Key content
Torsion of the ovary, tube or both is estimated to be responsible
for only a small number of all gynaecological emergencies, but is a
common diagnostic challenge in the emergency setting.
Diagnosis can be difficult and is mainly based on clinical
symptoms and imaging techniques such as ultrasound and MRI.
A normal ultrasound scan does not exclude adnexal torsion and
the decision to operate should be made on clinical grounds if
symptoms are severe.
Treatment is traditionally surgical removal of the ovary or
adnexum, however, there is increasing evidence for conservative
surgery, such as de-torsion and oophoropexy, particularly in
younger women.
This article provides an overview of the symptomatology,
ultrasound diagnosis and classification, as well as treatment
options for ovarian torsion.
Learning objectives
To understand the clinical presentation and ultrasound
characteristics associated with ovarian torsion.
To review the literature on the available surgical options.
Ethical issues
Oophorectomy is commonly performed for adnexal torsion
with a possible negative impact on fertility in women of
reproductive age. De-torsion is a more conservative surgical
approach that should be considered in all younger women with
ovarian torsion.
Key words: de-torsion / oophorectomy / oophoropexy / ovarian
cyst / ovarian torsion
Introduction
Torsion of the ovary, tube or both is responsible for between
2.7% and 7.4%1,2 of all gynaecological emergencies but is a
common diagnostic challenge in the emergency setting. It
most commonly occurs in women of reproductive age
(including during pregnancy) however, pre-pubertal girls
and postmenopausal women can also be affected. Delay or
misdiagnosis can result in the loss of the affected ovary
and subsequent reduced reproductive capacity. However,
diagnosis can be difficult, particularly in intermittent torsion
and the differential diagnosis can include several other
gynaecological and surgical emergencies.
Familiarity with the common presenting symptoms of
torsion, in combination with ultrasound and other imaging
modalities is important for maintaining a high index of
suspicion among emergency staff, to enable swift and
accurate diagnosis and an appropriate management strategy.
The risk of surgical intervention needs to be balanced
against the potential dangers of conservative management
and ovarian torsion is rarely managed expectantly.
De-torsion and oophoropexy, rather than oophorectomy,
are surgical techniques that are increasing in popularity.
Newer techniques to prevent recurrence, such as shortening
of the utero-ovarian ligament are also being performed but
require further appraisal.
Diagnosis
Ovarian torsion is far less common than other causes of acute
pelvic pain such as pelvic inflammatory disease (PID),
ovarian cyst haemorrhage and appendicitis.1 Diagnosis
usually relies on a combination of detailed clinical history
and ultrasound findings, with a high index of suspicion for
torsion. Attempts have been made to create scoring systems
for the prediction of torsion, using clinical history and
imaging findings. A recently published scoring system
identified five criteria that were independently associated
with adnexal torsion (Table 1) and allowed cases to be
placed into low- and high-risk groups.3 Interestingly, while
large ovarian cysts (5 cm) had a strong association with
torsion, other ultrasound features were not particularly presence of acute pelvic pain in prepubescent and
postmenopausal women is more likely to be caused by
torsion, whereas in the reproductive years, pain associated
with functional ovarian cysts is much more likely.
Scoring system for the identification of women with adnexal
torsion3
Criteria
Adjusted odds
ratio (95%CI)
1 Unilateral lumbar or abdominal pain 4.1 (1.2–14)
2 Pain duration >8 hours 8.0 (1.7–37.5)
3 Vomiting 7.9 (2.3–27)
4 Absence of leucorrhoea/metrorrhagia 12.6 (2.3–67.6)
5 Ovarian cyst >5 cm by ultrasound 10.6 (2.9–38.8)
Clinical features of adnexal torsion
Symptoms
General Pelvic or abdominal pain,
fluctuating, radiating to loin or thigh
Nausea
Vomiting
Signs
General Pyrexia
Tachycardia
Abdominal examination Generalised abdominal tenderness, localised
guarding, rebound
Vaginal examination Cervical excitation, adnexal tenderness,
adnexal mas
Differential diagnoses in acute lower
abdominal pain
Differential
diagnoses History Clinical features
PID Sexually active Non-migratory pain,
bilateral tenderness,
no nausea or
vomiting
Appendicitis Typically <40
years old
Migratory pain,
anorexia, vomiting
Functional
ovarian cyst
Natural cycles Sudden onset, sharp
stabbing pain
OHSS History of ovulation
induction
Bloating, pelvic pain,
nausea and vomiting
Fibroid torsion History of fibroids Constant, severe pain
Renal colic Generally idiopathic Unilateral loin pain
radiating to groin
Adnexal torsion History of ovarian cyst,
PCOS, ovulation
induction
Intermittent, colicky
acute pain, nausea,
vomiting, pyrexia
Management
The surgical management of adnexal torsion is clearly
determined by many factors in addition to the macroscopic
appearance of the adnexum; including age, menopausal
status, presence of pre-existing ovarian pathology and desire
to preserve fertility. Due to the relatively low incidence of the
disease, studies examining long-term outcomes are usually
retrospective and involve small numbers. Traditionally,
surgery has involved partial or complete oophorectomy or
salpingo-oophorectomy. There is evidence to suggest that the
clinical appearances of torsed adnexae do not correlate well
with the likelihood of residual ovarian function and
recovery and there are good outcome data to support
conservative management with laparoscopic de-torsion in the
majority of cases with little short or long-term associated
morbidity, even if the ovary appears dark purple or
black. In addition, outcomes from paediatric cases of torsion would support a more conservative approach to surgical
management in the form of de-torsion with or without
oophoropexy. The likelihood of preserving viable ovarian
tissue with conservative surgery (de-torsion) decreases over
time, with some evidence that pain for longer than 48 hours
is associated with a significant decrease in successful
outcome. Clearly, in cases where examination and
ultrasound suggest a high probability of ovarian torsion,
surgery should be performed as quickly as possible to enable
prompt restoration of the ovarian blood supply before
significant damage occurs. Cases of testicular torsion are
managed as a surgical emergency, as testicular torsion of
greater than 6 hours is thought unlikely to be accompanied
by testicular recovery. While there may be less time pressure
with ovarian torsion, the diagnosis is less obvious and the
process may be more lengthy, so once the decision for
laparoscopy has been made, the same degree of urgency
should be afforded in adnexal torsion
Conclusion
Adnexal torsion is frequently suspected in women with acute
pelvic pain, but rarely confirmed. It is apparent that prompt
diagnosis is dependent on clinical history and a high index of
suspicion. Accurate and detailed history taking is highly
important, both of the presenting complaint and of the
previous gynaecological and surgical history. Physical
examination may elicit an adnexal mass or adnexal
tenderness but can be non-specific. Transvaginal ultrasound
remains the first-line investigation; however MRI may be
more useful in the second and third trimesters of pregnancy.
The absence of radiological evidence suggestive of torsion
does not necessarily exclude it and the decision to operate
should be on clinical grounds if symptoms are severe.
Prompt intervention to preserve ovarian function should
be laparoscopic wherever possible and de-torsion the
treatment of choice in prepubescent girls and women of
reproductive age whose families are not complete, regardless
of the colour of the ovary at the time of surgery. In older and
postmenopausal women, oophorectomy is the treatment of
choice to completely remove the risk of re-torsion. In the
presence of a non-functional ovarian cyst, cystectomy or
interval cystectomy should be performed in younger women.