eMedicine Specialties > Radiology > Obstetrics/Gynecology

Ovarian Torsion

Author: Arthur C Fleischer, MD, Professor, Chief of Diagnostic Sonography, Departments of Radiology and Obstetrics/Gynecology, Vanderbilt University Medical Center
Coauthor(s): Eugene C Lin, MD, Consulting Radiologist, Virginia Mason Medical Center; Clinical Assistant Professor of Radiology, University of Washington School of Medicine
Contributor Information and Disclosures

Updated: Mar 13, 2009

Introduction

Background

In ovarian torsion (adnexal torsion), the ovary and fallopian tube are typically involved. This condition is usually associated with reduced venous return from the ovary as a result of stromal edema, internal hemorrhage, hyperstimulation, or a mass; it requires a quick and confident diagnosis to save the adnexal structures from infarction.

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Video depicts 2 findings: first, it shows an enlarged hypovascular left ovary; second, it shows flow in the healthy right ovary. A small amount of intraperitoneal fluid surrounds the left ovary.

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Video depicts 2 findings: first, it shows an enla...

Video depicts 2 findings: first, it shows an enlarged hypovascular left ovary; second, it shows flow in the healthy right ovary. A small amount of intraperitoneal fluid surrounds the left ovary.


Ultrasonography with color Doppler analysis is the method of choice for the evaluation of adnexal torsion because it can show morphologic and physiologic changes in the ovary. Gray-scale and spectral findings are correlated with the age of the torsion (ie, acute torsion or chronic torsion) and the degree of the twist or torsion.

Presentation

Demographics
Two groups of women tend to be affected by adnexal torsion (ovarian torsion): (1) women in their mid 20s and (2) women who are postmenopausal. Approximately 20% of the cases of torsion occur during pregnancy.1,2 Women with an adnexal mass who are postmenopausal may also be affected. Adolescents are also at risk; this may be because of changes in the weight of their maturing adnexa.2

Mortality resulting from ovarian torsion is rare. Cases in which pulmonary emboli result from thrombi in the pelvic veins have been reported in patients with ovarian torsion, adnexal torsion, or both. Morbidity usually arises from the pain associated with ovarian torsion. The adnexa may become gangrenous with chronic torsion.

Adnexal torsion (ovarian torsion) accounts for an estimated 3% of surgical gynecologic emergencies. Approximately 50-60% of cases of torsion are associated with an adnexal mass.

Natural history and presentation

The ovary has a dual arterial and venous blood supply. The arterial supply is derived from the ovarian arteries that branch from the abdominal aorta, as well as from the adnexal branches of the uterine artery. The venous system parallels the arterial, with the exceptions that the left ovarian vein empties into the left renal vein and that the right ovarian vein courses into the inferior vena cava. The fallopian tubes are fed and are drained by means of vessels that anastomose with ovarian branches derived from uterine vessels in the mesosalpinx.

Adnexal torsion (ovarian torsion) may develop without a definitive etiology. It often occurs as a result of increased weight of the ovary; this may be caused by reduced venous return from the ovary of unknown cause or by an actual ovarian and/or adnexal mass, with torsion of the ovary or torsion of the ovary and fallopian tube. The torsion itself further reduces venous return from the ovary. Greater degrees of adnexal torsion reduce arterial flow within the ovary as well, although flow within the vascular pedicle usually continues. Hemorrhagic infarction within the ovary may occur when the torsion is persistent or chronic.

According to Smorgick et al in a study of 33 pregnant women with 38 episodes of surgically proven ovarian torsion between the years 1993 and 2007, ovarian torsion is more common in the first trimester, and ovulation induction is a major risk factor. In this study, 16 (48.5%) of the pregnancies were conceived by either ovulation induction or in vitro fertilization. Of the 38 cases of ovarian torsion, 21 occurred in the first trimester (55.3%), 13 in the second (34.2%), and 4 in the third (10.5%).3

Confident and early diagnosis of adnexal torsion (ovarian torsion) is imperative. Color Doppler sonography has a vital role in the examination of women with lower abdominal and pelvic pain.4,5

The signs and symptoms associated with adnexal torsion are variable and nonspecific. Most patients present with severe lower abdominal and pelvic pain, nausea, and vomiting. The differential diagnosis to be considered at clinical examination include appendicitis, gastroenteritis, ectopic pregnancy, pelvic inflammatory disease, and ruptured corpus luteum. Among adolescents, hemorrhagic ovarian cysts must also be considered. Laboratory tests are not helpful, because most signs and symptoms of ovarian torsion can be associated with leukocytosis.

