Ovarian torsion is the fifth most common gynecologic emergency, involving complete or partial rotation of the ovary (and often the fallopian tube) on its ligamental supports, resulting in vascular compromise and potential ovarian ischemia/necrosis. [1-2] It is a surgical diagnosis — no clinical or imaging criteria are sufficient to confirm the preoperative diagnosis, and a high index of suspicion is paramount. [1]
1. History
- Sudden-onset, unilateral lower abdominal/pelvic pain — the hallmark symptom, present in ~95% of cases [1][3]
- Pain is classically intermittent, nonradiating, and may wax/wane (reflecting intermittent torsion/detorsion) [1]
- Nausea and vomiting in 62–90% of cases — a key distinguishing feature from simple ovarian cysts [1][3-4]
- Most patients (79%) present within 24 hours of symptom onset [3]
- Ask about: prior known ovarian cysts/masses, recent vigorous activity or positional change, fertility treatments (ovarian hyperstimulation), pregnancy status, prior episodes of similar pain that resolved spontaneously (intermittent torsion)
- Pain severity: 95% of patients require opioids for adequate analgesia [3]
- Right lower quadrant predominance (~60%), which can mimic appendicitis [3]
2. Alarm Features
- Severe, unrelenting pain with nausea/vomiting in a reproductive-age female
- Peritoneal signs (rebound, guarding) — present in 12–27% [1]
- Hemodynamic instability (suggests hemorrhagic infarction or rupture)
- Known adnexal mass >5 cm with acute pain
- Pain out of proportion to exam findings
- Fever with adnexal mass (consider tubo-ovarian abscess vs. necrotic torsion)
- Critical pearl: Presence of Doppler arterial flow does NOT rule out torsion — normal arterial flow is seen in up to 60% of surgically confirmed cases [1]
3. Medications
- ED pain management: Opioids (morphine, fentanyl) are the mainstay — nearly all patients require parenteral opioids. IV ketorolac can be used as adjunct [3]
- Antiemetics: Ondansetron for nausea/vomiting
- No medications treat the underlying torsion — definitive management is surgical
- Avoid delaying surgery for analgesic optimization
- In patients on ovulation induction agents (clomiphene, gonadotropins), be aware of increased torsion risk due to ovarian enlargement/hyperstimulation
4. Diet
- NPO once torsion is suspected, in anticipation of emergent surgery
- No specific dietary triggers or long-term dietary management
5. Review of Systems
- GI: nausea, vomiting, anorexia (common); diarrhea or constipation (less common)
- GU: dysuria, urinary frequency (may mimic UTI); vaginal bleeding or discharge (less common)
- OB/GYN: last menstrual period, possibility of pregnancy, history of ovarian cysts, fertility treatments
- Constitutional: low-grade fever may occur; high fever suggests alternative diagnosis (TOA, appendicitis)
- Vascular: no reported cases of venous thromboembolism after detorsion [1]
6. Collateral History and Family History
- Prior imaging showing ovarian cysts or masses
- History of fertility treatments or ovarian hyperstimulation syndrome
- Prior episodes of similar self-resolving pain (intermittent torsion)
- Family history of ovarian tumors (teratomas are the most common pathologic lead point) [3]
- In pediatric patients, collateral from parents regarding symptom timeline is critical
7. Risk Factors
- Ovarian mass or cyst — risk increases when masses exceed 5 cm [1]
- Reproductive age (peak incidence) — mean age ~27 years [3]
- Benign functional cysts and mature cystic teratomas are the most common associated pathologies [1][3]
- Ovarian hyperstimulation from fertility treatments
- Pregnancy (especially first trimester, due to corpus luteum cysts)
- Pediatric/adolescent patients: up to 46% have torsion without an associated mass, attributed to congenitally long ovarian ligaments or ligamentous laxity [1]
- Right side predominance (64%) — the descending colon may protect the left ovary [1]
- Prior tubal ligation, prior pelvic surgery
8. Differential Diagnosis
