Ovarian torsion
- Overview
- Theory
- Diagnosis
- Management
- Follow up
- Resources
Treatment algorithm
Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer
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surgical detorsion or salpingo-oophorectomy
Ovarian torsion is a surgical emergency. A delay in the timing of surgery is associated with a reduction in the possibility of ovarian salvage.[16]Kives S, Gascon S, Dubuc É, et al. No. 341 - diagnosis and management of adnexal torsion in children, adolescents, and adults. J Obstet Gynaecol Can. 2017 Feb;39(2):82-90. http://www.ncbi.nlm.nih.gov/pubmed/28241927?tool=bestpractice.com
Choice of surgical approach for detorsion, via laparoscopy versus laparotomy, depends on the expertise of the surgeon.[26]Bar-On S, Mashiach R, Stockheim D, et al. Emergency laparoscopy for suspected ovarian torsion: are we too hasty to operate? Fertil Steril. 2010 Apr;93(6):2012-5. http://www.ncbi.nlm.nih.gov/pubmed/19159873?tool=bestpractice.com [61]Mashiach S, Bider D, Moran O, et al. Adnexal torsion of hyperstimulated ovaries in pregnancies after gonadotropin therapy. Fertil Steril. 1990 Jan;53(1):76-80. http://www.ncbi.nlm.nih.gov/pubmed/2295348?tool=bestpractice.com [62]Way S. Ovarian cystectomy of twisted cysts. Lancet. 1946 Jul 13;2(6411):47-8.[63]McGovern PG, Noah R, Koenigsberg R, et al. Adnexal torsion and pulmonary embolism: case report and review of the literature. Obstet Gynecol Surv. 1999 Sep;54(9):601-8. http://www.ncbi.nlm.nih.gov/pubmed/10481857?tool=bestpractice.com [64]Gorkemli H, Camus M, Clasen K. Adnexal torsion after gonadotropin ovulation induction for IVF or ICSE and its conservative treatment. Arch Gynecol Obstet. 2002 Nov;267(1):4-6. http://www.ncbi.nlm.nih.gov/pubmed/12410364?tool=bestpractice.com [65]Ben-Rafael Z, Bider D, Mashiach S. Laparoscopic unwinding of twisted ischemic hemorrhagic adnexum after in vitro fertilization. Fertil Steril. 1990 Mar;53(3):569-71. http://www.ncbi.nlm.nih.gov/pubmed/2137796?tool=bestpractice.com [66]Oelsner G, Bider D, Goldenberg M, et al. Long-term follow-up of the twisted ischemic adnexa managed by detorsion. Fertil Steril. 1993 Dec;60(6):976-9. http://www.ncbi.nlm.nih.gov/pubmed/8243702?tool=bestpractice.com [67]Oelsner G, Cohen SB, Soriano D, et al. Minimal surgery for the twisted ischaemic adnexa can preserve ovarian function. Hum Reprod. 2003 Dec;18(12):2599-602. http://humrep.oxfordjournals.org/content/18/12/2599.full http://www.ncbi.nlm.nih.gov/pubmed/14645177?tool=bestpractice.com [68]Cohen SB, Wattiez A, Seidman DS, et al. Laparoscopy versus laparotomy for detorsion and sparing of twisted ischemic adnexa. JSLS. 2003 Oct-Dec;7(4):295-9. http://www.ncbi.nlm.nih.gov/pubmed/14626393?tool=bestpractice.com Laparoscopy is superior to laparotomy because it decreases hospital stay and postoperative pain, with reduced consumption of analgesic drugs.[60]Balasubramaniam D, Duraisamy KY, Ezhilmani M. Laparoscopic detorsion and fertility preservation in twisted ischemic adnexa - a single-center prospective study. Gynecol Minim Invasive Ther. 2020 Jan 23;9(1):24-8. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7008646 http://www.ncbi.nlm.nih.gov/pubmed/32090009?tool=bestpractice.com
