What is the management of ovarian torsion?

Management of Ovarian Torsion

The standard management of 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 resolves completely without intervention 1, 2
• Common associated symptoms include nausea and vomiting (present in approximately 70% of cases) 3
• Ovarian torsion can mimic other conditions such as appendicitis, renal colic, or urinary tract infection, which can lead to diagnostic delays 1, 2

Diagnostic Imaging

• Ultrasound is the first-line imaging modality with key findings including: 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: 1, 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
  • When ultrasound findings are inconclusive but clinical suspicion remains high, MRI (80-85% sensitivity) or CT may be utilized

Surgical Management Algorithm

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

   • Laparoscopy is the preferred approach for both diagnosis and treatment

2. Perform detorsion of the ovary regardless of its appearance 1, 4

   • Even black-bluish appearing ovaries can recover after detorsion
   • Preservation of the ovary should be attempted in all premenopausal women

3. Address underlying pathology 4

   • If an ovarian cyst or mass is present, perform cystectomy after detorsion
   • Consider oophoropexy to prevent recurrence, especially in cases with predisposing factors

4. Consider oophorectomy only in specific circumstances 1

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

Special Considerations

• Timing is critical: Early intervention is essential to preserve ovarian function and minimize morbidity 5, 6
• Fertility preservation: Conservative management with detorsion should be the standard approach in young women to preserve hormonal function and fertility 4
• Recurrence prevention: Oophoropexy to the pelvic sidewall or utero-ovarian ligament may be considered to prevent recurrence in high-risk cases 4
• Postoperative monitoring: Follow-up ultrasound is recommended to confirm normalization of ovarian size and morphology 4

Common Pitfalls to Avoid

• Diagnostic delay: Do not rule out ovarian torsion based on normal Doppler flow studies, as intermittent or partial torsion may still be present 1, 2
• Surgical overtreatment: Avoid unnecessary oophorectomy in young women, as even severely ischemic ovaries can recover after detorsion 4
• Incomplete evaluation: Always consider ovarian torsion in the differential diagnosis of acute abdominal pain in females of all ages 3, 7
• Misdiagnosis: Be aware that ovarian torsion can mimic other conditions such as appendicitis, renal colic, or urinary tract infection 1, 2