In ovarian torsion the ovary, often with the fallopian tube, twists on the ligaments that hold it, cutting off first its venous drainage and then its blood supply. It is a surgical emergency, usually linked to an enlarged ovary or a cyst, and quick surgery can save the ovary.
Key symptoms
- Sudden, severe one-sided lower abdominal or pelvic pain
- Nausea and vomiting with the pain
- Pain that may come and go if the ovary twists and untwists
- Low-grade fever in some patients
What you find on exam
- Tenderness in one lower quadrant, sometimes with guarding
- Tender adnexal mass on bimanual exam
- Vital signs: fast heart rate from pain, fever if the ovary is dying
- Peritoneal signs suggest necrosis or rupture
Tests
- Pregnancy test in every patient of reproductive age
- Pelvic ultrasound with Doppler: enlarged ovary, mass, abnormal flow
- Normal Doppler flow does not rule out torsion
- Blood count and basic labs before surgery
Treatment basics
- Urgent gynecology consult; do not delay surgery for more imaging when suspicion is high
- Diagnostic laparoscopy with detorsion, keeping the ovary whenever possible
- Remove a cyst, or the ovary only if it is clearly dead
- Pain control with IV opioids and an antiemetic such as ondansetron
Red flags
- Sudden severe pelvic pain with vomiting in a patient with a known ovarian cyst
- Fever, peritoneal signs or worsening pain suggesting a dead ovary
- Positive pregnancy test with pelvic pain: rule out ectopic pregnancy
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Sources: NCCPA PANCE Content Blueprint; NBOME COMLEX-USA clinical presentations; AAMC Core Entrustable Professional Activities (Core EPAs). Written by Making Synapses. Making Synapses is not affiliated with these organizations.