- Ruptured/hemorrhagic ovarian cyst — the most common alternative diagnosis at surgery [5]
- Appendicitis — especially with right-sided pain; CT may help differentiate
- Ectopic pregnancy — always obtain β-hCG in reproductive-age females
- Tubo-ovarian abscess / PID — fever, vaginal discharge, cervical motion tenderness
- Endometriosis / endometrioma — chronic dysmenorrhea, dyspareunia
- Nephrolithiasis / ureteral colic — hematuria, flank pain
- Degenerating leiomyoma — known fibroids, subacute pain
- Massive ovarian edema (without torsion)
- Ovarian hyperstimulation syndrome
- Mesenteric lymphadenitis (in pediatric patients)
- Pearl: In 50% of laparoscopies for suspected torsion, torsion is NOT found — but alternative gynecologic pathology is usually identified and treated [1]
9. Past Medical History
- Prior ovarian cysts, teratomas, or adnexal masses
- Previous episodes of ovarian torsion (recurrence rate ~10–15%)
- History of pelvic surgery or tubal ligation
- Fertility treatment history
- Endometriosis
- Known coagulopathy (relevant for surgical planning)
10. Physical Exam
- Vital signs: Usually normal; tachycardia may indicate severe pain or hemorrhage; fever is uncommon
- Abdominal exam: Unilateral lower quadrant tenderness (up to 88%); rebound/peritoneal signs in only 12–27% [1]
- Pelvic exam: Adnexal tenderness, possible palpable adnexal mass; cervical motion tenderness is less prominent than in PID
- Key pearl: A bimanual exam may not be tolerated or necessary in pediatric/adolescent patients [1]
- Guarding and rigidity suggest advanced ischemia or necrosis
11. Lab Studies
- β-hCG — mandatory in all reproductive-age females to rule out ectopic pregnancy
- CBC — WBC >11,000/μL increases likelihood of torsion but is nonspecific; leukocytosis is NOT useful for confirming or excluding torsion per ACOG [1][5]
- Urinalysis — to rule out UTI/nephrolithiasis; pyuria is not useful for torsion diagnosis [1]
- CRP, ESR — not useful for diagnosing torsion [1]
- Type and screen — if surgical intervention anticipated
- BMP — preoperative baseline
- D-dimer and IL-6 show promise as biomarkers but are not validated for clinical use [1][6]
- Elevated neutrophil-to-lymphocyte ratio may be a useful adjunct [7]
12. Imaging
- First-line: Pelvic ultrasound (combined transvaginal + transabdominal) — the imaging modality of choice per ACR Appropriateness Criteria [8-9]
- Pooled sensitivity 79%, specificity 76% (meta-analysis, 1,187 patients) [8][10]
- With Doppler: sensitivity 80%, specificity 88% [8][10]
- Key US findings:
- Unilateral ovarian enlargement (>4 cm or >20 cm³) — present in virtually all torsed ovaries [1]
- Whirlpool sign (twisted vascular pedicle) — sensitivity 65%, specificity 91%; 90% confirmed at laparoscopy [8][11]
- Ovarian stromal edema with peripherally displaced follicles ("string of pearls") — found in ~69–79% [12]
- Absent/abnormal venous flow — sensitivity 100%, specificity 97% [8]
- Absent arterial flow — sensitivity 76%, specificity 99% [8]
- Follicular ring sign — 100% specificity [13-14]
- Free pelvic fluid in ~71% [12]
- Critical pitfall: A normal-appearing ovary on US is unlikely to be torsed, but presence of Doppler flow does NOT exclude torsion [1][15]
- CT abdomen/pelvis with IV contrast: Sensitivity 74–95%, specificity 80–90%. Useful when US is inconclusive or when obtained for other indications (e.g., ruling out appendicitis). Findings include asymmetric ovarian enlargement, twisted pedicle, uterine deviation, absent ovarian enhancement [8]
- MRI pelvis: Pooled sensitivity 81%, specificity 91% — useful for equivocal cases [8]
- When imaging is unnecessary: If clinical suspicion is high, do NOT delay surgery to obtain imaging [1]
13. Special Tests
- Point-of-care ultrasound (POCUS): Can expedite identification of enlarged ovary, free fluid, and absent Doppler flow at bedside; considered an advanced emergency US application [9]
- No validated clinical scoring system is widely adopted, though composite indices combining vomiting, adnexal volume, and adnexal volume ratio (affected/unaffected ovary) have been studied [1]
