Ovarian torsion is a medical condition that requires prompt attention and treatment. It occurs when the ovary twists around the ligaments and tissues that support it, which may affect the blood supply to the ovary. Ovarian torsion can occur suddenly and may sometimes be associated with an ovarian cyst, mass, or other factors that increase ovarian mobility.The symptoms of ovarian torsion can vary from one case to another. However, lower abdominal or pelvic pain, particularly when it occurs suddenly and on one side, is one of the most common warning signs. It may also be accompanied by nausea or vomiting. Because these symptoms can resemble those of other medical conditions, an accurate medical evaluation is essential.In this article on Dalili Medical, we discuss the causes and types of ovarian torsion, its symptoms and diagnosis, treatment options including medications and surgery, ways to reduce the risk of ovarian torsion, and when urgent medical attention is necessary.

What Is Ovarian Torsion?

Ovarian torsion is a medical condition in which the ovary twists around the ligaments and tissues that hold it in its normal position. The fallopian tube may also twist along with the ovary. This twisting can reduce or completely cut off the blood supply to the ovary, making the condition one that requires urgent medical evaluation to prevent complications.

Does Ovarian Torsion Cause Constant Pain?

Not necessarily. The pain may occur in intermittent episodes if the ovary twists and then partially untwists or temporarily returns to its normal position. Therefore, temporary improvement or disappearance of pain does not necessarily mean that the problem has resolved.

Can Ovarian Torsion Occur Without a Cyst?

Yes. Ovarian torsion can occur even when there is no cyst or mass on the ovary. It may be associated with anatomical factors that make the ovary more mobile and prone to twisting. This is particularly observed in children and adolescents.

Does an Ultrasound Confirm Ovarian Torsion?

Pelvic ultrasound may reveal findings that support the diagnosis of ovarian torsion, particularly when Doppler ultrasound is used to assess blood flow. However, the presence of blood flow in the ovary does not completely rule out torsion. Therefore, doctors rely on the combination of symptoms, physical examination, and imaging findings when making the diagnosis.

Does Ovarian Torsion Always Require Removal of the Ovary?

No. Ovarian torsion does not necessarily mean that the ovary must be removed. Doctors generally aim to untwist and preserve the ovary whenever possible, particularly in children, adolescents, and women of reproductive age. Ovarian removal is considered only when the doctor determines that the ovary cannot be preserved or when there is another medical reason requiring its removal.

Can Ovarian Torsion Recur?

Yes. Ovarian torsion can recur, particularly in people who have experienced it previously or who have factors that increase ovarian mobility and susceptibility to twisting. In some cases, a gynecologist may recommend ovariopexy (ovarian fixation) to reduce the risk of recurrence, depending on the individual situation.

Does Ovarian Torsion Affect Fertility?

Ovarian function may remain normal when torsion is diagnosed and treated promptly and the ovary is preserved. However, delayed treatment can cause damage to ovarian tissue due to reduced or interrupted blood flow.

If removal of one ovary becomes necessary, the remaining ovary can, in many cases, continue to function and contribute to fertility.

Is Ovarian Torsion Dangerous?

Yes. Ovarian torsion requires urgent medical attention because prolonged twisting can reduce or completely interrupt the blood supply to the ovary, potentially causing damage to ovarian tissue. Prompt diagnosis and treatment can increase the chances of preserving the ovary and reducing the risk of complications.

When Should You Go to the Emergency Room?

Urgent medical care should be sought if sudden or severe pain develops in the lower abdomen or pelvis, particularly when the pain occurs on one side and is accompanied by nausea or vomiting.

It is not recommended to rely solely on painkillers or wait for the pain to improve, as ovarian torsion may require prompt medical intervention.

Types of Ovarian Torsion

Ovarian torsion can be classified according to the tissues involved, the degree of twisting, and how the torsion occurs. The main forms include:

1. Isolated Ovarian Torsion

This occurs when the ovary twists around the ligaments and supporting tissues without simultaneous twisting of the fallopian tube. It is less common than torsion involving both the ovary and fallopian tube.

2. Ovarian and Fallopian Tube Torsion

This is known as adnexal torsion and occurs when the ovary and fallopian tube twist around the tissues that support them. This is one of the most common forms of torsion.

3. Partial Torsion

Partial torsion occurs when the ovary does not completely twist, allowing some blood flow to continue. This may cause intermittent pain that improves temporarily and then returns.

