Suspected Ovarian Torsion
Acute pelvic/abdominal pain, often with nausea/vomiting
All Pathways
Obstetrics & GynecologyEmergency
Ovarian Torsion Management (ACOG 2019)
Ovarian Torsion Management (ACOG 2019): Suspected Ovarian Torsion → Clinical Presentation → Diagnostic Workup → Ultrasound Findings → ⚠️ Doppler DOES NO...
Pathway Overview
11 steps
Algorithm Steps
11 total
01Start 02Action 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
03Action 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)
04Decision Ultrasound Findings
Interpret with clinical suspicion
05Warning ⚠️ 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
06Decision Clinical Suspicion High?
Based on presentation, not just imaging
07Action 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
08Outcome 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
09Action 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
- Path rejoins step 08Shared downstream outcome
10Action 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
- Path rejoins step 08Shared downstream outcome
11Action 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
- Path rejoins step 07Shared downstream outcome
Guideline Source
ACOG Committee Opinion No. 783: Adnexal Torsion in Adolescents
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- Torsion is a surgical diagnosis - imaging can be negative
- Doppler flow does NOT rule out torsion
- Time to surgery affects ovarian salvage
- Applies to adolescents and adults
Applicable Regions
USEUGlobal
Version 1Next review: 2027-01-01
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Related Resources
Frequently Asked Questions
What is the Ovarian Torsion Management (ACOG 2019)?
The Ovarian Torsion Management (ACOG 2019) is a emergency clinical algorithm for Obstetrics & Gynecology. It provides a structured decision tree to guide clinical decision-making, based on ACOG Committee Opinion No. 783: Adnexal Torsion in Adolescents.
What guideline is the Ovarian Torsion Management (ACOG 2019) based on?
This algorithm is based on ACOG Committee Opinion No. 783: Adnexal Torsion in Adolescents (DOI: 10.1097/AOG.0000000000003373).
What are the limitations of the Ovarian Torsion Management (ACOG 2019)?
Known limitations include: Torsion is a surgical diagnosis - imaging can be negative; Doppler flow does NOT rule out torsion; Time to surgery affects ovarian salvage; Applies to adolescents and adults. Individual patient factors may require deviation from these recommendations.
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