- Diagnostic laparoscopy remains the gold standard — it is both diagnostic and therapeutic [1]
14. ECG
- Not routinely indicated for ovarian torsion diagnosis
- Obtain as part of preoperative evaluation if emergent surgery is planned
- Consider ECG if hemodynamically unstable to rule out cardiac etiology of abdominal pain in older patients
15. Assessment
Ovarian torsion is a time-sensitive gynecologic emergency that predominantly affects premenopausal women. The presentation is often nonspecific, leading to frequent misdiagnosis in the ED. [2] Key clinical summary points:
- The classic triad is acute unilateral pelvic pain + nausea/vomiting + adnexal mass, but atypical presentations are common
- Ovarian viability declines with time; a sharp decrease in ovarian function may occur after 72 hours of symptoms, though the ovary's dual blood supply provides some resilience. A pediatric series identified 34 hours from symptom onset to OR as a critical threshold for viability [1][16]
- Intraoperative appearance (blue-black ovary) is a poor predictor of viability — only 18–20% of necrotic-appearing ovaries are truly necrotic on pathology [1][7]
- Malignancy as a cause of torsion is rare, especially in adolescents [1]
16. Treatment Plan
Initial stabilization (ED)
- IV access, IV fluids
- Aggressive pain control: IV opioids (morphine 0.1 mg/kg or fentanyl 1–2 mcg/kg) ± IV ketorolac 15–30 mg
- Antiemetics: ondansetron 4 mg IV
- NPO status
- Emergent gynecology consultation — do not delay for additional workup if clinical suspicion is high [2]
Surgical management
- Laparoscopic detorsion with ovarian preservation is the standard of care regardless of ovarian appearance, per ACOG [1]
- A surgeon should not remove a torsed ovary unless oophorectomy is unavoidable (e.g., severely necrotic ovary that falls apart) [1]
- Cystectomy does not need to be performed at the time of detorsion — it may cause additional trauma. Incision and drainage of large cysts may be considered [1]
- Oophoropexy (fixation to pelvic sidewall) may be considered to prevent recurrence, though efficacy is debated [6][17]
- Despite updated ACOG guidelines, oophorectomy is still performed in ~70% of cases nationally, highlighting the need for continued education [18]
Myth debunked: There is no evidence of thromboembolic events after detorsion — no cases of VTE after untwisting have been reported [1]
17. Disposition
- All confirmed or highly suspected ovarian torsion requires admission for emergent/urgent surgical intervention
- Transfer to a facility with gynecologic surgical capability if not available on-site
- Observation may be considered if torsion is suspected but imaging is equivocal — serial exams and repeat imaging with close gynecology involvement
- Discharge is NOT appropriate if torsion remains on the differential
- Specialist consultation triggers: Emergent OB/GYN or gynecologic surgery consult for all suspected cases; pediatric surgery involvement for young patients
18. Follow Up / Return Precautions
Post-operative follow-up
- Ultrasound at 6–12 weeks to reevaluate ovarian morphology and any residual cyst [1]
- Assess for follicular activity on follow-up US as a marker of ovarian viability — necrotic-appearing ovaries have been shown to have follicular activity at 1 year post-detorsion [7]
- Recurrence rate is approximately 10–15%; counsel patients on symptoms of re-torsion
Return precautions (patient counseling)
- Return immediately for recurrence of severe unilateral pelvic pain, nausea/vomiting, or worsening symptoms
- Fever, increasing abdominal distension, or lightheadedness/syncope warrant immediate reevaluation
- Expected recovery: most patients recover well after laparoscopic detorsion with short hospital stays
Key ED pearl: Ovarian torsion is a commonly missed diagnosis in the ED. [2][9] Maintain a high index of suspicion in any reproductive-age female with acute pelvic pain, even with normal Doppler flow on ultrasound.
