Ovarian torsion is a gynaecological emergency 

What Is Ovarian Torsion?

Ovarian torsion is a gynaecological emergency where an ovary twists around the ligaments that support it, cutting off its blood supply. This causes sudden, severe pelvic pain and requires immediate medical attention to prevent permanent damage or loss of the ovary.

Twisting of the ovary (sometimes including the fallopian tube) on its supporting ligaments, blocking blood flow. Without prompt treatment, the ovary can become necrotic (tissue death), leading to loss of fertility or infection. It is the fifth most common gynaecological surgical emergency, accounting for about 3% of ER visits requiring reproductive surgery.

Symptoms

• Sudden, severe pelvic or abdominal pain (often on one side).
• Nausea and vomiting.
• Fever (if tissue damage begins).
• Abnormal vaginal bleeding or discharge.
• Pain may radiate to the back, thighs, or flank and can be constant or intermittent.

Causes & Risk Factors

• Ovarian cysts or masses (especially >5 cm).
• Pregnancy (hormonal changes and corpus luteum cysts).
• Fertility treatments (stimulated ovaries with multiple cysts).
• Congenital anatomical variations (longer ovarian ligaments).
• Physical activity or intercourse may sometimes trigger torsion, though it can occur spontaneously.

Risks if Untreated

• Permanent ovarian damage or loss.
• Reduced fertility.
• Severe infection (peritonitis).
• Life-threatening complications in rare cases.

If you or someone else experiences sudden, severe pelvic pain, especially with known ovarian cysts or during pregnancy, go to the emergency room immediately. Early intervention is critical to save the ovary and preserve fertility.

Types of Ovarian Torsion

Complete torsion

• The ovary rotates fully around its supporting ligaments.
• Cuts off both venous and arterial blood supply.
• Leads quickly to ischemia and necrosis if untreated.
• Presents with sudden, severe, constant pain.

Partial torsion

• The ovary twists only partway.
• Venous and lymphatic flow are impaired first, causing swelling and congestion, but arterial supply may remain intact for a time.
• Symptoms may be less intense initially but progress if not treated.

Intermittent torsion

• The ovary twists and untwists spontaneously.
• Pain comes and goes, sometimes confusing diagnosis.
• Still dangerous because repeated twisting damages tissue and can eventually lead to full torsion.

Adnexal torsion

• Involves twisting of the ovary and fallopian tube together.
• More severe because both structures lose blood supply.
• Can result in loss of fertility if not treated promptly.

Key Risks

• Complete torsion → fastest progression to tissue death.
• Intermittent torsion → often misdiagnosed, delays treatment.
• Adnexal torsion → threatens both the ovary and fallopian tube, impacting fertility.

How Is Ovarian Torsion Diagnosed?

Ovarian torsion is diagnosed through a combination of clinical suspicion, imaging studies, and sometimes direct surgical visualisation. Because it’s a medical emergency, doctors aim to confirm it quickly to prevent permanent damage to the ovary.

Steps in Diagnosis

Clinical evaluation

• Doctors look for sudden, severe pelvic pain, nausea, and vomiting.
• A pelvic exam may reveal tenderness or an enlarged ovary.
• Patient history (e.g., ovarian cysts, fertility treatment, pregnancy) raises suspicion.
• Ultrasound with Doppler
• First-line imaging test.
• Shows an enlarged ovary, abnormal position, or reduced/absent blood flow.
• “Whirlpool sign” (twisted vascular pedicle) is a classic finding.
• Sometimes blood flow appears normal if torsion is intermittent, so clinical judgment is key.

CT or MRI

• Used if ultrasound is inconclusive.
• Helps rule out other causes of abdominal pain (appendicitis, kidney stones, etc.).
• MRI can show twisted ligaments and ovarian oedema more clearly.

Definitive diagnosis

• Made during laparoscopy (minimally invasive surgery).
• Surgeons directly visualize the twisted ovary and untwist it.
• This step is both diagnostic and therapeutic.

Treatment of Ovarian Removal

Treatment and Medication Options for Ovarian Torsion

Ovarian torsion is treated almost exclusively with emergency surgery, not medication. The main goal is to untwist the ovary quickly to restore blood flow and prevent tissue death. Medications are used only for pain relief, nausea control, and post-surgical recovery—not as a primary treatment.

Primary Treatment Options

Laparoscopy

• Minimally invasive surgery using small incisions and a camera.
• Surgeons untwist the ovary (detorsion) and often remove any cysts causing torsion (cystectomy).
• Preferred method due to faster recovery and lower complication risk.
• Most patients go home the same day.

Laparotomy

• Open abdominal surgery is used in severe or complex cases.
• Longer recovery time usually requires hospitalization.
• Chosen if laparoscopy isn’t safe or feasible.

Oophorectomy

• Removal of the ovary if it is nonviable (necrotic) or cancerous.
• Less common—surgeons aim to preserve fertility whenever possible.
• Fertility is usually maintained with one healthy ovary.

Oophoropexy

• A preventive procedure to fix the ovary in place to reduce recurrence risk.
• Sometimes recommended for children or women with repeated torsion episodes.

Medication Options (Supportive Only)

• Pain management: Analgesics (NSAIDs, opioids in severe cases).
• Nausea control: Antiemetics to reduce vomiting.
• Antibiotics: Used if infection risk is present post-surgery.
• Hormonal therapy: Sometimes considered to reduce cyst recurrence, especially in women with repeated torsion linked to ovarian cysts.

Risks if Untreated

• Necrosis (tissue death) of the ovary.
• Loss of fertility if both ovaries are affected.
• Severe infection (peritonitis).
• Rare but possible life-threatening complications.

Complications of Ovarian Torsion

Complications of ovarian torsion arise when the ovary remains twisted for too long, cutting off blood supply and damaging surrounding structures. If untreated, it can lead to serious health consequences, including loss of fertility.

Major Complications

• Ovarian necrosis
• Prolonged torsion causes tissue death due to a lack of blood flow.
• Often requires removal of the ovary (oophorectomy).
• Infertility
• Loss of one ovary reduces egg reserve.
• If both ovaries are affected, fertility can be severely compromised.
• Infection and peritonitis
• Dead ovarian tissue can trigger infection.
• May spread to the abdominal cavity, causing life-threatening peritonitis.

Hemorrhage

• Twisting and tissue damage can rupture blood vessels.
• Leads to internal bleeding and shock in severe cases.

Recurrence

• Even after detorsion surgery, torsion can recur.
• Preventive surgery (oophoropexy) may be considered.
• Loss of the fallopian tube
• In adnexal torsion, both the ovary and the tube are affected.
• May require removal of the tube, impacting fertility further.

Conclusion 

The cornerstone of management is prompt surgical intervention to untwist the ovary and restore blood flow. Medications play only a supportive role in pain and recovery. If left untreated, complications such as ovarian necrosis, infertility, infection, and hemorrhage can occur.

Early recognition and immediate treatment save the ovary and preserve fertility in most cases. Awareness of risk factors like ovarian cysts, pregnancy, and fertility treatments is vital for timely diagnosis.

Ovarian torsion should always be treated as an emergency. Quick action can mean the difference between saving or losing the ovary.