Preferred Examination

Diagnostic sonography should be the first examination performed; typically, the affected ovary is enlarged, with multiple immature or small follicles along its periphery. Color Doppler sonography can help in determining whether blood flow is impaired.5,6,7,8 Rarely, computed tomography (CT) or magnetic resonance imaging (MRI) is needed to make a definitive diagnosis. CT or MRI can serve as a secondary modality when ultrasonographic findings are nondiagnostic.9,10,11

Limitations of Techniques

Although a lack of intraovarian arterial and venous flow enables confident diagnosis, adnexal torsion (ovarian torsion) may be incomplete; incomplete torsion may be associated with adnexal flow, as depicted with color Doppler sonography. Rarely, the use of improper settings can cause erroneous findings of absent flow. Check that the proper settings are used by looking for flow in the internal iliac vein.

In some cases, flow depiction may be difficult to obtain from the affected ovary, as well as the healthy contralateral ovary. In these cases, the characteristic gray-scale morphologic image of ovarian torsion alone may help in making the diagnosis.

More on Ovarian Torsion

Overview: Ovarian Torsion
Imaging: Ovarian Torsion
Multimedia: Ovarian Torsion
References
Further Reading
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References

  1. Bider D, Mashiach S, Dulitzky M, Kokia E, Lipitz S, Ben-Rafael Z. Clinical, surgical and pathologic findings of adnexal torsion in pregnant and nonpregnant women. Surg Gynecol Obstet. Nov 1991;173(5):363-6. [Medline].

  2. Griffin D, Shiver SA. Unusual presentation of acute ovarian torsion in an adolescent. Am J Emerg Med. May 2008;26(4):520.e1-3. [Medline].

  3. Smorgick N, Pansky M, Feingold M, Herman A, Halperin R, Maymon R. The clinical characteristics and sonographic findings of maternal ovarian torsion in pregnancy. Fertil Steril. Nov 4 2008;[Medline].

  4. Fleischer AC, Brader KR. Sonographic depiction of ovarian vascularity and flow: current improvements and future applications. J Ultrasound Med. Mar 2001;20(3):241-50. [Medline].

  5. Lee EJ, Kwon HC, Joo HJ, Suh JH, Fleischer AC. Diagnosis of ovarian torsion with color Doppler sonography: depiction of twisted vascular pedicle. J Ultrasound Med. Feb 1998;17(2):83-9. [Medline].

  6. Fleischer AC, Stein SM, Cullinan JA, Warner MA. Color Doppler sonography of adnexal torsion. J Ultrasound Med. Jul 1995;14(7):523-8. [Medline].

  7. Peña JE, Ufberg D, Cooney N, Denis AL. Usefulness of Doppler sonography in the diagnosis of ovarian torsion. Fertil Steril. May 2000;73(5):1047-50. [Medline].

  8. Filho SM, Júnior EA, Serafini P, Filho HA, Pires CR, Nardozza LM, et al. Diagnosis of ovarian torsion by three-dimensional power Doppler in first trimester of pregnancy. J Obstet Gynaecol Res. Apr 2008;34(2):266-70. [Medline].

  9. Kimura I, Togashi K, Kawakami S, Takakura K, Mori T, Konishi J. Ovarian torsion: CT and MR imaging appearances. Radiology. Feb 1994;190(2):337-41. [Medline].

  10. Siegelman ES, Outwater EK. Tissue characterization in the female pelvis by means of MR imaging. Radiology. Jul 1999;212(1):5-18. [Medline].