Intraoperative evaluation should be performed. Conservative management with detorsion is highly recommended regardless of the actual appearance of the ovary, which may be dusky, blue-black, or necrotic-appearing.[1]American College of Obstetricians and Gynecologists. Adnexal torsion in adolescents: ACOG committee opinion no, 783. Obstet Gynecol. 2019 Aug;134(2):e56-63. https://journals.lww.com/greenjournal/fulltext/2019/08000/adnexal_torsion_in_adolescents__acog_committee.45.aspx http://www.ncbi.nlm.nih.gov/pubmed/31348225?tool=bestpractice.com [35]Rousseau V, Massicot R, Darwish AA, et al. Emergency management and conservative surgery of ovarian torsion in children: a report of 40 cases. J Pediatr Adolesc Gynecol. 2008 Aug;21(4):201-6. http://www.ncbi.nlm.nih.gov/pubmed/18656074?tool=bestpractice.com [56]Wang JH, Wu DH, Jin H, et al. Predominant etiology of adnexal torsion and ovarian outcome after detorsion in premenarchal girls. Eur J Pediatr Surg. 2010 Sep;20(5):298-301. http://www.ncbi.nlm.nih.gov/pubmed/20533130?tool=bestpractice.com [57]Dasgupta R, Renaud E, Goldin AB, et al. Ovarian torsion in pediatric and adolescent patients: a systematic review. J Pediatr Surg. 2018 Jul;53(7):1387-91. http://www.ncbi.nlm.nih.gov/pubmed/29153467?tool=bestpractice.com [58]Yasa C, Dural O, Bastu E, et al. Impact of laparoscopic ovarian detorsion on ovarian reserve. J Obstet Gynaecol Res. 2017 Feb;43(2):298-302. http://www.ncbi.nlm.nih.gov/pubmed/27928855?tool=bestpractice.com [59]Geimanaite L, Trainavicius K. Ovarian torsion in children: management and outcomes. J Pediatr Surg. 2013 Sep;48(9):1946-53. http://www.ncbi.nlm.nih.gov/pubmed/24074673?tool=bestpractice.com This ensures preservation of ovarian function in most cases.
Salpingo-oophorectomy may be performed if the ovary is thought to be nonviable or if malignancy is suspected. However, the frequency of malignant tumors is extremely low in premenopausal women and adolescents.[2]Hibbard LT. Adnexal torsion. Am J Obstet Gynecol. 1985 Jul 15;152(4):456-61. http://www.ncbi.nlm.nih.gov/pubmed/4014339?tool=bestpractice.com [4]Varras M, Tsikini A, Polyzos D, et al. Uterine adnexal torsion: pathologic and gray-scale ultrasonographic findings. Clin Exp Obstet Gynecol. 2004;31(1):34-8. http://www.ncbi.nlm.nih.gov/pubmed/14998184?tool=bestpractice.com [12]Sommerville M, Grimes DA, Koonings PP, et al. Ovarian neoplasms and the risk of adnexal torsion. Am J Obstet Gynecol. 1991 Feb;164(2):577-8. http://www.ncbi.nlm.nih.gov/pubmed/1992704?tool=bestpractice.com [17]Cass DL. Ovarian torsion. Semin Pediatr Surg. 2005 May;14(2):86-92. http://www.ncbi.nlm.nih.gov/pubmed/15846564?tool=bestpractice.com [21]Oltmann SC, Fischer A, Barber R, et al. Pediatric ovarian malignancy presenting as ovarian torsion: incidence and relevance. J Pediatr Surg. 2010 Jan;45(1):135-9. http://www.ncbi.nlm.nih.gov/pubmed/20105593?tool=bestpractice.com
Involvement of the fallopian tube in the torsion of the adnexa may significantly damage the tube, which may need to be surgically removed (salpingectomy).
