Ovarian Torsion

Written By Danial Mirza

Definition

Ovarian torsion is the complete or partial rotation of the ovary, and frequently the fallopian tube, on its ligamentous and vascular supports (1). This mechanical twisting obstructs the adnexal blood supply, creating a time-critical gynaecological emergency that requires prompt diagnosis and management to prevent irreversible necrosis of the ovarian tissue (2).

Epidemiology

Ovarian torsion accounts for approximately 2.7% to 3% of all gynaecological emergencies (1). While it can occur at any age, it is most common in women of reproductive age. Pregnancy is a significant independent risk factor, implicated in about 20-25% of all torsion cases, with the risk being highest during the first trimester due to the development of a large corpus luteum cyst (4). In the Malaysian context, while specific national prevalence data is not readily published, the clinical presentation and management principles align with international standards (116). A notable challenge within the Malaysian healthcare system is the absence of a specific national Clinical Practice Guideline (CPG) for ovarian torsion from the Ministry of Health (MOH) or the Obstetrical & Gynaecological Society of Malaysia (OGSM), which places a greater onus on the clinician's judgment based on international guidelines and institutional protocols (13, 15).

Pathophysiology

The core pathology of ovarian torsion stems from vascular compromise. The ovary is suspended by the infundibulopelvic ligament (containing the ovarian artery and vein) and the utero-ovarian ligament (3). Torsion occurs when the ovary rotates on this axis, which is far more common when a "lead point"—most often an ovarian mass or cyst with a diameter greater than 5 cm—creates a weight imbalance (4). Benign neoplasms like mature cystic teratomas (dermoid cysts) are common culprits, whereas malignant tumours are less likely to cause torsion as they often create adhesions that fix the ovary to surrounding structures (19).

The ischaemic cascade unfolds sequentially:

  1. Venous and Lymphatic Obstruction: The initial twist compresses the thin-walled, low-pressure veins and lymphatic vessels, while the thicker-walled arteries remain patent (2).

  2. Vascular Congestion and Ovarian Edema: With venous outflow blocked but arterial inflow continuing, the ovary becomes intensely congested, leading to massive stromal edema and significant swelling—a hallmark finding on ultrasound (2).

  3. Arterial Compromise: As intra-ovarian pressure from the edema rises, it eventually exceeds arterial pressure, leading to the compression of arterial inflow and initiating true ischaemia (2).

  4. Haemorrhagic Infarction and Necrosis: Prolonged ischaemia results in haemorrhagic infarction and, without timely reperfusion, progresses to irreversible liquefactive necrosis (2).

A critical anatomical feature is the ovary's dual blood supply from the ovarian artery and secondarily from the uterine artery (4). This is the reason for a major diagnostic pitfall: collateral flow from the uterine artery may persist even when the ovarian artery is occluded. Therefore, the presence of arterial flow on a Doppler ultrasound does not exclude the diagnosis of ovarian torsion (2).

Clinical Presentation

The diagnosis of ovarian torsion is primarily clinical, supported by imaging, but the presentation is notoriously variable and non-specific.

Diagnostic Clues: The classic presentation is a triad of acute pelvic pain, nausea, and vomiting (37).

Common Symptoms (>50%):

  • Pain: The cardinal symptom is the sudden onset of severe, unilateral pain in the lower abdomen or pelvis, typically described as sharp, stabbing, or colicky (4).

  • Nausea and Vomiting: These symptoms are extremely common, accompanying the pain in 70% to 85% of patients, and their presence alongside acute pelvic pain is a strong positive predictor (37).

Less Common Symptoms (10-50%):

  • A history of intermittent, crampy pain that occurs over several days or weeks prior to the acute event is a major red flag, believed to be caused by the ovary intermittently twisting and spontaneously untwisting (4).

  • A low-grade fever may be present in about 20% of cases, suggesting developing tissue necrosis (2).

  • Abnormal vaginal bleeding is an uncommon but reported symptom (4).

⚠️ Red Flag Signs & Symptoms:

  • Sudden, severe, unilateral pelvic pain.

  • Pain accompanied by nausea and vomiting.

  • A history of intermittent, self-resolving episodes of similar pain.

  • Pain that is reported by the patient to be out of proportion to the objective findings on physical examination (36).

Complications

  • Acute: The most feared immediate complication is irreversible ovarian necrosis due to delayed treatment, leading to the functional loss of the ovary (4). Peritonitis can occur in late presentations with established necrosis (2).

