Ovarian Cyst Torsion
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Direct answer
Ovarian torsion is a surgical emergency in which the adnexa twists on its ligamentous pedicle, occluding first the venous and lymphatic drainage and later the arterial supply, producing sudden severe unilateral lower abdominal pain with nausea and vomiting. Dermoid cysts are the classic trigger in reproductive-age women, and in paediatric patients a completely normal ovary may torsate because of its excessive mobility. Doppler showing absent arterial flow is confirmatory, but preserved flow never excludes the diagnosis because torsion is often intermittent or incomplete. Treatment is emergency laparoscopy with detorsion and cystectomy or cyst aspiration in almost all cases — a necrotic-looking black ovary usually recovers, so oophorectomy is reserved for frankly gangrenous or non-viable tissue.
What you must remember
- Population and pathology: reproductive-age women most often, with a dermoid (mature cystic teratoma) as the commonest mass; premenarchal girls torsate normal ovaries; the right side is said to be involved slightly more often (sigmoid colon cushions the left).
- Clinical triad: sudden-onset colicky unilateral pain radiating to the groin and flank, nausea and vomiting in the majority, and a tender adnexal mass with peritoneal signs — pain may wax and wane with spontaneous detorsion.
- Imaging: ultrasound shows an enlarged oedematous ovary with peripherally crowded follicles, a "whirlpool" or twisted pedicle sign, and free fluid; the comma-shaped ovary is a described sign. Doppler absence of flow supports torsion, but normal flow does not exclude it — an exam-favourite discriminator.
- Tumour markers first: CA-125, and in a dermoid-looking mass, do not delay surgery awaiting markers — torsion is a clinical and surgical diagnosis.
- Surgical principle: detorsion plus conservation, even of a dusky ovary; follow-up studies show the vast majority of detorsioned ovaries regain function and follicular activity on later ultrasound. Oophorectomy only for gangrene, necrotic tissue prolapse into the pelvis, or suspicion of malignancy.
- Timing: operate as soon as possible — the traditional window quoted for ovarian salvage is within about 24-36 hours of pain onset, though later salvage is reported.
- Prevent recurrence: oophoropexy is considered in girls with torsion of a normal ovary or after bilateral episodes; cystectomy removes the weighted mass that predisposes to retorsion.
A typical midnight theatre decision
Picture a 24-year-old with six hours of right iliac fossa pain, two episodes of vomiting, a tender abdomen and a palpable mass. The appendicitis debate ends with an ultrasound showing a 7 cm complex echogenic mass with a whirled pedicle and no arterial flow. The registrar asks the exam-relevant questions in order: is she haemodynamically stable (torsion can infarct and rarely cause fever and peritonitis), is pregnancy excluded (a corpus luteum haemorrhage mimics this), and is the theatre available. At laparoscopy the ovary is purple-black — the instinct to remove it is wrong. Detorsion is performed, the ovary observed, and cystectomy or fenestration done depending on the pathology; a dermoid is sent for histology. Oophorectomy would be reserved for a gangrenous, leaking or frankly malignant-looking adnexa, an uncommon scenario. Postoperatively, the questions examiners ask write themselves: why did the ovary survive (dual blood supply from ovarian and uterine arteries, and venous occlusion precedes arterial), and why did Doppler mislead (intermittent torsion, dual supply).
Where students slip
Two errors recur. The first is treating Doppler as the gatekeeper: waiting for absent flow before operating loses ovaries, since partial and intermittent torsion maintains arterial inflow while the organ is still strangulating on its venous side. The second is the postmenopausal patient — torsion occurs in older women too, and because malignant masses torsate, a solid elevated CA-125 mass in a 60-year-old changes both consent (possible laparotomy, oncology referral) and surgical plan. In Indian viva settings, the adnexal mass with acute pain in a young girl is frequently worked up conservatively until peritonism sets in; the teaching point to articulate is that the diagnosis is clinical plus surgical, and conservative observation has no role.
Frequently asked questions
Which imaging finding is most specific for ovarian torsion?
The whirlpool sign — the twisted vascular pedicle seen as a spiral or coiled structure — is considered the most specific ultrasound feature, more reliable than absent Doppler flow.
Why can normal Doppler flow be seen in ovarian torsion?
Torsion is often incomplete or intermittent, and the ovary has a dual arterial supply from the ovarian and uterine arteries, so arterial inflow may persist while venous outflow is obstructed.
What is the treatment of choice for a torsioned dusky ovary in a young woman?
Laparoscopic detorsion with cystectomy and ovarian conservation, regardless of the black-purple appearance, because most such ovaries recover function; oophorectomy is reserved for gangrenous or suspicious masses.
Which ovarian cyst most commonly causes torsion?
Mature cystic teratoma (dermoid) is the classic torsating mass in reproductive-age women because of its weight and mobility.
Is oophoropexy ever indicated after torsion?
Yes — oophoropexy is considered for torsion of a histologically normal ovary, recurrent torsion, or solitary ovary, to reduce the risk of repeat twisting.