DOI: 10.1111/j.1744-4667.2012.00131.

2012;14:22936

Review

The Obstetrician & Gynaecologist

http://onlinetog.org

An update on the diagnosis and management of ovarian

torsion
Emmanuel Damigos

a
Ptychio latrikes [MBBS],

Jemma Johns

b,
MBBS MD MRCOG, *

Jackie Ross

MBBS FRCOG

ST5 in Obstetrics and Gynaecology, Friarage Hospital, South Tees Hospitals Trust, Northallerton, North Yorkshire DL6 1JG, UK
Consultant Gynaecologist, Kings College Hospital, Denmark Hill, London SE5 9RS, UK
c
Consultant Obstetrician and Gynaecologist, Kings College Hospital, Denmark Hill, London SE5 9RS, UK
*Correspondence: Jemma Johns. Email: jemma.johns@nhs.net
b

Key content

Learning objectives

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.

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

Please cite this paper as: Damigos E, Johns J, Ross J. An update on the diagnosis and management of ovarian torsion. The Obstetrician & Gynaecologist
2012;14:22936.

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.

2012 Royal College of Obstetricians and Gynaecologists

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

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An update on the diagnosis and management of ovarian torsion

Table 1. Scoring system for the identication of women with adnexal

torsion3

Criteria
1
2
3
4
5

Unilateral lumbar or abdominal pain

Pain duration >8 hours
Vomiting
Absence of leucorrhoea/metrorrhagia
Ovarian cyst >5 cm by ultrasound

Adjusted odds
ratio (95%CI)
4.1
8.0
7.9
12.6
10.6

(1.214)
(1.737.5)
(2.327)
(2.367.6)
(2.938.8)

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. The
differential diagnoses in women presenting with acute lower
abdominal or pelvic pain are listed in Box 2.
Box 2. Differential diagnoses in acute lower
abdominal pain
Differential
diagnoses

History

Clinical features

predictive and the highest scoring features were clinical.

These results are promising but need to be subjected to large
prospective assessment.

PID

Sexually active

Clinical history

Appendicitis

The clinical presentation of adnexal torsion, like other

pathologies, is with acute onset of pelvic pain but can be
non-specific, frequently presenting diagnostic difficulties.
Nausea and vomiting are also common presenting features,
occurring in 85% of cases of ovarian torsion.4 A low-grade
pyrexia and sinus tachycardia may also be present. The
clinical features of torsion are described in Box 1.

Functional
ovarian cyst
OHSS

Typically <40
years old
Natural cycles

Non-migratory pain,
bilateral tenderness,
no nausea or
vomiting
Migratory pain,
anorexia, vomiting
Sudden onset, sharp
stabbing pain
Bloating, pelvic pain,
nausea and vomiting
Constant, severe pain
Unilateral loin pain
radiating to groin
Intermittent, colicky
acute pain, nausea,
vomiting, pyrexia

Box 1. Clinical features of adnexal torsion

Symptoms
General

Signs
General
Abdominal examination
Vaginal examination

Pelvic or abdominal pain,

uctuating, radiating to loin or thigh
Nausea
Vomiting
Pyrexia
Tachycardia
Generalised abdominal tenderness, localised
guarding, rebound
Cervical excitation, adnexal tenderness,
adnexal mass

It is key to take a detailed history of any woman presenting

with acute pelvic pain when ovarian torsion is suspected.
Torsion may present as an acute-on-chronic condition if there
is a history of an ovarian cyst, particularly a dermoid, or
polycystic ovary syndrome (PCOS) (associated with the
enlarged ovary). Data regarding cyst size and risk of torsion
are conflicting, with some suggesting that torsion may be more
likely in larger cysts (>5 cm),3,5 and others suggesting that
cysts larger than 5 cm in size are less likely to undergo torsion
than smaller ones.6 It has also been suggested that malignancies
and endometriomas undergo torsion less frequently because of
their association with pelvic adhesions.5 In prepubescent girls,
torsion frequently occurs in the absence of adnexal pathology7
and recent data suggest that the malignancy rate is low at 0.5
1.8%, rather than the frequently quoted figure of 10%.8,9 The

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Fibroid torsion
Renal colic
Adnexal torsion

History of ovulation
induction
History of broids
Generally idiopathic
History of ovarian cyst,
PCOS, ovulation
induction