References
1. Adnexal Torsion in Adolescents: ACOG Committee Opinion No, 783. — Committee on Adolescent Health Care Obstetrics and Gynecology. 2019.
2. High Risk and Low Prevalence Diseases: Ovarian Torsion. — Bridwell RE, Koyfman A, Long B. The American Journal of Emergency Medicine. 2022.
3. Ovarian Torsion: A Retrospective Case Series at a Tertiary Care Center Emergency Department. — Tabbara F, Hariri M, Hitti E. PloS One. 2023.
4. Identifying Reliable Predictors of Ovarian Torsion in Acute Gynecological Presentations: A Retrospective Case-Control Study. — Aiob A, Shushan Marom SB, Gumin D, Lowenstein L, Sharon A. European Journal of Obstetrics, Gynecology, and Reproductive Biology. 2025.
5. Acute Abdominal Pain in Adults: Evaluation and Diagnosis. — Yew KS, George MK, Allred HB. American Family Physician. 2023.
6. Ovarian Torsion: A Review of the Evidence. — Zhu TW, Li XL. Obstetrical & Gynecological Survey. 2024.
7. Adnexal Torsion: A Review of Diagnosis and Management Strategies. — Chang-Patel EJ, Palacios-Helgeson LK, Gould CH. Current Opinion in Obstetrics & Gynecology. 2022.
8. ACR Appropriateness Criteria® Acute Pelvic Pain in the Reproductive Age Group: 2023 Update. — Brook OR, Dadour JR, Robbins JB, et al. Journal of the American College of Radiology : JACR. 2024.
9. Ultrasound Guidelines: Emergency, Point-of-Care, and Clinical Ultrasound Guidelines in Medicine. — American College of Emergency Physicians (2023). 2023.
10. Accuracy of Imaging Modalities for Adnexal Torsion: A Systematic Review and Meta-Analysis. — Wattar B, Rimmer M, Rogozinska E, et al. BJOG : An International Journal of Obstetrics and Gynaecology. 2021.
11. Diagnostic Accuracy of Ultrasound Signs for Detecting Adnexal Torsion: Systematic Review and Meta-Analysis. — Garde I, Paredes C, Ventura L, et al. Ultrasound in Obstetrics & Gynecology : The Official Journal of the International Society of Ultrasound in Obstetrics and Gynecology. 2023.
12. Imaging in Gynecological Disease (20): Clinical and Ultrasound Characteristics of Adnexal Torsion. — Moro F, Bolomini G, Sibal M, et al. Ultrasound in Obstetrics & Gynecology : The Official Journal of the International Society of Ultrasound in Obstetrics and Gynecology. 2020.
13. Sonographic Signs of Pediatric Ovarian Torsion: Multicenter Study With Surgical Correlation. — Almalki YE, Basha MAA, Nada MG, et al. European Journal of Radiology. 2025.
14. Predictive Value of Single or Combined Ultrasound Signs in the Diagnosis of Ovarian Torsion. — Yatsenko O, Vlachou PA, Glanc P. Journal of Ultrasound in Medicine : Official Journal of the American Institute of Ultrasound in Medicine. 2021.
15. Pearls and Pitfalls in Imaging of Pelvic Adnexal Torsion: Seven Tips to Tell It's Twisted. — Strachowski LM, Choi HH, Shum DJ, Horrow MM. Radiographics : A Review Publication of the Radiological Society of North America, Inc. 2021.
16. Time's a Tickin': When Should Surgical Intervention Occur in Ovarian Torsion?. — Byrne MM, Loszko A, Wirth K, Nicandri K, Arca MJ. Journal of Pediatric Surgery. 2026.
17. Fertility Preserving Management of Ovarian Torsion. — Sandrieser L, Perricos A, Husslein H, Wenzl R, Kuessel L. Fertility and Sterility. 2023.
18. Changing Practices in the Surgical Management of Adnexal Torsion: An Analysis of the National Surgical Quality Improvement Program Database. — Ryles HT, Hong CX, Andy UU, Farrow MR. Obstetrics and Gynecology. 2023.