  • Post-Surgical: Ischemia-Reperfusion (I/R) Injury can occur after detorsion. The restoration of blood flow paradoxically triggers a secondary wave of tissue damage mediated by the production of reactive oxygen species (ROS), causing oxidative stress and inflammation (21).

Prognosis

The primary objective in managing ovarian torsion is the preservation of ovarian function and future fertility, an outcome directly dependent on the duration of ischaemia. The principle of "time is ovary" is paramount, with evidence suggesting the most favourable outcomes are achieved when surgical detorsion is performed within eight hours of symptom onset (4).

The long-term prognosis for ovarian function following conservative surgery is remarkably good. Multiple studies have shown that over 90% of ovaries that are detorsed and preserved—even those appearing severely ischaemic during surgery—regain normal function, as evidenced by subsequent follicular development on ultrasound (4). Ovarian torsion and its surgical management do not appear to have a significant negative impact on a woman's overall future fertility or her potential to have a live birth (20).

Differential Diagnosis

A broad differential diagnosis must be considered for any woman presenting with acute pelvic pain. The diagnostic process is one of synthesis, integrating multiple data points to build a compelling case.

  • Ectopic Pregnancy: This is a key differential, especially if the patient presents with amenorrhea and vaginal bleeding (1). It is distinguished by a positive urine or serum β-hCG test and ultrasound findings of an empty uterus with an adnexal mass. However, it is critical to remember that torsion can occur concurrently with pregnancy (4).

  • Ruptured or Haemorrhagic Ovarian Cyst: This can present with sudden, sharp, unilateral pain, often occurring mid-cycle or after intercourse, making it very difficult to distinguish from torsion on clinical grounds alone (1). Pelvic ultrasound showing a complex adnexal cyst with free fluid is suggestive, but the imaging findings can overlap significantly with torsion (2).

  • Pelvic Inflammatory Disease (PID): Consider this if the pain is bilateral and of more gradual onset, associated with vaginal discharge, fever, and dyspareunia (1). Examination findings of bilateral adnexal tenderness and purulent cervical discharge, along with positive endocervical swabs and elevated inflammatory markers, support a PID diagnosis (1).

  • Acute Appendicitis: This is a primary non-gynaecological differential, classically presenting with periumbilical pain migrating to the right iliac fossa, anorexia, and fever (1). Tenderness at McBurney's point, leukocytosis with neutrophilia, and imaging (ultrasound or CT) showing an inflamed appendix help differentiate it (1).

  • Urolithiasis (Renal Colic): Consider this if the pain is severe, colicky, radiates from the flank to the groin, and is associated with urinary symptoms (1). Costovertebral angle tenderness and haematuria on urinalysis are key distinguishing features, with a non-contrast CT of the kidneys, ureters, and bladder (CT KUB) being the gold standard for diagnosis (1).

Investigations

The diagnostic pathway relies on integrating clinical suspicion with findings from laboratory tests and, most importantly, diagnostic imaging. No single test can definitively confirm or exclude ovarian torsion.

Immediate & Bedside Tests

  • Urine Pregnancy Test (hCG): This is the mandatory first step for any female of reproductive age to immediately rule out an ectopic pregnancy (the action), which is a critical differential, while remembering that torsion itself is more common during pregnancy (the rationale) (43).

Diagnostic Workup

  • First-Line Investigations: The initial test of choice is a Pelvic Ultrasound (Transabdominal and Transvaginal). It is highly valuable for detecting unilateral ovarian enlargement (often >5 cm), stromal edema, and peripheral displacement of follicles (the "string of pearls" sign) (the rationale), which helps to confirm the clinical suspicion non-invasively (the action) (2).

  • Gold Standard: The definitive diagnosis is established with Diagnostic Laparoscopy, as it allows direct visualization of the twisted adnexa (the rationale), leaving no room for diagnostic doubt and allowing for immediate therapeutic intervention (the action) (20).

  • Doppler Sonography: This is performed alongside the ultrasound to assess blood flow. The "whirlpool sign," showing the twisted vascular pedicle, is a pathognomonic finding (2). However, it is fundamentally important to understand that the presence of normal arterial or even venous Doppler flow does not rule out ovarian torsion due to the ovary's dual blood supply (the rationale), meaning clinical suspicion and grayscale findings must always supersede a falsely reassuring Doppler result (the action) (2).

