Ovarian Torsion with Dr. Jennifer Dietrich
With Dr. Jennifer Dietrich · hosted by Dr. Todd Ponsky · StayCurrentMD
Cued at 44:32 · stops at 45:17 · press play
Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
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What the experts said
In all reproductive age females presenting with lower abdominal pain, a pregnancy test should be checked regardless of sexual activity history.
Ultrasound provides adequate penetration for ovarian evaluation in both low and high BMI females when the patient has a full bladder.
Significant asymmetry between ovaries on ultrasound, particularly enlargement on the symptomatic side, raises concern for adnexal torsion.
Complete absence of blood flow on ultrasound is the most concerning and reliable finding for torsion; presence of blood flow is less reliable and does not rule out torsion.
Blood flow may be present in torsion because only the tube is torsed (ovary still perfused) or because the torsion is intermittent or loose rather than complete.
Intermittent torsion can occur, and if the diagnosis is uncertain, observation with repeat ultrasound may help if the patient declares herself with worsening pain.
Peripheralization of follicles to the ovarian periphery suggests vascular congestion from torsion, as the edematous center pushes follicles outward.
Lesions 5-6 cm or larger increase the risk of torsion in the setting of symptoms by making the adnexa heavy enough to twist.
In prepubertal girls, normal ovaries can torse, and torsion is the most common reason for gynecologic surgery in this age group.
There is no absolute size cutoff for torsion risk; in a prepubertal child with a normally 1-1.5 cm ovary, even a 2-3 cm cyst can cause torsion.
Complex ultrasound features (partly cystic, partly solid), hypervascular flow on Doppler within a lesion, and elevated tumor markers raise concern for malignancy.
CT is useful to distinguish an adnexal lesion from an abscess or appendiceal pathology; MRI is useful to distinguish torsion from müllerian anomalies with hematosalpinx.
The tumor marker panel for pediatric ovarian lesions includes alpha-fetoprotein, quantitative beta-HCG, lactate dehydrogenase, and CA-125.
It is impossible to predict preoperatively whether a torsion is loose (more time available) or tight (rapid ischemia), so suspected torsion should be addressed as soon as the diagnosis is made.
If clinical suspicion for torsion is high, it is a clinical diagnosis and surgery should proceed regardless of ultrasound findings; if uncertain, observation with potential repeat imaging is acceptable but the patient should not be sent home.
A classic torsion presentation includes acute onset pain after vigorous physical activity (gymnastics, bouncing on a boat), persistent pain unresponsive to over-the-counter measures, nausea and vomiting, and an enlarged ovary on the symptomatic side.
Hemorrhagic ovarian cysts are more likely in menstruating females; menstrual history (regularity, timing of last cycle) helps determine risk for hemorrhagic or corpus luteum cysts.
In hemorrhagic cysts, Doppler shows no flow within the cyst itself but flow peripheral to the cyst, which can help differentiate from torsion.
Surgical management of torsion includes detorsion and removal of any causative lesion (ovarian or peritubal cyst) to eliminate the weight that caused torsion.
Oophorectomy and salpingo-oophorectomy should be avoided; the goal is ovarian salvage even when the ovary appears purple, black, and blue, as many recover over time.
For ovarian cysts, cystectomy (complete excision of cyst wall) is preferred over drainage alone; peritubal cysts will recur if not completely excised.
For peritubal cysts, open the mesosalpinx beneath the splayed fallopian tube, expose the cyst wall, and shell it out.
For hemorrhagic ovarian cysts, if the cyst wall is not completely removed, the cyst may continue to bleed.
Even necrotic-appearing ovaries should be salvaged unless the tissue is literally falling apart during detorsion; follow-up studies show return of ovarian function and follicles within months.
Whether to remove a necrotic fallopian tube depends on whether it is involved in the torsion and completely devitalized; this is a judgment call at the time of surgery.
Ovarian bivalving involves making an incision into the ovarian cortex after detorsion to release compartment syndrome-like pressure and improve blood supply to the periphery.
Bivalving is indicated when the ovary remains edematous after detorsion, when there is no lesion to remove but the ovary is bulky and at risk for re-torsion, or when debulking is needed after cystectomy.
Energy devices such as harmonic scalpel or monopolar hook can be used for ovarian bivalving and debulking.
Oophoropexy is considered in cases of recurrent torsion, when a patient has only one ovary, or when the ovary remains at high risk for re-torsion after addressing the primary pathology.
Oophoropexy may change future fertility potential by altering ovarian position, but preserving the ovary is better than losing it, and IVF remains an option.
Absorbable suture can be used for oophoropexy to hold the adnexa still for 4-6 weeks while inflammation resolves, minimizing near-term re-torsion risk; permanent suture is used for long-term fixation.
Clipping the utero-ovarian ligament does not reliably prevent torsion because the adnexa can still twist on either the utero-ovarian ligament or the infundibulopelvic ligament.
Oophoropexy techniques include shortening the utero-ovarian ligament (by suturing or clipping it in an accordioned fashion), pexing to the pelvic sidewall (away from ureters), or pexing to the posterior uterus.
For tubo-ovarian abscess, antibiotics should be started and the abscess should not be disturbed surgically unless the patient is unstable, to avoid seeding other pelvic structures.
Ectopic pregnancy can present similarly to torsion with acute pain and an adnexal mass; surgery is indicated for ruptured or unstable ectopic regardless of pregnancy status.
Transvaginal ultrasound is more sensitive than transabdominal for detecting early pregnancy, but many children's hospitals do not perform or have access to transvaginal probes.
For tubal ectopic pregnancy, perform salpingostomy (longitudinal incision), remove the ectopic pregnancy, ensure hemostasis, and do not suture the tube closed; pelvic structures heal well without suturing and suturing may cause stricture.
Endometriosis in adolescents presents with early lesions that are clear or red rather than the classic blue-black lesions seen in adults with advanced disease.
To visualize clear endometriosis lesions, fill the pelvis with crystalloid fluid and dive the camera under to see bleb-like lesions pulling away from the peritoneum, particularly in the cul-de-sac.
Endometriosis lesions can be excised with cold scissors (especially near ureter or bowel) or ablated depending on location.
After laparoscopic management of torsion, patients can be discharged the same day if they meet milestones, with activity restriction for 4-6 weeks to allow incision healing and avoid hernia formation.
Oral contraceptives can prevent recurrence if the torsion was caused by a functional cyst, but they do not prevent recurrence from dermoid cysts or peritubal cysts.
Surveillance ultrasound is performed at 3 months postoperatively (to allow inflammation to resolve), then at 3-6 months if the ovary is still recovering, then annually.
Studies from Boston Children's show higher ovarian salvage rates when surgery occurs within 24-72 hours of pain onset compared to one week.