4. Complete Torsion

Complete torsion occurs when the twisting is severe enough to significantly interfere with blood flow to the ovary. If left untreated, prolonged torsion can damage ovarian tissue, making urgent medical evaluation and treatment necessary.

5. Intermittent Torsion

In some cases, the ovary may twist and then partially or completely untwist temporarily. This can cause recurrent episodes of pain rather than continuous pain, which may make the condition more difficult to diagnose.

6. Ovarian Torsion Associated With a Cyst or Mass

A cyst or mass may increase the size or weight of the ovary, making it more mobile and more likely to twist around its supporting tissues. Ovarian cysts and masses are among the important factors associated with ovarian torsion, and most masses associated with torsion are benign.

7. Ovarian Torsion Without a Cyst or Mass

Torsion can occur even when there is no obvious ovarian mass, particularly when anatomical factors increase ovarian mobility. This possibility is especially important in children and adolescents.

Major Causes and Risk Factors for Ovarian Torsion

Several factors may increase the likelihood of ovarian torsion, including:

Ovarian Cysts or Masses

The presence of an ovarian cyst or mass is one of the major risk factors for torsion, particularly when it is large. An increase in the size or weight of the ovary can make it more likely to rotate around its supporting ligaments.

However, having an ovarian cyst does not necessarily mean that torsion will occur, and most masses associated with torsion are benign.

Enlarged Ovary

Any condition that increases the size or weight of the ovary may increase its mobility and susceptibility to twisting, thereby increasing the risk of torsion.

Ovarian Stimulation and Fertility Treatments

Certain ovarian stimulation medications can increase the size of the ovaries and lead to the development of multiple follicles, which may increase the risk of ovarian torsion. These medications should therefore be used under the supervision of a gynecologist with appropriate medical monitoring.

Pregnancy

Pregnancy may be associated with an increased risk of ovarian torsion, particularly when an ovarian cyst or ovarian enlargement is present.

Anatomical Variations of the Supporting Ligaments or Fallopian Tube

Some individuals may be more susceptible to torsion because of anatomical variations that allow the ovary to move more freely, such as increased length of certain supporting ligaments. In these cases, torsion can occur even without a cyst or mass, particularly in children and adolescents.

Previous Ovarian Torsion

The risk of recurrent ovarian torsion may be higher in individuals who have experienced torsion previously. For this reason, doctors carefully assess potential risk factors and anatomical factors that may increase the likelihood of recurrence.

A Mass or Cyst Near the Ovary

The mass does not necessarily have to originate within the ovarian tissue itself to increase the risk of torsion. Certain cysts or masses located near the ovary may increase ovarian mobility and make twisting more likely.

Symptoms of Ovarian Torsion

Symptoms of ovarian torsion can vary from one person to another. They may develop suddenly and severely, while in some cases they may occur as intermittent episodes of pain. Ovarian torsion requires urgent medical evaluation, because prolonged torsion can affect blood flow to the ovary and lead to complications.

Sudden Lower Abdominal or Pelvic Pain

Pain is one of the most common symptoms of ovarian torsion and usually occurs on one side of the lower abdomen or pelvis. The pain may be severe and sudden, or it may begin as moderate pain and gradually become more intense.

The pain may radiate to the lower back, thigh, or one side of the abdomen. It may occur during movement or physical activity, but it can also develop while resting without an obvious trigger.

Intermittent or Recurrent Pain

The pain does not necessarily remain constant. In some cases, the ovary may twist partially and then untwist or the twisting may temporarily decrease, resulting in recurrent episodes of pain.

Therefore, temporary disappearance or improvement of pain does not necessarily mean that the condition has resolved, particularly if the pain returns.

Nausea and Vomiting

Ovarian torsion may cause nausea, and vomiting may also occur, especially when the pain is severe. Sudden pelvic pain accompanied by nausea or vomiting is an important warning sign that requires urgent medical evaluation.

Pelvic Pain or Pressure

Some individuals may experience a feeling of heaviness, pressure, or discomfort in the pelvic area. The sensation may be more noticeable on the side of the affected ovary and may become worse with movement in some cases.

Abdominal Bloating or a Feeling of Fullness

Abdominal bloating or a feeling of fullness may occur, particularly when ovarian torsion is associated with an ovarian cyst or enlargement of the ovary.

