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Summary Table

Category	Details
Risk Factors	Reproductive-age women (most common in 20s-30s), ovarian cysts or masses >5 cm, ovarian hyperstimulation syndrome (fertility treatments), pregnancy (especially first trimester), history of prior torsion, elongated utero-ovarian ligament
Etiology	Rotation of the ovary (and often the fallopian tube) around the infundibulopelvic ligament and utero-ovarian ligament, leading to vascular compromise. The right side is more common than the left (the sigmoid colon limits mobility on the left).
Patient Presentation	Sudden-onset, severe unilateral lower abdominal or pelvic pain, often with nausea and vomiting. Pain may be intermittent if the ovary is torsing and detorsing.
Classic Physical Exam	Unilateral adnexal tenderness, palpable adnexal mass, guarding. Notably, peritoneal signs are often absent early. Low-grade fever may be present if necrosis has set in.
Key Diagnostic Results	Pelvic ultrasound with Doppler showing an enlarged ovary with decreased or absent blood flow. A "whirlpool sign" on Doppler is characteristic. Normal Doppler flow does not rule out torsion.
Management	Emergency surgical intervention: laparoscopic detorsion with ovarian conservation is preferred in reproductive-age women. Oophorectomy is reserved for nonviable (necrotic) ovary.
Keywords	"Sudden pelvic pain with nausea/vomiting," "enlarged ovary on ultrasound," "absent Doppler flow," "young woman with ovarian cyst," "whirlpool sign," "intermittent colicky pelvic pain"

1. Pathophysiology

Ovarian torsion occurs when the ovary rotates along the axis of its supporting ligaments, namely the infundibulopelvic ligament (which carries the ovarian artery and vein) and the utero-ovarian ligament. This rotation kinks the vascular pedicle and progressively obstructs blood flow.

The sequence of vascular compromise follows a predictable pattern. Because veins and lymphatics are low-pressure systems, they are occluded first. This leads to venous congestion and edema of the ovary, which causes the ovary to enlarge. As the ovary swells, interstitial pressure rises, and eventually the arterial inflow is also compromised. If left untreated, this progresses to hemorrhagic infarction and necrosis. This is why imaging classically shows an enlarged, edematous ovary, sometimes with peripheral follicles pushed to the surface ("string of pearls" appearance from stromal edema).

The reason ovarian masses (especially those 5 cm or larger) predispose to torsion is straightforward: a heavier or larger ovary has more momentum and is more likely to rotate around its pedicle. Dermoid cysts (mature cystic teratomas) are the single most common benign neoplasm associated with torsion because they are heavy, solid-cystic masses that shift the center of gravity. Importantly, malignant tumors rarely cause torsion because adhesions from local invasion anchor the ovary in place.

The pain in ovarian torsion is sudden and severe because the peritoneum overlying the ovary is being stretched by rapid edema, and the ischemia itself triggers visceral nociceptors. The characteristic nausea and vomiting result from peritoneal irritation and vagal stimulation, and this association is so strong that it helps differentiate torsion from other causes of acute pelvic pain.

The right ovary torsion is more common than the left. This is because the sigmoid colon occupies the left lower quadrant and physically limits the left ovary's range of motion. The right side has no such anatomic barrier.

2. Classification and Clinical Manifestation

By Structure Involved

Type	Description	Clinical Relevance
Isolated ovarian torsion	Only the ovary rotates on the utero-ovarian ligament	Less common; seen in pediatric patients or those with elongated ligaments
Adnexal torsion	The ovary and fallopian tube rotate together on the infundibulopelvic ligament	Most common form; the tube and ovary share the same vascular pedicle
Isolated tubal torsion	Only the fallopian tube torsion without ovarian involvement	Rare; associated with hydrosalpinx, paratubal cysts, or prior tubal ligation

By Degree of Vascular Compromise

Stage	Pathologic State	Clinical Features
Partial/Intermittent torsion	Ovary rotates and spontaneously reduces (torsion-detorsion)	Recurrent, colicky pelvic pain that comes and goes. Doppler may show preserved flow between episodes. Often misdiagnosed.
Venous congestion only	Veins and lymphatics occluded; arteries still patent	Enlarged, edematous ovary. Pain is present but arterial flow may still be detected on Doppler.
Complete vascular occlusion	Both arterial and venous supply compromised	Severe constant pain, absent arterial and venous flow on Doppler, ovary at risk of irreversible necrosis
Necrotic/Gangrenous	Hemorrhagic infarction with tissue death	Fever, leukocytosis, peritoneal signs. The ovary appears dark or black at surgery. Oophorectomy required.

