Recommendations

Key Recommendations

The goal of treatment is to prevent irreversible damage to the ovary. To achieve this, the diagnosis must be suspected, and prompt surgical intervention is required.[16]

Untwisting of the ovary (detorsion) with laparoscopy, regardless of the dusky, blue-black appearance, allows preservation and return of normal function and fertility in most cases.[56][57][58][59][60]

Laparotomy instead of laparoscopy may be done, depending on the expertise of the surgeon.[26][61][62][63][64][65][66][67][68]

Surgical evaluation

Once ovarian torsion is suspected, the patient should have nothing by mouth. A delay in the timing of surgery is associated with a reduction in the possibility of ovarian salvage.[16]

Laparoscopy is superior to laparotomy because it decreases hospital stay and postoperative pain, with reduced consumption of analgesic drugs.[60]

Intraoperative evaluation should be performed at the time of surgery. 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][35][56][57][58][59] The return of color may not be seen at time of surgery. If torsion is concurrent with an ovarian cyst, cystectomy is appropriate. Draining the cyst without removing the cyst wall should be avoided because this may increase the incidence of recurrence.[35]

Alternatively, a salpingo-oophorectomy may be performed if the ovary is thought to be nonviable. This is also the case if malignancy is suspected. However, the frequency of such tumors is extremely low.[2][4][12][17][21] Involvement of the fallopian tube in the torsion of the adnexa may significantly damage the tube, which may need to be surgically removed.

Considerations in specific populations

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.[1][57][58] Detorsion saves >90% of these ovaries, as variability in the degree of compromise and the collateral vasculature help preserve ovarian function.[48][57][59][61][69]

  • 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 to decrease the risk of recurrent ovarian torsion.[1][34][70][71] One systematic review found no clear evidence to support oophoropexy in pediatric and adolescent patients after a first episode of ovarian torsion.[57] Oophoropexy may be considered by some specialists in specific settings (e.g., absent contralateral ovary, elongated ovarian ligament, and torsion of normal adnexa).[16][71]

  • Peritonitis and systemic infection is rare if a necrotic ovary is left in place.[72]

  • 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]

Postmenopausal

  • Risk of malignancy is elevated in postmenopausal women. Given this risk, a salpingo-oophorectomy should be considered[16]

Pregnancy

  • 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.[73]

Infants and children

  • Conservative management with laparoscopic detorsion is also recommended to preserve ovarian function.[56][57][59]

  • One systematic review found no clear evidence to support oophoropexy in pediatric and adolescent patients after a first episode of ovarian torsion.[57] Oophoropexy remains controversial; its use is not generally recommended to decrease the risk of recurrent ovarian torsion.[1][34][70][71] Oophoropexy may be considered in specific settings.[71]

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