Monitoring & Staging

  • Full Blood Count (FBC): A mild leukocytosis may be present as a non-specific inflammatory response to tissue stress (the rationale), and this test is performed to help build the overall clinical picture and rule out other causes of pain (the action) (7).

  • C-Reactive Protein (CRP): Similar to the white cell count, CRP is a non-specific inflammatory marker that may be elevated (the rationale), but it lacks diagnostic specificity and is primarily used to support the clinical assessment (the action) (7).

Management

Management Principles

The management of ovarian torsion is surgical. The primary goals are to confirm the diagnosis, relieve the vascular obstruction by untwisting the adnexa, and preserve ovarian function (1). The decision to proceed to the operating theatre is a clinical one and should not be unduly delayed by waiting for advanced imaging if the initial assessment is highly suggestive of torsion (40).

Acute Stabilisation (The First Hour)

  • Circulation: Secure two large-bore IV cannulas and administer potent analgesia, such as intravenous opioids (the action), to manage the severe pain, which is essential for patient comfort and to facilitate further assessment and preparation for surgery (the rationale) (25).

  • Disability/Exposure: Perform a thorough abdominal and pelvic examination to identify any palpable mass or peritoneal signs (the action), which helps refine the diagnosis and assess for late-stage complications like necrosis that would influence the surgical plan (the rationale) (36).

Definitive Therapy

  • First-Line Treatment: Laparoscopic detorsion is the current gold standard. The procedure involves gently untwisting the adnexal pedicle to restore blood flow (64). A fundamental principle is that the intraoperative visual appearance of the ovary (e.g., dark blue or black) is a poor predictor of its long-term viability (4). Therefore, the current standard of care is to preserve the ovary whenever possible, as over 90% of such ovaries recover significant function (4). If a benign-appearing ovarian cyst is identified as the lead point, an ovarian cystectomy is generally recommended to reduce the risk of recurrence (3).

  • Second-Line/Escalation: Laparotomy (open surgery) is reserved for situations where laparoscopy is not feasible, such as in patients with an extremely large ovarian mass or a high suspicion of malignancy (20). Salpingo-oophorectomy (surgical removal of the ovary and fallopian tube) is indicated only in specific circumstances: frank necrosis where the tissue is friable and disintegrates, in postmenopausal women where malignancy risk is significantly higher, or if the ovarian mass has features suspicious for cancer (4).

Supportive & Symptomatic Care

  • A multimodal analgesia approach is the standard of care for post-operative pain management. This strategy combines regular administration of non-opioid analgesics like paracetamol and/or a non-steroidal anti-inflammatory drug (NSAID) with opioids for moderate-to-severe breakthrough pain, often via Patient-Controlled Analgesia (PCA) in the immediate post-operative period (78). The Malaysian MOH "Pain Management in Obstetrics and Gynaecology Guidelines" advocate for this holistic approach (81).

Key Nursing & Monitoring Instructions

  • Strict input/output chart monitoring.

  • Regular pain assessment using a validated pain scale (Pain as the 5th Vital Sign).

  • Encourage early mobilisation post-operatively to reduce the risk of thromboembolism.

  • Inform medical staff immediately if the patient develops a fever, worsening pain, or abdominal distension post-operatively.

Long-Term Plan & Patient Education

  • A follow-up pelvic ultrasound is recommended approximately 6 to 12 weeks after surgery to confirm the viability of the preserved ovary and assess any underlying cyst that may have been left in situ (40).

  • Patient counselling is essential and should include an explanation of the condition, reassurance regarding the excellent prognosis for future fertility, and clear information about the small but real risk of recurrence (~10%) (5, 108). Patients must be advised to seek immediate medical attention if similar symptoms of sudden, severe pelvic pain occur in the future (11).

When to Escalate

Call Your Senior (MO/Specialist) if:

  • You have a high index of clinical suspicion for ovarian torsion in any female presenting with acute pelvic pain, especially when accompanied by nausea and vomiting. Prompt communication is the most critical action a house officer can take.

  • The patient develops any new signs of clinical deterioration, such as worsening peritoneal signs, fever, or hemodynamic instability.

  • Post-operatively, the patient's pain is poorly controlled despite adequate analgesia, or if there are any signs of surgical complications.

Referral Criteria:

  • If intraoperative findings are suspicious for malignancy (e.g., solid components, papillary excrescences, significant ascites), an urgent intraoperative consultation with a gynaecological oncologist is mandatory.

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