Recommendations
Key Recommendations
Suspect ovarian (or adnexal) torsion in girls or women with acute, severe pelvic or abdominal pain.[25] The pain is typically intermittent but may be constant.[5]
Request an urgent ultrasound scan in patients with suspected ovarian (or adnexal) torsion. Transvaginal ultrasound (TVUS) should be used in sexually active adolescents and adult women. Transrectal or abdominal ultrasound should be used in children and other patients where TVUS is not appropriate, including patients who have not been sexually active and those with vaginal stenosis.
Ensure the patient goes to surgery without delay where there is suspicion of torsion based on clinical signs and symptoms and/or findings on imaging.
A definitive diagnosis is based on surgical findings. It is imperative that ovarian torsion be suspected early in order to be promptly diagnosed and surgically managed to preserve ovarian function.
In primary care, refer a patient with suspected ovarian (or adnexal) torsion for urgent hospital assessment, including ultrasound.
The pain is usually so severe that most patients will go straight to hospital.
Suspect ovarian torsion (adnexal torsion) in girls or women with acute, severe pelvic or abdominal pain.[25] Most patients present with sudden-onset lower abdominal pain, often associated with nausea and vomiting. The pain may be constant or intermittent, chronic or acute, or may radiate to the back, flank, or groin. This may resemble renal colic.
In primary care, refer a patient with suspected torsion for urgent hospital assessment, including ultrasound.
Practical tip
The pain associated is usually so severe that most patients will go straight to a hospital emergency department.
Check for the commonest signs and symptoms of ovarian/adnexal torsion:[5][13][21][26][27][28]
Pain: 70% to 96%
Nausea and vomiting: 70%
Diarrhoea: 8%
Palpable adnexal mass: 43% to 53%
Rebound or guarding: 14% to 18%
Tenderness
Localised: 68% to 90%
Diffuse: 20%
Adnexal: 73%
Cervical motion tenderness: 13%
Fever: <2%.
The following five criteria (based on the Self Assessment Questionnaire for Gynecologic Emergencies, SAQ-GE) have been found to be independently associated with adnexal torsion confirmed by surgery:[29]
Unilateral lumbar or abdominal pain
Absence of leucorrhoea and metrorrhagia
Ovarian pain
Unbearable pain
Vomiting.
Recognise that the presentation of ovarian torsion is non-specific, with no absolute clinical profile. This makes the diagnosis a challenge.
When a female presents with pelvic or abdominal pain, ovarian torsion must be suspected. The difficulty for the clinician lies in differentiating between ovarian torsion and other aetiologies such as ectopic pregnancy, appendicitis, ovarian cysts, pelvic inflammatory disease, urinary tract infection, nephrolithiasis, and endometriosis.
Although use of imaging can assist in the diagnosis, the characteristic imaging features are not consistently detected. Therefore, the burden lies on clinical judgement. Laboratory and imaging evaluation should not delay consultation if you suspect ovarian torsion.[2]
Consider ovarian torsion in patients with a recent history of either infertility treatment or strenuous physical activity presenting with severe lower-quadrant pain. It is sometimes seen in pregnancy and may also be associated with sudden increases in intra-abdominal pressure that can occur with coughing or hiccupping. Consider adnexal torsion in patients with known adnexal cysts or neoplasm as these are associated with increased risk of torsion.[6]
Diagnosis in specific populations
Pregnant women
Be alert for ovarian torsion in pregnant women who present with abdominal pain. Although fairly uncommon in pregnancy, the risk of ovarian torsion is approximately 5 in 10,000 and it can cause high patient morbidity and fetal mortality if not immediately treated.[12] The highest risk of torsion is during the first trimester, probably because of the high prevalence of functional ovarian cysts.[5][30]
The risk is significantly higher in women who have had recent fertility treatment.
The presentation is usually non-specific, with severe lower-quadrant pain, nausea, vomiting, and possibly a palpable mass. Clinical suspicion is the most important tool in diagnosis.[7][10][11][22] Incidental adnexal masses can also be found on routine ultrasonography in pregnancy.[30]
Infants and children
Consider the possibility of ovarian torsion in girls who present with acute lower abdominal pain accompanied by nausea/vomiting; the incidence of ovarian torsion in children seen in emergency departments is 0.5 to 2 per 10,000 patients.[28]
Request an abdominal or rectal ultrasound in children and other patients where transvaginal ultrasound (TVUS) is not appropriate, including those who have never been sexually active and patients with vaginal stenosis.[25][31]
Post-menopausal women
Take a detailed medical, gynaecological, and surgical history in a patient presenting with acute pelvic pain when you suspect ovarian/adnexal torsion.
Ask the patient to describe the onset and character of the pain in her own words (even if you are not the first person to see the patient).
Ask about any recent treatment to induce ovulation (such as gonadotrophins or clomiphene). This can cause ovarian hyperstimulation syndrome, which is associated with increased risk of ovarian torsion.
