Back to Basics: Ovarian Torsion

Ovarian Torsion


- Twisting of ovary and infundibulopelvic (suspensory) ligament, which holds ovarian vessels, impeding lymphatic and venous outflow and arterial inflow

- Increased in first year of life, menarche, pregnancy, ovulation, induction during infertility treatment

- 50% initially misdiagnosed

Risk Factors

- large ovarian cyst or tumor especially if >5cm tubal ligation


- 70% R sided (longer utero-ovarian lig, sigmoid colon on L)

- Acute onset severe unilateral pain, often after exertion (although half with gradual onset)

- Nausea and vomiting in 70%

- +/- low grade fever


- Unilateral lower abdominal tenderness with guarding, adnexal tenderness on bimanual exam, palpable adnexal mass


- Appendicitis, PID, TOA, ectopic pregnancy, ruptured ovarian cyst

Work up:

- Obtain beta-Hcg

- Pelvic Ultrasound w/ doppler

- not 100% sensitive or specific

- most common - ovary >4cm due to cyst, tumor, or edema

- heterogenous appearance of stroma

- multiple peripheral follicles ("string of pearls")

- decrease/absent flow within the ovary

- Confirmation of diagnosis is direct visualization


- Surgical emergency - consult OB/Gyn


- loss of ovarian function

- necrosis

- hemorrhage

- peritonitis

Key Point: Maintain a high index of suspicion as this is easy to miss and has significant consequences if not caught early!


Heniff, M, Fleming, H. “Abdominal and Pelvic Pain in the Nonpregnant Female.” Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 8eEds. Judith E. Tintinalli, et al. New York, NY: McGraw-Hill, 2016.