OHSS = ovarian hyperstimulation syndrome; PCOS = polycystic ovary

syndrome; PID = pelvic inammatory disease

It is obvious from this list that a detailed gynaecological,

surgical and medical history is paramount in determining the
most likely cause of the pain. Clinical features that favour the
diagnosis of PID are non-migratory pain, bilateral pelvic
tenderness and absence of nausea or vomiting. Appendicitis
typically presents with poorly localised colicky central
abdominal pain associated with anorexia and vomiting. As
the condition worsens, and peritonitis develops, the pain
becomes more localised to the right iliac fossa, with localised
guarding and tenderness. A history of sudden-onset,
stabbing, sharp pain should raise the suspicion of
haemorrhage from a functional cyst. Functional ovarian
cysts are unlikely to occur in women who are using
contraceptives or other medications that cause ovarian
suppression (for example, combined oral contraceptives,
long-acting reversible contraceptive such as depo provera, or
GnRH analogues). Pain from haemorrhage into a cyst should
resolve over the next few days.10 Women with ovarian
hyperstimulation syndrome (OHSS) will usually give a
history of recent ovulation induction with gonadotrophins
or occasionally clomiphene. Rarely, cases will occur in
spontaneous pregnancies.11 The severity at presentation is
variable but symptoms include abdominal bloating, pelvic
pain and nausea and vomiting. Determining whether the

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Damigos et al.

Figure 1. Top row: polycystic left ovary in a pregnant woman. Bottom row: contralateral torted ovary in same individual

enlarged ovaries are undergoing torsion can be extremely

difficult under these circumstances and the ultrasound
features are discussed further below. Fibroid degeneration
rarely causes pain outside of pregnancy, although torsion of
pedunculated fibroids is not unusual and should be
considered in women known to have fibroids. Rupture of a
surface vessel over a fibroid is also a rare but reported cause
of
acute
abdominal
pain
and
intraperitoneal
haemorrhage.12,13 Renal colic typically presents with sudden
onset of severe unilateral colicky pain radiating from the loin
to the groin, which comes in waves, very similar to torsion.
There is often associated microscopic haematuria.

Ultrasound
The ultrasound appearance of torsion of a normal ovary can
be highly variable, representing the dynamic nature of the
pathophysiological process. It is therefore essential to be
aware of the different possible ultrasound appearances and
combine these with the clinical picture in order to make a
swift diagnosis of ovarian torsion. It is frequently described
as unilateral ovarian enlargement and oedema with
peripherally arranged follicles (Figure 1),11,14 the latter sign

2012 Royal College of Obstetricians and Gynaecologists

being more common in pre-pubescent ovaries.15 The affected

ovary may appear as a solid mass with hypo- and
hyperechoic areas14 in keeping with haemorrhage and
necrosis (Figure 2). The pedicle that is twisted may be seen
as a whirlpool that is visible both in grey scale and on
colour Doppler16 and has been shown to increase the
diagnostic sensitivity for torsion.17 Of the above appearances,
unilateral ovarian enlargement and oedema appears to be the
most consistent finding in the literature. If there is a simple
cyst within the ovary, the cyst tends to become haemorrhagic
as the ovary undergoes venous congestion, so the fluid
within it becomes more echogenic. Normal ovarian tissue
adjacent to the cyst also becomes oedematous and the
borders of the ovary less well defined (Figure 3). The tube
may also be involved and may fill with haemorrhagic
fluid (Figure 4).
Abnormal Doppler signals in the ovarian vessels have been
identified in up to 100% of cases of adnexal torsion17;
however, a complete absence of perfusion may be a relatively
late event, so the presence of flow within the ovary does not
exclude the diagnosis of torsion.11 Coiling of the ovarian
vessels may be seen in early or subacute cases (Figure 5).18
Attempts have been made to classify the severity of torsion in

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An update on the diagnosis and management of ovarian torsion

Figure 2. Top left: normal ovary. Top right and bottom row: enlarged, haemorrhagic, torted contralateral ovary

the presence of coiling of the ovarian vessels, but this has yet
to be confirmed in larger studies. In any case of suspected
ovarian torsion, comparison with the contralateral ovary will
show a distinct difference in the appearances of the two
ovaries (Figures 13). There is often haemorrhagic fluid in
the pouch of Douglas15 but this is not invariable. Anechoic
fluid in the pelvis may be a normal finding, so cannot be used
as a marker of torsion.

Ovarian cysts and torsion in assisted

reproduction and pregnancy
An ovarian cyst (  25 mm simple or complex cyst) can be
found in up to 5% of pregnancies,19 with a 13% torsion
rate.1921 The risk of torsion appears to decrease with
increasing gestation,21 is unusual after 20 weeks22 and
becomes harder to diagnose. The use of laparoscopy in
pregnancy has been shown to be safe in any trimester,
providing the appropriate surgical expertise is available.23
The risk of perinatal morbidity is no greater than when
compared with open surgery, although it is generally high in
both due to the emergency nature of the procedure.24
Oophorectomy is likely to be used more frequently to avoid