Ask about any previous history of adnexal torsion; around 5% of patients have had adnexal torsion previously.[5]
Ask whether an ovarian cyst (e.g., dermoid cyst) or cystadenoma has been found on previous imaging carried out for another reason. Presence of ovarian cysts is associated with increased risk of ovarian torsion.
Torsion may present with acute-on-chronic pain in patients with a history of an ovarian cyst, particularly a dermoid cyst.[34]
Polycystic ovary syndrome can result in larger, more mobile ovaries that may be more prone to torsion.[24]
Pregnancy test
Request a urinary pregnancy test in all women of childbearing age presenting with abdominal or pelvic pain.[2][24]
Urinalysis
Request urinalysis to rule out a urinary tract infection and check for haematuria.
Blood tests
Request a full blood count (FBC) in all patients.[2][24] There are no specific laboratory findings, although a raised white cell count may be present.[2][28][35][36]
Order a group and save and a sickle cell test in case the patient needs surgery.
Request a C-reactive protein (CRP). This may be raised in adnexal torsion.[37] A negative result can also be helpful in ruling out appendicitis, which may present in a similar manner to ovarian torsion.[38]
Tests for pelvic inflammatory disease (PID)
Request a PCR or nucleic acid amplification (NAAT) test or cervical cultures for chlamydia and gonorrhoea to assess for PID. British Association for Sexual Health & HIV: PID guidelines 2019 Opens in new window
Ultrasound
An urgent transvaginal ultrasound (TVUS) scan is the imaging modality of choice in any adult patient (or adolescent who has been sexually active) who presents with pelvic pain and suspected ovarian torsion.[2][39][40]
Both the affected and contralateral ovary should be examined. It is important to also look at the contralateral ovary as part of assessing the potential impact of removing the affected ovary. Look for asymmetry, with the twisted ovary being significantly larger than the other. Also look for an ovarian cyst that may have predisposed to torsion.
Request an abdominal or rectal ultrasound in children with suspicion of ovarian torsion, and in other patients where TVUS is not appropriate.[25] Use whichever gives the best view.
The most common finding on ultrasound is a unilaterally enlarged ovary, with an ovarian mass characterised by ovarian stromal oedema with or without peripherally displaced antral follicles, the whirlpool sign (which appears as twisting of the thickened vascular pedicle of the enlarged ovary) and free fluid in the pelvis.[5][25] The mass will typically be tender on pressure with the ultrasound probe.
The ultrasound findings depend on the duration and degree of torsion, as well as the presence or absence of an ovarian mass.[21]
In 70% of surgically confirmed cases of torsion, a cystic, solid, or complex adnexal mass, in addition to free fluid in the cul-de-sac, is visualised at ultrasound prior to surgery.[6][41][42]
Ultrasound findings described as predictors of torsion include adnexal location cranial to the uterine fundus, thickening of the adnexal wall, unilateral ovarian enlargement with multiple peripherally located follicles, and cystic haemorrhage.[43][44] Thickening of the fallopian tube may be visualised as a heterogeneous fusiform or tubular structure between the adnexal mass and the uterus.[39][43] Rarely, the fallopian tube alone may be twisted (without the ovary).
Refer any woman whose ultrasound suggests ovarian cancer to a gynaecological cancer service using a suspected cancer pathway referral for further investigation. In practice, it may be necessary to undertake emergency treatment for the torsion even if cancer is suspected.[45][46]
Doppler flow ultrasound may be used to assess blood flow to the ovary but is of limited use because loss of blood flow to the ovary is a late event. One review found that evaluating ovarian vascular flow using Doppler slightly improved the diagnostic accuracy of ultrasound but this was not statistically significant.[40]
Other imaging
Consider computed tomography (CT) or magnetic resonance imaging (MRI) if expert ultrasound is not immediately available or if the ultrasound results are inconclusive. However, these modalities have less diagnostic value than TVUS and risk causing delay before proceeding to surgery.[32][40]
Findings in ovarian torsion include fallopian tube thickening, smooth wall thickening of the twisted adnexal cystic mass, low-volume ascites, and uterine deviation towards the twisted side.[44][47][48]
Avoid CT in pregnancy because of radiation exposure.
Direct visualisation of torsion during surgery is the definitive diagnostic tool in patients where there is a high clinical suspicion of torsion.[1] It also allows for treatment.
Direct visualisation of torsion during laparoscopy is the definitive diagnostic tool in patients where there is a high clinical suspicion of torsion. Surgery also allows for treatment.
Ensure the patient goes to surgery without delay where there is suspicion of ovarian torsion based on clinical signs and symptoms and/or findings on imaging.
It is imperative that ovarian torsion be suspected early in order to be promptly diagnosed and surgically managed to preserve ovarian function.
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