Recommendations
Key Recommendations
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.[25]
Counsel the patient carefully before surgery about the possible procedures that may be performed and their benefits and risks.
Intraoperative evaluation should be performed at the time of surgery, which can be performed through laparoscopy or laparotomy.[50]
Intraoperative assessment of the ovary is the main parameter guiding decisions on the surgical management of ovarian torsion, together with the patient’s clinical situation, previous medical and surgical history, age, and the patient’s desire to preserve their fertility.[50]
Surgical management may be conservative, involving detorsion with preservation of the ovary, or may require removal of the adnexa, including oophorectomy.[50] Cystectomy or interval cystectomy may be performed in patients where ovarian torsion involves non-functional ovarian cysts.
The goal of treatment depends on the clinical situation but includes preventing irreversible damage to the ovary in patients who may wish to have children in the future. 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, and where preserving fertility is a priority.
Suspect ovarian torsion early and arrange rapid investigations to enable prompt surgical investigation and intervention to reduce the risk of damage to the ovary and to preserve ovarian function in women who wish to maintain their fertility.
Untwisting of the ovary (detorsion) with laparoscopy, even if the ovary has a dusky, blue-black appearance, allows preservation and return of normal function and fertility in most cases.[51][52][53][54][55]
In patients not wishing to preserve their fertility, the goal of treatment may be to reduce the risk of recurrence of ovarian torsion, which may make salpingo-oophorectomy an option.
Keep the patient nil by mouth from the point at which ovarian torsion is suspected.
Be aware, however, that it is not usually appropriate to delay surgery to wait until the patient is 'starved'.
Counsel the patient (or parents/guardian where the patient is a child) carefully about:
How surgical management depends on the findings at intraoperative assessment
The risks and benefits of different surgical management approaches for ovarian torsion
The possibility of removing an ovary and implications for future fertility. In a woman of childbearing age, ask about whether she has completed her family or if she hopes to have children in the future.
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.
A delay in the timing of surgery is associated with a reduction in the possibility of ovarian salvage.[15]
Intraoperative options
Intraoperative evaluation should be performed at the time of surgery, which can be performed through laparoscopy or laparotomy.[50]
The choice of surgical approach depends on the clinical situation and patient characteristics. Laparoscopy is generally preferred, where appropriate; it is associated with reduced hospital stay and postoperative pain, with reduced consumption of analgesic drugs.[56][57]
Intraoperative assessment of the ovary is the main parameter guiding the surgeon’s decisions on the surgical management of ovarian torsion, together with the patient’s clinical situation, previous medical and surgical history, age, and the patient’s desire to preserve their fertility.[50]
Conservative management with detorsion and ovary sparing may be possible even if the ovary is dusky blue-black or necrotic-appearing, although the success of this depends on the clinical situation.[50][51][52][53][54][55] The return of colour may not be seen at time of surgery.
Salpingo-oophorectomy may be performed if the ovary is thought to be non-viable or to reduce the risk of recurrence of ovarian torsion in women who do not wish to preserve fertility. This is also the case if malignancy is suspected. However, the frequency of such tumours is extremely low.[31]
Involvement of the fallopian tube in the torsion of the adnexa may significantly damage the tube, which may occasionally need to be surgically removed.
If torsion is concurrent with a true ovarian cyst, cystectomy at the time of de-torsion may be performed. However, this may be risky because of the friable nature of the tissues. Elective cystectomy at a later date may be preferred.[34]
In some specific clinical situations, performing a cystectomy at the same time as de-torsion may have important advantages; for example, in a pregnant woman with torsion caused by a cyst, removing the cyst can prevent recurrence (although this might require use of the minilaparotomy technique).
If open surgery is required, draining the cyst without removing the cyst wall (if present) should be avoided because this may increase the risk of recurrence.[31]
The risk of recurrent ipsilateral or asynchronous contralateral ovarian torsion is not known. It seems to range from 2% to 5%.[17][58] Recurrence is more common in children with no underlying pathology found at the time of ovarian torsion surgery, with the risk reported from 2% to 35%.[16][17][59]
Should torsion recur, treatment is the same.
Adolescents and women of reproductive age
Detorsion of the twisted adnexa in an adolescent or a reproductive-age woman is the preferred management, because gross appearance of the ovary does not correlate with outcome.[25][52][53] Detorsion saves >90% of these ovaries, as variability in the degree of compromise and the collateral vasculature help to preserve ovarian function.[22][52][54][60][61]
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]
Oophoropexy, a procedure to fix the ovary in position to limit its range of movement, remains controversial; its use is not generally recommended as a means to decrease the risk of recurrent ovarian torsion.[1][25] Oophoropexy may be considered in specific settings; for example, absent contralateral ovary, elongated ovarian ligament, and torsion of normal adnexa.[15][62]
Peritonitis is rare if a necrotic ovary is left in place.[63]
Fear of leaving behind a potential malignancy has been cited as a reason to perform oophorectomy. However, cancer in this age group rarely presents as adnexal torsion.[1]
Post-menopausal women
Salpingo-oophorectomy may be preferred in post-menopausal women as risk of malignancy is elevated.[15]
Pregnant women
Surgery should be avoided in pregnant women where possible. In clinical practice, aspiration of the ovary, with transvaginal or transabdominal ultrasound guidance, may be considered to see if this achieves detorsion. Laparoscopic detorsion has been successfully performed during pregnancy of up to 20 weeks' gestation. However, this may be more technically difficult due to the size of the gravid uterus.[64]
Infants and children
Conservative management with laparoscopic detorsion is recommended to preserve ovarian function.[51][52][54] Guidelines on adnexal torsion in adolescents recommend that surgeons should not remove a torsed ovary unless oophorectomy is unavoidable (e.g., when a severely necrotic ovary falls apart).[1]
As torsion of normal ovaries is more common in children, oophoropexy, either unilateral or bilateral, may be helpful at the time of surgery to prevent recurrence.[63][65][66][67] However, the benefit of oophoropexy remains uncertain.[25][68][69] Oophoropexy remains controversial; its use is not generally recommended to decrease the risk of recurrent ovarian torsion.[1]
Oophoropexy may be considered in specific settings.[62]
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