Ovarian Torsion: Symptoms, Types, Causes and Treatment

Ovarian torsion is a gynecological emergency that can have serious consequences if not promptly diagnosed and treated. While rare, it presents a significant risk to ovarian function and fertility. Understanding its symptoms, types, causes, and treatment options is crucial for anyone involved in women's health, including patients, parents, and healthcare providers. This article offers a comprehensive look into ovarian torsion, synthesizing current research and best practices for recognition and management.

Symptoms of Ovarian Torsion

Ovarian torsion can be a deceptive and challenging diagnosis. Its symptoms often overlap with other common abdominal and pelvic conditions, making awareness and prompt recognition vital for preserving ovarian health and function.

Symptom	Description	Prevalence/Pattern	Sources
Abdominal Pain	Sudden onset, often severe and unilateral	Most common presenting symptom	1 2 3 4 5 7 11 12
Nausea/Vomiting	Frequently accompanies pain	Seen in 70–85% of cases	1 2 3 5 11
Abdominal Tenderness	Discomfort on palpation	Present in up to 88%	1 11
Palpable Mass	Detectable mass on abdominal exam	Only in a minority (~24%)	1 12
Other	Fever, abnormal imaging, elevated CRP	Less common, nonspecific	3 4 6

Table 1: Key Symptoms of Ovarian Torsion

Pain: The Hallmark but Not Always Obvious

The classic symptom is a sudden, sharp, and often severe pain localized to one side of the lower abdomen or pelvis. However, the pain may also be gradual or intermittent, and can sometimes mimic other causes of acute abdomen such as appendicitis or kidney stones. In pediatric and adolescent patients, the pain may not always be clearly localized or described 1 3 5 7 12.

Gastrointestinal Symptoms

Nausea and vomiting often accompany the pain, occurring in approximately 70–85% of patients—especially in younger girls and those with acute onset 1 2 3 5 11. The presence of vomiting and a short duration of pain can be particularly predictive in pediatric cases 3.

Physical Exam Findings

Abdominal tenderness is very common and may be elicited during a physical exam in up to 88% of cases 1 11. However, a palpable mass is only present in about a quarter of patients, and its absence does not rule out torsion 1 12.

Laboratory and Imaging Clues

Blood tests are not diagnostic, though elevated C-reactive protein (CRP) can be seen in some cases, especially in children 3. Imaging—primarily ultrasound—may reveal an enlarged, edematous ovary, but normal ultrasound findings do not exclude torsion 1 5 6 12.

Nonspecific and Variable Presentation

Symptoms can be variable and may mimic other conditions. Ovarian torsion can occur at any age and should be considered in the differential diagnosis of acute abdominal or pelvic pain in females, regardless of age, menstruation status, or the presence of an adnexal mass 1 5 12.

Types of Ovarian Torsion

Ovarian torsion is not a one-size-fits-all diagnosis. Its presentation and underlying anatomical changes can vary, influencing both symptoms and management. Understanding the different types helps guide clinical suspicion and treatment.

Type	Description	Affected Groups	Sources
Complete Torsion	Ovary rotates fully (>360°), blocks blood flow	All ages, more severe	3 5 6 7
Partial Torsion	Incomplete rotation, intermittent symptoms	All ages, variable severity	5 6
Adnexal Torsion	Ovary + fallopian tube twisted together	Common in reproductive age	4 5 7
Isolated Ovarian Torsion	Only the ovary twists, tube not involved	More common in children	6 7

Table 2: Types of Ovarian Torsion

Complete vs. Partial Torsion

Complete torsion occurs when the ovary (sometimes with the fallopian tube) rotates around its supporting ligaments more than 360 degrees. This leads to total obstruction of venous and arterial blood flow, resulting in rapid onset of severe symptoms and, if not corrected, ovarian necrosis 3 5 6.
Partial torsion involves less rotation, which may cause intermittent or less severe symptoms and may sometimes spontaneously resolve or progress to complete torsion 5 6. Because the symptoms can wax and wane, diagnosis may be delayed.

Adnexal (Ovarian + Tubal) Torsion

When both ovary and fallopian tube twist together, it is referred to as adnexal torsion. This is the most common form in reproductive-aged women, often associated with a mass or cyst acting as a lead point 4 5 7. The entire adnexa can become enlarged and edematous, and rapid intervention is required to prevent infarction.

Isolated Ovarian Torsion

In isolated ovarian torsion, only the ovary is twisted, without involvement of the fallopian tube. This type is more frequently seen in pediatric and premenarchal girls, possibly because of different ligamentous laxity and anatomical factors in younger patients 6 7.

The Spectrum: From Acute to Chronic

There is also a spectrum from acute, complete torsion with sudden severe symptoms to subacute or chronic, partial torsion with intermittent or mild pain. Recognizing this diversity is essential for timely diagnosis and management.

Causes of Ovarian Torsion

Why does ovarian torsion happen? Understanding the underlying causes and risk factors can help in early identification and even prevention in some cases.