232

the small but potential risk of repeat torsion during the

pregnancy. Isolated reports of cyst aspiration to prevent
recurrence are available in the literature but the technique
needs further evaluation.25,26
OHSS presents with enlarged ovaries containing multiple
luteinised cysts or corpora lutea in association with ascites. If
torsion occurs, areas of swelling, haemorrhage or necrosis
can be seen within the parenchyma of the torted ovary
(Figure 6), however, the typical features are frequently
masked by the large multicystic ovaries. The use of assisted
reproductive technology (ART) is associated with an 11-fold
increased risk of ovarian torsion.27 In one recent study of
ovarian torsion in pregnancy, 48.5% of cases were associated
with ovulation induction or in vitro fertilisation (IVF), of the
36% of cases that had multicystic ovaries; 86% had conceived
by ART,28 leading them to conclude that it is a major risk
factor for ovarian torsion in pregnancy.

Other imaging techniques

Computed tomography (CT) and magnetic resonance
imaging (MRI) have been shown to be useful in the
diagnosis of adnexal torsion and findings include

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Damigos et al.

Figure 3. Two cases of adnexal torsion associated with simple ovarian cysts. Contralateral ovaries are normal (left). Torted ovaries are enlarged,
oedematous and less well dened (right)

Figure 4. Grossly distended fallopian tube lled with haemorrhagic

uid in association with an ovarian torsion

Figure 5. Coiling of the ovarian vessels in a case of subacute torsion

enlargement of the ovarian stroma, tube thickening, ascites

and uterine deviation to the affected side,2931 with a good
negative predictive value.31 These modalities are expensive
however, are less readily available than ultrasound and rarely

provide additional diagnostic information. MRI is more

useful (and safe)32 in the second and third trimesters of
pregnancy for diagnosing abdominal pain, where the ovaries
and appendix are more difficult to visualise by ultrasound

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An update on the diagnosis and management of ovarian torsion

Figure 6. Two cases of ovarian torsion after ART. Top: hyperstimulated ovary with areas of haemorrhage and necrosis (arrows). Bottom:
multicystic ovaries with areas of haemorrhage

and should be considered early in the investigation of unwell

pregnant women with abdominal pain, not thought to be
obstetric in nature.

proved to have sufficient diagnostic accuracy to enter into

routine use. Recently, ischaemia-modified albumin has been
shown in animal models to be raised in cases of ovarian
torsion; however this has yet to be assessed in humans.34

Serum markers
Blood is routinely taken from women presenting to the
emergency department (ED) with acute pelvic pain, to detect
evidence of infection, anaemia and inflammation. No single
or combined markers have been identified that improve
diagnostic accuracy in adnexal torsion. Torsion results in an
ischaemic insult to the ovary, which is either intermittent or
complete, and markers of ischaemia or ischaemia-reperfusion
injury could theoretically be raised in the serum of women
with torsion. The commonest and easiest marker to examine
is C-reactive protein, an acute phase protein that is raised in
the presence of inflammation; the white cell count is also
often measured and is raised in approximately 50% of women
with adnexal torsion.11 Unfortunately, neither of these
markers has been found to be useful in the diagnosis of
torsion because of low sensitivity and specificity. Several other
pro-inflammatory markers (such as interleukin-6 and tumour
necrosis factor-a33) have been assessed, but again, none have

234

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
recovery3539 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,36,3841 even if the ovary appears dark purple or
black. In addition, outcomes from paediatric cases of torsion

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Damigos et al.

would support a more conservative approach to surgical

management in the form of de-torsion with or without
oophoropexy.42,43 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.44 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.45
Follow up of women who have undergone de-torsion,
suggests that in the majority of cases, function appears to
recover (based on the presence of follicular activity on
follow-up ovarian ultrasound, pregnancy rates, response to
ovulation induction or second-look laparoscopy).4,35,40,41,46
Whether or not to perform oophoropexy when de-torsion of
normal adnexae is performed is less clear. In cases where
recurrent torsion has occurred, oophoropexy has been shown
to be effective in reducing the recurrence rate.47 There are
case reports in the literature of fixing the de-torted ovary, or
contralateral ovary, to the back of the uterus, or shortening
of the utero-ovarian ligament. These reports are mainly in
children and adolescents, however, long-term outcomes in
these cases are unclear.43 In cases where torsion has occurred
in the presence of a true ovarian cyst, cystectomy at the time
of de-torsion is often risky due to the friable nature of the
tissues, but early elective cystectomy has been described after
an interval of 23 weeks to allow time for the oedema and
congestion to resolve.4 In all cases of adnexal torsion, the
laparoscopic approach would be the preferred route in order
to reduce admission time, postoperative pain and long-term
risk of adhesion formation. As always, however, the route
should be determined by the clinical expertise of the
operator, and based on the patients suitability for
laparoscopic surgery.

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

2012 Royal College of Obstetricians and Gynaecologists

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.

Conflict of interest
None declared.

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