  11. Van Kerkhove F, Cannie M, Op de Beeck K, Timmerman D, Pienaar A, Smet MH, et al. Ovarian torsion in a premenarcheal girl: MRI findings. Abdom Imaging. May-Jun 2007;32(3):424-7. [Medline].

  12. Gittleman AM, Price AP, Goffner L, Katz DS. Ovarian torsion: CT findings in a child. J Pediatr Surg. Aug 2004;39(8):1270-2. [Medline].

  13. Moore C, Meyers AB, Capotasto J, Bokhari J. Prevalence of abnormal CT findings in patients with proven ovarian torsion and a proposed triage schema. Emerg Radiol. Aug 5 2008;[Medline].

  14. Kawakami K, Murata K, Kawaguchi N, Furukawa A, Morita R, Tenzaki T, et al. Hemorrhagic infarction of the diseased ovary: a common MR finding in two cases. Magn Reson Imaging. 1993;11(4):595-7. [Medline].

  15. MacDuff R, Anthony GS, MacLennan AC. Ovarian torsion diagnosed by MRI. J Obstet Gynaecol. Oct 2007;27(7):743-4. [Medline].

  16. Shadinger LL, Andreotti RF, Kurian RL. Preoperative sonographic and clinical characteristics as predictors of ovarian torsion. J Ultrasound Med. Jan 2008;27(1):7-13. [Medline].

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Keywords

ovarian torsion, ovary torsion, adnexal torsion, twisted ovary, fallopian tubes

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Contributor Information and Disclosures

Author

Arthur C Fleischer, MD, Professor, Chief of Diagnostic Sonography, Departments of Radiology and Obstetrics/Gynecology, Vanderbilt University Medical Center
Arthur C Fleischer, MD is a member of the following medical societies: American College of Radiology, American Institute of Ultrasound in Medicine, and Society of Radiologists in Ultrasound
Disclosure: Nothing to disclose.

Coauthor(s)

Eugene C Lin, MD, Consulting Radiologist, Virginia Mason Medical Center; Clinical Assistant Professor of Radiology, University of Washington School of Medicine
Eugene C Lin, MD is a member of the following medical societies: American College of Nuclear Medicine, American College of Radiology, Radiological Society of North America, and Society of Nuclear Medicine
Disclosure: Nothing to disclose.

Medical Editor

Harris L Cohen, MD, FACR, Vice Chairman/Associate Chairman (Research Activities), Director, Division of Body Imaging, Professor of Radiology, Stony Brook School of Medicine; Visiting Professor of Radiology, Johns Hopkins School of Medicine
Harris L Cohen, MD, FACR is a member of the following medical societies: American College of Radiology, American Institute of Ultrasound in Medicine, Association of Program Directors in Radiology, Radiological Society of North America, Society for Pediatric Radiology, and Society of Radiologists in Ultrasound
Disclosure: Nothing to disclose.

Pharmacy Editor

Bernard D Coombs, MB, ChB, PhD, Consulting Staff, Department of Specialist Rehabilitation Services, Hutt Valley District Health Board, New Zealand
Disclosure: Nothing to disclose.

Managing Editor

Karen L Reuter, MD, FACR, Professor, Department of Radiology, Lahey Clinic Medical Center
Karen L Reuter, MD, FACR is a member of the following medical societies: American Association for Women Radiologists, American College of Radiology, American Institute of Ultrasound in Medicine, American Roentgen Ray Society, and Radiological Society of North America
Disclosure: Nothing to disclose.

CME Editor

Robert M Krasny, MD, Consulting Staff, Department of Radiology, The Angeles Clinic and Research Institute
Robert M Krasny, MD is a member of the following medical societies: American Roentgen Ray Society and Radiological Society of North America
Disclosure: Nothing to disclose.

Chief Editor

Lawrence M Davis, MD, Assistant Professor of Diagnostic Imaging (Clinical), Department of Diagnostic Imaging, Warren Alpert Medical School at Brown University
Lawrence M Davis, MD is a member of the following medical societies: American College of Radiology, American Roentgen Ray Society, American Society of Neuroradiology, Radiological Society of North America, and Rhode Island Medical Society
Disclosure: Nothing to disclose.

 
 
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