Increased Body Temperature

A fever may develop in some cases, particularly when torsion persists and complications occur. However, the absence of a fever does not rule out ovarian torsion.

Urinary or Digestive Symptoms

Some symptoms may occur as a result of pressure on or irritation of the surrounding tissues, including:

• Increased need to urinate.

• Pain or discomfort during urination.

• Constipation.

• Difficulty passing gas.

However, these symptoms are not specific to ovarian torsion and may occur with many other medical conditions. Therefore, they cannot be relied upon alone to diagnose ovarian torsion.

When Do Symptoms Require Emergency Medical Attention?

Urgent medical evaluation is necessary if sudden or severe pain develops in the lower abdomen or pelvis, particularly when it occurs on one side and is accompanied by nausea or vomiting. It is not recommended to wait for the pain to disappear or rely solely on painkillers, as prompt diagnosis and treatment may help preserve ovarian function and reduce the risk of complications.

Diagnosis of Ovarian Torsion

Diagnosing ovarian torsion can sometimes be challenging because its symptoms may resemble those of several other conditions that cause lower abdominal or pelvic pain, such as appendicitis and certain ovarian conditions. Therefore, doctors rely on the medical history, physical examination, and imaging findings to reach an appropriate diagnosis. No single test can definitively rule out ovarian torsion.

1. Medical History and Symptoms

The doctor begins by assessing the nature and timing of the symptoms and may ask about:

• When the lower abdominal or pelvic pain began and whether it started suddenly.

• Where the pain is located and whether it is concentrated on one side.

• The presence of nausea or vomiting.

• Whether the pain is continuous or occurs in intermittent episodes.

• The possibility of pregnancy.

• A previous history of ovarian cysts or masses.

• The use of ovarian stimulation medications or fertility treatments.

• A previous history of ovarian torsion.

This information helps the doctor assess the likelihood of ovarian torsion and determine which tests may be appropriate.

2. Physical Examination

The doctor examines the abdomen and pelvis for findings that may support the diagnosis, such as:

• Localized pain in the lower abdomen.

• Tenderness when pressure is applied to the pelvic area.

• A palpable mass or enlarged ovary in some cases.

• Other signs that may suggest a different cause of the pain.

However, a normal physical examination does not rule out ovarian torsion.

3. Ultrasound

Ultrasound is one of the most important imaging tests used when ovarian torsion is suspected. A pelvic ultrasound with Doppler imaging is often performed to evaluate the appearance of the ovary and assess its blood flow.

Ultrasound may show findings that support the diagnosis, including:

• An enlarged ovary.

• An ovarian cyst or mass.

• An ovary that is larger than the opposite ovary.

• Small follicles arranged in an unusual pattern within the ovary.

• Free fluid in the pelvis.

• Reduced or altered blood flow on Doppler examination.

It is important to note that the presence of blood flow on Doppler ultrasound does not completely rule out ovarian torsion, because some blood flow may remain despite the presence of torsion.

4. Blood Tests

The doctor may order blood tests to help evaluate the condition or rule out other causes of abdominal or pelvic pain. These may include:

• Complete blood count (CBC).

• Inflammatory markers when appropriate.

• A pregnancy test when pregnancy is possible.

Blood tests alone cannot confirm ovarian torsion, and their results may be normal during the early stages of the condition.

5. CT Scan or Magnetic Resonance Imaging (MRI)

A CT scan or magnetic resonance imaging (MRI) may be used in some cases when the diagnosis is unclear or when the doctor needs to rule out other causes of abdominal or pelvic pain.

These imaging techniques may reveal findings that support the possibility of ovarian torsion, but they are not a substitute for urgent medical evaluation when there is a strong clinical suspicion of torsion.

6. Laparoscopy

If the symptoms strongly suggest ovarian torsion but imaging tests do not provide a definitive answer, the doctor may recommend diagnostic laparoscopy to directly evaluate the ovary.

Laparoscopy allows the surgeon to directly visualize the ovary and determine whether it is twisted. If torsion is confirmed, the procedure can also be used to untwist the ovary and treat the underlying cause when necessary.

Can Ovarian Torsion Be Confirmed by Ultrasound Alone?

Not always. Ultrasound findings can help doctors assess the likelihood of ovarian torsion, but they cannot definitively rule out torsion in every case. Therefore, when symptoms are strongly suggestive or there is a high clinical suspicion, surgical intervention may be necessary to confirm the diagnosis and treat the condition, particularly because delaying treatment may increase the risk of damage to ovarian tissue.