Clinical Manifestation by Population

Population	Key Features
Reproductive-age women	Most common group. Pain typically correlates with an ovarian cyst or mass. Often presents mid-cycle or in early pregnancy.
Pregnant women	Risk is highest in the first trimester (corpus luteum is large) and decreases as the uterus enlarges and limits adnexal mobility. Associated with ovarian hyperstimulation in IVF patients.
Pediatric/Adolescent	May torsion even with a normal ovary (elongated ligaments, increased mobility). Higher index of suspicion needed because presentation overlaps with appendicitis.
Postmenopausal women	Uncommon. When it occurs, always evaluate the ovarian mass for malignancy (though malignant masses torse less often due to adhesions).

3. Diagnostic Workup

Test	Role	Key Findings
Pelvic ultrasound with Doppler	Best initial test	Enlarged ovary (>4 cm), free pelvic fluid, decreased or absent arterial/venous flow, whirlpool sign
Serum beta-hCG	Required in all reproductive-age women	Rules out ectopic pregnancy (the most dangerous mimic)
CBC	Supportive	Leukocytosis suggests necrosis or advanced ischemia
Urinalysis	Supportive	Rules out urinary tract pathology
CT abdomen/pelvis	Not first-line, but often obtained	May show enlarged ovary with deviation to the midline, uterine deviation toward affected side
Surgical exploration (laparoscopy)	Gold standard / confirmatory	Direct visualization of the twisted pedicle. This is both diagnostic and therapeutic.

Pelvic ultrasound with Doppler is the best initial test. The hallmark finding is a unilaterally enlarged, edematous ovary. Doppler evaluation may show decreased or absent blood flow, and the "whirlpool sign" (a spiral pattern of the twisted vascular pedicle) is considered highly characteristic when identified.

However, the single most important teaching point for exam purposes is this: normal Doppler flow does not exclude ovarian torsion. Because torsion can be intermittent (the ovary torsion and then partially reduce), arterial flow may be transiently preserved at the time of imaging. Additionally, dual blood supply from the ovarian artery and uterine artery collaterals can maintain detectable flow even when the pedicle is twisted. If clinical suspicion is high, do not be reassured by normal Doppler findings. Proceed to surgical exploration.

Other supportive ultrasound findings include free fluid in the pelvis (from transudation of the congested ovary), peripherally displaced follicles, and a coexisting ovarian mass.

A serum beta-hCG must be obtained in every reproductive-age woman with acute pelvic pain. This is not optional. It rules out ectopic pregnancy, which is the primary life-threatening differential.

CT scan is not the preferred initial study, but many patients with acute abdominal pain undergo CT before the clinical picture points toward a gynecologic cause. On CT, you may see the ovary displaced from its expected position, enlarged and edematous, sometimes with the "target sign" from the twisted pedicle. While CT can raise suspicion, it is not reliable enough to confirm or exclude torsion.

The gold standard for diagnosis is direct surgical visualization via laparoscopy. This is where the twisted pedicle is seen directly, and the procedure simultaneously serves as treatment (detorsion). The decision to operate is clinical: if clinical suspicion is high, do not delay surgery for additional imaging.

4. Management and Treatment

Clinical Scenario	Management	Details
Suspected torsion, hemodynamically stable	Emergency laparoscopy	Do not delay for further imaging if clinical suspicion is high
Viable ovary at surgery	Laparoscopic detorsion	Untwist the pedicle and observe for return of normal color. Conservative approach to preserve fertility.
Nonviable (necrotic) ovary	Laparoscopic oophorectomy	If the ovary is black, gangrenous, or does not reperfuse after detorsion
Ovarian mass present	Detorsion + cystectomy	Remove the mass (e.g., dermoid cyst) to prevent recurrence, while preserving remaining ovarian tissue
Recurrent torsion	Oophoropexy	Surgical fixation of the ovary to the pelvic sidewall or uterus to prevent re-torsion
Pregnant patient	Same principles, laparoscopy preferred	Safe in all trimesters; left lateral positioning in later pregnancy

The cornerstone of management is emergency surgical intervention. Ovarian torsion is a surgical emergency because delays lead to irreversible ischemic damage and potential loss of the ovary.

Laparoscopic detorsion with ovarian conservation is the preferred approach in reproductive-age women. Even if the ovary appears dusky or congested at surgery, the current evidence supports untwisting and observing, because ovaries that look ischemic at the time of surgery often regain viability after reperfusion. The outdated concern that detorsing a necrotic ovary would release emboli or toxins into the circulation has been largely disproven. Therefore, the modern approach is to detorse first and reassess. Oophorectomy is reserved for tissue that is clearly gangrenous and nonviable, or in postmenopausal women where malignancy needs to be excluded.