Cause/Risk Factor	Mechanism/Description	Relative Frequency/Group	Sources
Ovarian Mass/Cyst	Increases ovary size/weight, acts as lead point	Most common, all ages	2 5 6 7
Normal Ovary	No underlying lesion, often in children	20–40% pediatric cases	6 7 9 10
Pregnancy	Hormonal/structural changes increase risk	Reproductive age	5 6
Assisted Reproduction	Ovarian hyperstimulation increases size	IVF patients	4 5
Anatomical Variations	Long utero-ovarian ligament, laxity	Children, adolescents	6 7

Table 3: Causes and Risk Factors for Ovarian Torsion

Ovarian Masses and Cysts

The overwhelming majority of ovarian torsion cases are associated with the presence of an ovarian mass or cyst—benign or, less commonly, malignant. Masses increase the weight and mobility of the ovary, making torsion more likely 2 5 6 7. Cysts larger than 5 cm are particularly risky.

Torsion in Normal Ovaries

Surprisingly, ovarian torsion can also occur in normal ovaries, especially in children and young adolescents. Up to 20–40% of pediatric torsion cases have no underlying mass or cyst 6 7 9 10. Factors such as ligamentous laxity, increased mobility, or minor trauma may contribute.

Pregnancy and Hormonal Factors

Pregnant women, particularly in the first trimester, are at increased risk due to hormonal influences and anatomical changes that can increase ovarian size and mobility 5 6.

Assisted Reproduction and Hyperstimulation

Women undergoing fertility treatments, particularly ovarian hyperstimulation, are at higher risk due to enlarged, cystic ovaries 4 5.

Anatomical and Developmental Factors

Long or lax supporting ligaments and other anatomical variations are more common in children and can predispose to torsion even in the absence of a mass 6 7.

Other Contributing Factors

Rapid body movements, strenuous physical activity, or trauma may precipitate torsion in susceptible individuals.

Treatment of Ovarian Torsion

Timely intervention is critical in ovarian torsion to prevent irreversible damage. Treatment strategies have evolved over the years, with a strong emphasis now on ovarian conservation, especially in children and reproductive-aged women.

Treatment	Approach/Goal	Indications	Sources
Surgical Detorsion	Untwist ovary, restore blood flow	First-line, all cases	2 5 6 8 9 10 11 12
Oophorectomy	Remove ovary (if necrotic/suspicious)	Rare, malignancy/necrosis	8 9 10 11
Cystectomy/Drainage	Remove cyst, preserve ovary	Coexisting cysts	9 10 11
Oophoropexy	Fix ovary to prevent recurrence	High recurrence risk	8 11
Imaging Surveillance	Monitor ovary post-detorsion	After conservative surgery	8 9 10

Table 4: Treatment Options for Ovarian Torsion

Surgical Detorsion: The Mainstay of Therapy

The current standard for ovarian torsion is prompt surgical intervention—either laparoscopy or laparotomy—to untwist the ovary and restore blood flow 2 5 6 8 9 10 11 12. Early detorsion is associated with high rates of ovarian salvage, even when the ovary appears dark or necrotic at surgery 8 9 10.

Conservative Surgery and Ovarian Preservation

Whenever possible, conservative management is preferred. This involves untwisting the ovary and addressing any underlying cysts or masses via cystectomy or drainage, aiming to preserve the ovary and its function 8 9 10 11. Studies show that even ovaries that look severely compromised can often recover normal function 9 10.

Oophorectomy: Last Resort

Oophorectomy—removal of the ovary—is reserved for situations where the ovary is nonviable, extensively necrotic, or if malignancy is strongly suspected 8 9 10 11. The risks of leaving behind malignancy are very low, particularly in children 8.

Oophoropexy and Recurrence Management

Oophoropexy, or fixation of the ovary, may be considered in cases of recurrent torsion, anatomical predisposition, or when both ovaries are at risk 8 11. Its use after a single episode is debated.

Postoperative Surveillance

After detorsion and ovarian salvage, follow-up imaging (typically ultrasound at 3 months) is recommended to monitor recovery and check for recurrence or underlying pathology 8 9 10.

Safety and Outcomes

Conservative management is safe and effective, with low rates of complications such as thromboembolism or infection. Fertility and ovarian function are usually preserved, and pregnancies have occurred even after detorsion of previously torsed ovaries 8 9 10.

Conclusion

Ovarian torsion is a rare but critical condition that requires high clinical suspicion and rapid action. Its symptoms can be subtle or mimic other disorders, and it affects females of all ages. Advances in diagnosis and treatment have dramatically improved outcomes—especially the chances of preserving ovarian function and fertility.

Key Takeaways:

• Symptoms: Sudden, severe abdominal pain with nausea and vomiting are classic, but presentations can vary. Imaging and labs help but are not definitive 1 2 3 5 6 12.
• Types: Torsion can be complete or partial, involve the ovary alone or both ovary and tube, and present in children as well as adults 3 4 5 6 7.
• Causes: Most common in the presence of ovarian masses or cysts, but can occur in normal ovaries, especially in children. Pregnancy and assisted reproduction increase risk 2 5 6 7 9 10.
• Treatment: Surgical detorsion (often via laparoscopy) is the mainstay, with strong preference for ovarian preservation. Oophorectomy is rare. Postoperative monitoring is essential 2 5 6 8 9 10 11 12.

Early recognition and intervention are the keys to protecting ovarian health and fertility in patients with ovarian torsion. If you suspect it—act fast!