Ovarian Torsion Management (ACOG 2019)

Algorithm Steps

1. ▶

   Start

   Suspected Ovarian Torsion

   Acute pelvic/abdominal pain, often with nausea/vomiting

   1. ●

      Action

      Clinical Presentation

      Classic features

      • Sudden onset, severe unilateral pelvic pain
      • Intermittent, colicky (comes and goes with twisting)
      • Nausea and vomiting (90%)
      • May have history of ovarian cyst
      • Low-grade fever possible
      • Adnexal tenderness on exam
      1. ●

         Action

         Diagnostic Workup

         Imaging and labs

         • Pelvic ultrasound with Doppler - FIRST LINE
         • Findings: Enlarged ovary, free fluid, absent/reduced flow
         • 'Whirlpool sign' - twisted vascular pedicle
         • Pregnancy test (rule out ectopic)
         • CBC, BMP
         • Urinalysis (rule out UTI)
         1. ◆

            Decision

            Ultrasound Findings

            Interpret with clinical suspicion

            1. ⚠

               Warning

               ⚠️ Doppler DOES NOT Rule Out Torsion

               Normal flow seen in 60% of confirmed torsion cases

               • Dual blood supply allows intermittent flow
               • High clinical suspicion = surgery regardless of Doppler
               • Do NOT delay surgery for normal Doppler
            2. ◆

               Decision

               Clinical Suspicion High?

               Based on presentation, not just imaging

               1. ●

                  Action

                  Surgical Intervention

                  Laparoscopy is standard approach

                  • DETORSION - untwist the adnexa
                  • Ovarian preservation regardless of appearance
                  • Black/necrotic ovary does NOT mandate oophorectomy
                  • Ovary often recovers after detorsion
                  • Cystectomy NOT required at time of detorsion
                  • Consider oophoropexy if recurrent or high risk
                  1. ✓

                     Outcome

                     Postoperative Care

                     Recovery and follow-up

                     • Pain management
                     • Follow-up ultrasound in 6-8 weeks
                     • Counsel on recurrence risk (~10%)
                     • Discuss oophoropexy if recurrent
                     • Fertility counseling if oophorectomy performed
                  2. ●

                     Action

                     Oophorectomy (Rare)

                     Only if unavoidable

                     • Do NOT remove based on appearance alone
                     • Consider only if:
                     • - Frankly necrotic and falling apart
                     • - Malignancy strongly suspected
                     • Err on side of preservation for fertility
               2. ●

                  Action

                  Torsion Not Found at Surgery

                  Common - occurs in ~50% of cases

                  • Evaluate for other pathology
                  • Ruptured cyst, endometrioma, appendicitis
                  • Document findings
                  • Diagnostic laparoscopy still therapeutic for diagnosis
            3. ●

               Action

               If Pregnant

               Special considerations

               • Torsion more common in pregnancy (corpus luteum cysts)
               • Laparoscopy safe in pregnancy
               • Avoid delays - same urgency
               • Left lateral tilt positioning
               • Fetal monitoring as appropriate