What is the urgency of managing ovarian torsion?

From the Guidelines

Ovarian torsion is a medical emergency that requires immediate surgical intervention, ideally within 8 hours of symptom onset, to preserve ovarian function and prevent tissue necrosis. The management of ovarian torsion should prioritize minimizing the time the ovary remains twisted, as prolonged torsion increases the risk of permanent damage due to compromised blood flow 1. Initial management includes pain control with analgesics and antiemetics while preparing for surgery.

The definitive treatment is laparoscopy or laparotomy to untwist the ovary and assess its viability. If the ovary appears viable after detorsion, it should be preserved, even if it initially appears dark or bluish. Oophorectomy is reserved only for cases with clear necrosis. Doppler ultrasound may be used for diagnosis but should not delay surgical intervention if clinical suspicion is high, given its sensitivity and specificity for ovarian torsion, as reported in a meta-analysis of 12 studies including 1,187 patients, with a pooled sensitivity of 79% and a pooled specificity of 76% 1.

Key signs of ovarian torsion on US include ovarian tissue edema, absence of intraovarian vascularity, absence of arterial flow, and absence or abnormal venous flow, with varying accuracy for each sign 1. A recent study published in the Journal of the American College of Radiology in 2024 emphasizes the importance of prompt diagnosis and treatment, highlighting the role of ultrasound in the initial assessment of suspected ovarian torsion 1.

In the context of adnexal masses during pregnancy, the management of ovarian torsion does not differ significantly, with the goal of preserving ovarian function and preventing complications, as outlined in a 2023 study published in the American Journal of Obstetrics and Gynecology 1. Laparoscopic surgery is preferred over open surgery when possible, due to its benefits in terms of shorter hospital length of stay, less postoperative pain, and lower risks of fetal loss, preterm birth, and low birthweight 1.

Therefore, immediate surgical intervention within 8 hours of symptom onset is crucial for the management of ovarian torsion, prioritizing the preservation of ovarian function and minimizing the risk of complications, as supported by the most recent and highest quality evidence 1.

From the Research

Management of Ovarian Torsion

• Ovarian torsion is a gynecological emergency that requires early diagnosis and treatment to preserve ovarian function 2, 3, 4.
• The main risk in ovarian torsion is an ovarian mass, and the most common symptom is acute onset of pelvic pain, followed by nausea and vomiting 2.
• Surgery or detorsion is the mainstay of diagnosis and treatment, and it is essential to perform surgery as soon as possible to prevent ovarian necrosis 2, 3, 5.
• The time from pain onset to surgery is a critical factor in determining the outcome, and surgical management should not be delayed 5.
• Studies have shown that patients who undergo surgery within 24 hours of pain onset have a better prognosis and are more likely to preserve ovarian function 5.

Timing of Surgical Intervention

• The literature suggests that early surgical intervention is crucial in managing ovarian torsion, and delays in treatment can lead to ovarian necrosis and infertility 3, 4, 5.
• A study found that all patients with necrotic ovaries in histopathology underwent surgery after 24 hours of pain onset, while there was no necrosis in those who had surgery before 24 hours 5.
• Therefore, it is essential to prioritize timely surgical intervention in cases of suspected ovarian torsion to optimize outcomes.

Diagnostic Challenges

• Ovarian torsion can be challenging to diagnose, and symptoms often mimic other disorders such as appendicitis, pyelonephritis, and nephrolithiasis 3.
• Normal arterial blood flow on ultrasound does not rule out ovarian torsion, and not every patient will have a mass on imaging or a palpable mass on examination 3.
• A high index of suspicion and prompt evaluation are necessary to diagnose ovarian torsion accurately and initiate timely treatment 3, 4.