Treatment of Ovarian Torsion With Medications

It is important to clarify that medications do not treat ovarian torsion itself. The underlying problem is the twisting of the ovary and its supporting tissues, which can reduce or interrupt blood flow to the ovary. Therefore, when ovarian torsion is suspected, urgent medical evaluation is necessary, and the primary treatment is often surgical intervention to untwist the ovary and preserve it whenever possible.

What Is the Role of Medications in Treating Ovarian Torsion?

Medications are mainly used to relieve symptoms or support the patient's condition while preparing for definitive treatment. They do not untwist the ovary. Common treatments may include:

Pain Relievers

A doctor may prescribe an appropriate pain reliever based on the patient's age and overall health. In cases of severe pain, stronger pain medications may be administered in the hospital under medical supervision.

Medications for Nausea and Vomiting

Anti-nausea and anti-vomiting medications may be used when these symptoms occur. In cases where the patient cannot take medication by mouth, these medications may be administered intravenously.

Intravenous Fluids

Intravenous fluids may be given, particularly when there is repeated vomiting or dehydration. They can also help support the patient's general condition while preparing for surgery.

Antibiotics

Antibiotics are not routinely used to treat ovarian torsion because torsion itself is not a bacterial infection. However, a doctor may prescribe antibiotics in specific circumstances, such as when an infection is suspected or depending on the findings during or after surgery.

Can Ovarian Torsion Be Treated With Medication Alone?

There are no pills or injections that can reliably untwist the ovary and return it to its normal position. Therefore, relying solely on painkillers and waiting for the pain to improve may delay necessary treatment.

---

Surgical Treatment of Ovarian Torsion

Ovarian torsion is a gynecological emergency. The main goals of surgical treatment are to untwist the ovary, restore blood flow, and preserve ovarian tissue and function whenever possible.

1. Preparation Before Surgery

When ovarian torsion is strongly suspected, the medical team performs an urgent assessment, which may include:

• Checking vital signs.

• Performing a physical examination.

• Ordering appropriate blood tests.

• Performing a pregnancy test when pregnancy is possible.

• Performing a pelvic ultrasound, often with Doppler imaging.

• Administering intravenous fluids when needed.

• Treating pain and nausea.

• Preparing the patient for anesthesia and surgery.

When clinical suspicion is high, necessary treatment should not be significantly delayed simply to perform additional tests that are unlikely to change the immediate management.

2. Laparoscopic Surgery

Laparoscopy is one of the most commonly used surgical approaches for treating ovarian torsion when the patient's condition is suitable for this procedure.

Laparoscopy is usually performed under general anesthesia. The surgeon inserts a camera and small surgical instruments through small incisions in the abdomen.

During the procedure, the surgeon may:

• Examine both ovaries, the fallopian tubes, and surrounding tissues.

• Identify the twisted ovary.

• Untwist the ovary and return it to its normal position.

• Assess the condition of the ovary after detorsion.

• Look for the underlying cause, such as a cyst or mass.

• Treat or remove a cyst or mass when appropriate and safe.

• Evaluate the opposite ovary when necessary.

Is the Ovary Always Removed?

No. Ovarian torsion does not necessarily require removal of the ovary. Doctors generally aim to untwist and preserve the ovary whenever possible, particularly in children, adolescents, and women of reproductive age.

The ovary may appear swollen or discolored because of reduced blood flow during torsion. However, changes in its appearance alone do not necessarily mean that removal is required. The surgeon assesses whether the ovary may recover after the torsion is corrected.

3. Ovarian Fixation

In some cases, particularly when torsion has recurred or anatomical factors increase ovarian mobility, the doctor may consider a procedure called ovariopexy (ovarian fixation).

The goal of this procedure is to reduce ovarian mobility and lower the likelihood of recurrent torsion. Ovariopexy is not necessary for every patient and is considered based on the individual clinical situation.

4. Treatment of the Cyst or Mass Causing the Torsion

If an ovarian cyst or mass contributed to the torsion, the surgeon may:

• Remove the cyst while preserving as much healthy ovarian tissue as possible.

• Remove the mass depending on its size, nature, and location.

• In some cases, postpone treatment of the cyst if doing so is considered safer for the patient.