If an ovarian mass (such as a dermoid cyst) is identified as the lead point, cystectomy should be performed at the same time to reduce the risk of recurrence. Simply detorsing without removing the precipitating mass leaves the patient vulnerable to re-torsion.

For patients with recurrent torsion (especially in the pediatric population where normal ovaries may torse due to ligamentous laxity), oophoropexy can be performed. This involves surgically fixing the ovary to the pelvic sidewall or the posterior surface of the uterus.

Pain management with IV analgesics (ketorolac 15 to 30 mg IV or morphine 0.1 mg/kg IV) and antiemetics (ondansetron 4 mg IV) should be initiated in the emergency department, but these are temporizing measures. Definitive treatment is surgical, and analgesic response should never be used to downgrade clinical suspicion.

In pregnant patients, laparoscopy is safe and remains the preferred approach. The principles are identical. In the second and third trimesters, the patient should be positioned with a left lateral tilt to prevent compression of the inferior vena cava by the gravid uterus.

5. Differential Diagnosis and Distractors

Differential Diagnosis	Why It Is Similar	Key Discriminator
Ruptured ovarian cyst	Sudden-onset unilateral pelvic pain in a young woman, free fluid on ultrasound	Pain in ruptured cyst typically improves over time (self-limited), while torsion pain worsens. Ultrasound shows a collapsed cyst with free fluid rather than an enlarged, edematous ovary. Doppler flow is normal.
Ectopic pregnancy	Acute pelvic pain, adnexal mass, reproductive-age woman	Positive beta-hCG with empty uterus on ultrasound. Ectopic pregnancy presents with vaginal bleeding, which is not a feature of torsion.
Acute appendicitis	Right lower quadrant pain, nausea, vomiting, leukocytosis	Appendicitis features periumbilical pain migrating to McBurney point, anorexia is prominent, and the pain is more gradual. No adnexal mass on ultrasound. CT shows appendiceal dilation and periappendiceal fat stranding.
Tubo-ovarian abscess (TOA)	Adnexal mass with pelvic pain, fever, leukocytosis	TOA typically has a history of PID (vaginal discharge, cervical motion tenderness, sexually active patient). Fever is higher and more sustained. Ultrasound shows a complex, multiloculated adnexal mass, not a simple enlarged ovary.
Kidney stone (ureteral colic)	Sudden, severe, colicky flank or lower abdominal pain with nausea/vomiting	Pain in renal colic radiates to the groin or flank, and urinalysis shows hematuria. No adnexal pathology on imaging. CT shows ureteral stone.
Hemorrhagic ovarian cyst	Acute pelvic pain, complex adnexal mass on ultrasound	The ovary is not enlarged to the same degree, Doppler flow is preserved, and the mass has internal echoes from blood ("reticular" or "fishnet" pattern) rather than the solid edematous appearance of a torsed ovary.
Mittelschmerz	Mid-cycle pelvic pain, young woman	Mittelschmerz is mild and self-limited, occurring around day 14 of the cycle. No adnexal mass, no vomiting, no ultrasound abnormality.

6. Traps and High-Yield Pearls

The single most tested "gotcha" on this topic is the normal Doppler flow trap. Students who see "Doppler shows preserved arterial flow" in a vignette often incorrectly rule out ovarian torsion and pivot to a less urgent diagnosis. This is exactly what the test-writer wants you to do. Remember: Doppler has a sensitivity of roughly 60 to 70% for torsion, meaning it misses a substantial number of cases. When clinical suspicion is high (sudden pelvic pain, nausea, enlarged ovary), the next step is surgical exploration regardless of Doppler findings.

The second common error is confusing ovarian torsion with a ruptured ovarian cyst. Both present with sudden pelvic pain and free fluid. The discriminator is the trajectory of pain: ruptured cyst pain peaks and then gradually improves, while torsion pain persists or escalates. Additionally, the ovary in torsion is enlarged and edematous, whereas in a ruptured cyst the ovary may appear deflated or normal-sized.

Students also struggle with the management question: the answer to "what is the next best step" in a clinically suspected ovarian torsion is almost always surgery (laparoscopy), not further imaging. If the vignette gives you a classic presentation with high suspicion, do not order a CT or MRI. Go to the operating room.

Finally, remember the fertility-preservation principle. The answer is almost never oophorectomy in a young woman unless the ovary is explicitly described as necrotic or gangrenous. Detorsion with ovarian conservation is the standard of care, even when the ovary appears ischemic intraoperatively. Test-writers reward you for choosing the less aggressive, fertility-sparing option.

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