4, 3

   • Laparoscopy is both diagnostic and therapeutic
   • Early intervention is crucial to preserve ovarian function and minimize morbidity

2. Perform laparoscopic detorsion of the ovary 1, 5

   • This should be done regardless of the macroscopic appearance of the ovary
   • Even dark blue or black-appearing ovaries can recover after detorsion

3. Address underlying pathology 5

   • If a cyst is present, perform cystectomy after detorsion
   • Cysts are a common risk factor for torsion

4. Consider oophoropexy to prevent recurrence 5

   • Fixation of the ovary to the pelvic sidewall or utero-ovarian ligament
   • Particularly important in cases with risk of recurrence

5. Oophorectomy should be limited to specific cases only: 1

   • Definitive necrosis with no signs of recovery after detorsion
   • Large malignant masses
   • Postmenopausal women

Evidence for Conservative Management

• Traditional management often included oophorectomy, but current evidence strongly supports ovarian preservation 5, 6
• Studies demonstrate successful recovery of ovarian function after detorsion, even in cases with:
  • Prolonged symptoms (>36-48 hours) 6
  • Severely ischemic appearance of the ovary 6
• Post-operative ultrasound with Doppler can confirm restoration of blood flow and normalization of ovarian size 5, 6

Clinical Pearls and Pitfalls

• Diagnostic delays are common due to nonspecific symptoms and overlap with other conditions 4, 3
• The absence of classic symptoms does not rule out torsion - pain may not always be sudden in onset or severe 3
• Ovarian torsion can affect females of all ages, including premenarchal girls, pregnant women, and postmenopausal women 3, 7
• Ovarian torsion occurs in approximately 2-15% of patients who have surgical treatment of adnexal masses 7
• Surgical overtreatment (unnecessary oophorectomy) remains common despite evidence supporting conservative management 5