The decision depends on several factors, including the patient's age, the size and characteristics of the cyst or mass, the appearance of the ovary during surgery, and the possibility of preserving ovarian tissue.

5. Oophorectomy

Removal of the ovary is medically known as oophorectomy and is generally not the first choice when the ovary can be preserved.

Oophorectomy may become necessary in certain situations, such as:

• Severe ovarian damage that makes preservation impossible.

• A mass that requires removal of the ovary.

• Complications that make removal necessary.

• Other circumstances determined by the surgeon during the operation.

If one ovary needs to be removed, the doctor evaluates the condition of the remaining ovary and the reproductive system as a whole.

6. Open Surgery

Open surgery is known as laparotomy and involves making a larger abdominal incision to access the ovary and surrounding tissues.

A doctor may choose open surgery in certain situations, such as:

• The presence of a very large mass.

• Circumstances that make laparoscopy unsuitable.

• The need for wider surgical access.

• Other medical reasons requiring an open abdominal procedure.

When laparoscopy is appropriate, it is generally less invasive and may be associated with a faster recovery compared with open surgery.

Main Goal of Surgery

The primary goal of surgical treatment for ovarian torsion is to untwist the ovary as promptly as appropriate, restore blood flow, and preserve the ovary and its function whenever possible.

The doctor determines the most appropriate surgical approach based on factors such as the patient's age, the cause of torsion, the condition of the ovary, the presence of cysts or masses, and the patient's overall health.

Ways to Prevent Ovarian Torsion

There is no method that can guarantee complete prevention of ovarian torsion, as it can sometimes occur suddenly or result from anatomical factors that cannot be controlled. However, the risk and potential complications can be reduced by identifying risk factors, monitoring them, and addressing them appropriately.

1. Monitoring Ovarian Cysts

The presence of an ovarian cyst or mass is an important risk factor for torsion, particularly if it increases the size or weight of the ovary.

When an ovarian cyst is detected, a gynecologist determines the appropriate follow-up plan based on factors such as:

• The size of the cyst.

• Its appearance and characteristics on ultrasound.

• The patient's age.

• Associated symptoms.

• The likelihood that the cyst will persist or increase in size.

Not all ovarian cysts require surgery. Some can be monitored medically according to the doctor's assessment.

2. Treating Cysts or Masses That Increase the Risk of Torsion

If a cyst is large, causes symptoms, or has characteristics that may increase the risk of complications, the doctor may recommend treatment or removal.

In appropriate cases, treating the cyst can address an underlying risk factor and reduce the likelihood of ovarian torsion when the cyst is clearly contributing to the risk.

3. Monitoring During Ovarian Stimulation Treatment

Certain ovarian stimulation medications may increase the size of the ovaries and cause multiple follicles to develop, potentially increasing the risk of ovarian torsion.

These medications should therefore be used under the supervision of a gynecologist, with the recommended ultrasound examinations and follow-up tests used to monitor the ovaries' response.

4. Follow-Up After Previous Ovarian Torsion

Ovarian torsion can recur in some patients. Therefore, it is important to inform the gynecologist about any previous history of ovarian torsion.

In some cases, particularly when torsion has recurred or anatomical factors increase ovarian mobility, the doctor may consider ovariopexy (ovarian fixation) to reduce the likelihood of recurrence.

5. Medical Follow-Up When Risk Factors Are Present

Medical follow-up is particularly important when one or more risk factors for ovarian torsion are present, such as:

• A known ovarian cyst.

• An enlarged ovary.

• Previous ovarian torsion.

• Use of ovarian stimulation medications.

• Anatomical factors that increase ovarian mobility.

Regular follow-up can help identify changes that may require further evaluation or treatment.

6. Does Avoiding Physical Activity Help Prevent Ovarian Torsion?

There is no general recommendation to avoid physical activity or normal daily movement to prevent ovarian torsion. Normal activities should not be restricted solely because of fear of torsion unless a doctor recommends specific limitations based on an individual's medical condition.

7. Recognizing Symptoms and Seeking Prompt Medical Care

Because ovarian torsion cannot always be completely prevented, recognizing warning signs and seeking medical attention promptly are among the most important ways to reduce the risk of complications.

If sudden or severe pain develops in the lower abdomen or pelvis, particularly on one side and accompanied by nausea or vomiting, urgent medical evaluation is necessary. Prompt diagnosis and treatment can increase the chances of preserving the ovary and reduce the likelihood of complications.