Guidelines recommend that, in adolescents, surgeons should not remove a torsed ovary unless oophorectomy is unavoidable (e.g., when a severely necrotic ovary falls apart).[1]American College of Obstetricians and Gynecologists. Adnexal torsion in adolescents: ACOG committee opinion no, 783. Obstet Gynecol. 2019 Aug;134(2):e56-63. https://journals.lww.com/greenjournal/fulltext/2019/08000/adnexal_torsion_in_adolescents__acog_committee.45.aspx http://www.ncbi.nlm.nih.gov/pubmed/31348225?tool=bestpractice.com
oophoropexy
Treatment recommended for SOME patients in selected patient group
Oophoropexy remains controversial; its use is not generally recommended to decrease the risk of recurrent ovarian torsion.[1]American College of Obstetricians and Gynecologists. Adnexal torsion in adolescents: ACOG committee opinion no, 783. Obstet Gynecol. 2019 Aug;134(2):e56-63. https://journals.lww.com/greenjournal/fulltext/2019/08000/adnexal_torsion_in_adolescents__acog_committee.45.aspx http://www.ncbi.nlm.nih.gov/pubmed/31348225?tool=bestpractice.com [34]Ritchie J, O’Mahony F, Garden A; British Society for Paediatric and Adolescent Gynaecology. Guideline for the management of ovarian cysts in children and adolescents. Jun 2017 [internet publication]. https://britspag.org/wp-content/uploads/2024/05/Ovarian-cyst-management-in-PAG-guideline.pdf [70]Comeau IM, Hubner N, Kives SL, et al. Rates and technique for oophoropexy in pediatric ovarian torsion: a single-institution case series. J Pediatr Adolesc Gynecol. 2017 Jun;30(3):418-21. http://www.ncbi.nlm.nih.gov/pubmed/27887999?tool=bestpractice.com [71]Adeyemi-Fowode O, Lin EG, Syed F, et al. Adnexal torsion in children and adolescents: a retrospective review of 245 cases at a single institution. J Pediatr Adolesc Gynecol. 2019 Feb;32(1):64-9. https://www.doi.org/10.1016/j.jpag.2018.07.003 http://www.ncbi.nlm.nih.gov/pubmed/30012428?tool=bestpractice.com
One systematic review found no clear evidence to support oophoropexy in pediatric and adolescent patients after a first episode of ovarian torsion.[57]Dasgupta R, Renaud E, Goldin AB, et al. Ovarian torsion in pediatric and adolescent patients: a systematic review. J Pediatr Surg. 2018 Jul;53(7):1387-91. http://www.ncbi.nlm.nih.gov/pubmed/29153467?tool=bestpractice.com Oophoropexy may be considered in specific settings (e.g., absent contralateral ovary, elongated ovarian ligament, and torsion of normal adnexa).[16]Kives S, Gascon S, Dubuc É, et al. No. 341 - diagnosis and management of adnexal torsion in children, adolescents, and adults. J Obstet Gynaecol Can. 2017 Feb;39(2):82-90. http://www.ncbi.nlm.nih.gov/pubmed/28241927?tool=bestpractice.com [71]Adeyemi-Fowode O, Lin EG, Syed F, et al. Adnexal torsion in children and adolescents: a retrospective review of 245 cases at a single institution. J Pediatr Adolesc Gynecol. 2019 Feb;32(1):64-9. https://www.doi.org/10.1016/j.jpag.2018.07.003 http://www.ncbi.nlm.nih.gov/pubmed/30012428?tool=bestpractice.com
ovarian cystectomy
Treatment recommended for SOME patients in selected patient group
Cystectomy (removal of the cyst and cyst wall) rather than cyst drainage is appropriate.[35]Rousseau V, Massicot R, Darwish AA, et al. Emergency management and conservative surgery of ovarian torsion in children: a report of 40 cases. J Pediatr Adolesc Gynecol. 2008 Aug;21(4):201-6. http://www.ncbi.nlm.nih.gov/pubmed/18656074?tool=bestpractice.com
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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer
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