Written by Sam Parnell
Ovarian torsion is a rare condition that is difficult to diagnose and associated with significant morbidity. Key points are summarized here, but reading the entire article is highly recommended. It’s short and packed with important information.
Why does this matter?
Ovarian torsion is a true gynecologic surgical emergency. Without appropriate treatment, there is the potential for ovarian necrosis and reduced fertility. Furthermore, patients with ovarian torsion present with variable symptoms, and diagnosis can be challenging. So, what does the available evidence say about this high risk and low prevalence disease?
Twist and shout…for help!
Ovarian torsion occurs when there is complete or partial rotation of an ovary along its supporting ligaments. This can lead to vascular compression, ischemia, and eventual necrosis. Ovarian torsion, though rare, is one of the most common gynecologic surgical emergencies. It most commonly affects reproductive age women, especially those between the ages of 29 to 34 years. Women who are pregnant, have polycystic ovarian syndrome, or who are undergoing ovulation induction for infertility treatment may experience enlarged ovarian cysts and are at particularly high risk of torsion. A significant number of cases also occur in the premenarchal and postmenopausal populations.
Ovarian torsion is often associated with a pelvic abnormality such as an ovarian cyst or mass. Ovarian masses larger than 5 cm confer especially high risk, but any ovarian mass can be associated with torsion.
The classic presentation of ovarian torsion is sudden, severe, unilateral pelvic pain with associated nausea and vomiting. Unfortunately, atypical presentations are common, and symptoms can be continuous or intermittent. Physical exam can be misleading, and up to a third of patients may not have pelvic or abdominal tenderness.
Diagnosis can be difficult, and laboratory analysis (besides a pregnancy test) is usually not helpful. Transvaginal ultrasound (TVUS) with doppler (or transabdominal in children) is considered the first line imaging modality for evaluation of ovarian torsion. TVUS demonstrates excellent specificity but variable sensitivity, ranging from 35 to 85%. Therefore, a normal ultrasound cannot effectively rule out this diagnosis if there is high clinical suspicion. CT of the abdomen and pelvis with IV contrast can be very useful in the evaluation of suspected ovarian torsion, evaluating for reduced or absent ovarian enhancement with contrast, peripherally displaced follicles, enlarged ovary with a follicular ovarian stroma, and a thickened fallopian tube with target/beak-like appearance.
If ovarian torsion is confirmed or highly suspected, gynecology should be immediately consulted. The gold standard treatment is surgical detorsion through laparoscopy or laparotomy. Ovarian torsion is a time-sensitive gynecologic emergency. Remember, time is ovary! However, there is no clear time after which ovaries are not salvageable, and ovarian salvage has been reported up to 36 hours in pediatric patients. Therefore, when in doubt, consult your friendly neighborhood gynecologist.
High risk and low prevalence diseases: Ovarian torsion. Am J Emerg Med. 2022 Mar 31;56:145-150. doi: 10.1016/j.ajem.2022.03.046. Online ahead of print.