Ovarian torsion: recognising a gynaecological emergency in AU general practice

Ovarian torsion is one of the conditions a general practitioner must not miss. The window for saving the ovary is narrow — around six to eight hours from onset — and the diagnosis is clinical, not radiological. A normal Doppler ultrasound does not exclude torsion. When the story fits, the GP’s role is to establish intravenous access, administer analgesia and antiemetics, and arrange same-hour transfer to a centre with emergency laparoscopic capability, telephoning ahead to the gynaecology team before the patient even arrives.

A. Core clinical — the AU general-practice framework

What ovarian torsion is

Ovarian torsion — more precisely adnexal torsion when the fallopian tube twists alongside the ovary, which occurs in around two-thirds of cases — is the rotation of the ovary around its supporting ligaments, compressing the vascular pedicle (eTG complete — Gynaecological emergencies). Venous and lymphatic outflow occludes first, causing engorgement and oedema. As the ovary enlarges it exerts more traction on its pedicle, eventually occluding arterial inflow and progressing to ischaemia and infarction.

The time from torsion to irreversible ovarian loss is not a fixed cliff but a probability curve. Lee et al (Fertil Steril 2008) and Galinier et al (2008) report ovarian salvage rates exceeding 90 per cent when detorsion occurs within six to eight hours; beyond 24 hours, salvage rates fall to approximately 20 per cent. The practical implication is that every hour matters.

Who is at risk

Reproductive-age women with ovarian cysts are the highest-risk group in adults. Any mass larger than five centimetres shifts the centre of gravity of the ovary and provides a fulcrum for axial rotation. Dermoid cysts (mature cystic teratomas) are disproportionately represented in torsion series compared with their prevalence.

Pregnant women — particularly in the first trimester, when a corpus luteal cyst is present — account for approximately 22 per cent of all torsion cases (Asfour et al 2015). Pregnancy-related ligament laxity and the enlarging uterus also increase the mobility of adnexal structures.

Women undergoing IVF or ovulation induction face approximately a fivefold elevated risk in the first two weeks after oocyte retrieval, when ovarian hyperstimulation syndrome can dramatically enlarge both ovaries. This is among the highest-risk periods for torsion.

Premenarchal girls can torte a completely normal ovary due to a longer, more mobile infundibulopelvic ligament. Ovarian torsion affects approximately 4.9 per 100,000 girls per year (Geimanaite & Trainavicius 2013). The condition is frequently misdiagnosed as gastroenteritis or constipation in this age group — the vomiting and abdominal pain pattern can look identical.

Right side is more common than left — the sigmoid colon is thought to mechanically limit left-sided torsion (Houry & Abbott 2001). Right-sided torsion is therefore readily confused with appendicitis.

Presentation

Sudden, severe, unilateral lower abdominal or pelvic pain is the universal feature. The onset is typically abrupt, often precipitated by a specific movement — exercise, intercourse, a sudden position change, or even vigorous vomiting. The pain is usually constant once established, though approximately half of confirmed torsion patients describe prior intermittent episodes that resolved spontaneously (Houry & Abbott 2001). Explicitly asking “have you had similar sudden pain before that came and went?” helps identify this pattern.

Nausea and vomiting accompany the pain in approximately 90 per cent of cases, often post-prandially, and can dominate the clinical picture to the point where the presentation appears to be gastroenteritis. This is one of the most dangerous diagnostic detours.

Examination: most women are haemodynamically stable until late in the course — tachycardia is present in approximately 90 per cent, low-grade fever in approximately 25 per cent. Hypotension implies late necrosis or a concurrent diagnosis such as ectopic pregnancy. Unilateral adnexal tenderness is the dominant finding; peritonism occurs only in advanced presentations with necrosis or secondary peritonitis.

The critical pitfall: normal Doppler does not exclude torsion

This cannot be overstated. Up to 60 per cent of surgically confirmed ovarian torsion cases retain normal arterial Doppler flow on ultrasound (Servaes et al, Pediatr Radiol 2007; Khalil et al, Pediatr Radiol 2013). The reason is anatomical: the ovary receives blood from both the ovarian artery (from the aorta) and the uterine-ovarian anastomosis, meaning that even when one arterial supply is compressed, the other may maintain detectable flow.

An ultrasound report reassuringly stating “normal ovarian blood flow” is not a reason to de-escalate management when the clinical picture is consistent with torsion. The diagnosis is clinical — the imaging is supportive, not definitive.

Findings on pelvic ultrasound that should raise suspicion include: unilateral ovarian enlargement (the most consistent finding), peripherally displaced follicles, free pelvic fluid, an underlying cyst or dermoid, and the whirlpool sign of the twisted vascular pedicle, which is highly specific when present.

Investigations

Urine βhCG is mandatory in every reproductive-age woman with acute pelvic pain (eTG; RANZCOG). Ectopic pregnancy is the more immediately life-threatening differential, and a positive test requires its exclusion in parallel — importantly, pregnancy does not exclude torsion and in fact increases its probability.

Pelvic ultrasound with Doppler is first-line imaging. Transvaginal ultrasound is preferred in non-pregnant adults for its resolution advantage. Transabdominal ultrasound is used for premenarchal girls and pregnant women.

Bloods: FBC (MBS 65070), UEC (MBS 66509), CRP, lipase (to differentiate from pancreatitis), group and hold prior to theatre. Leucocytosis is non-specific and present in approximately 50 to 70 per cent of cases.

CT abdomen and pelvis (MBS 56412) is second-line and reserved for diagnostic uncertainty when the ultrasound is equivocal and surgical exploration has not yet been committed to.

Diagnostic and therapeutic laparoscopy is the definitive step and should not be delayed waiting for imaging perfection when clinical suspicion is moderate to high. The operation is both the diagnosis and the treatment.

B. Evidence appraisal

The single most important evidence shift in ovarian torsion management over the past two decades has been the move from routine oophorectomy to detorsion. Classical teaching held that a dark, discoloured ovary should be removed because it was presumed non-viable and potentially thromboembolic. Multiple cohort studies have overturned this assumption.

Cohen et al (2003), Lee et al (2008), Galinier et al (2008), and Geimanaite & Trainavicius (2013) collectively demonstrate that approximately 80 to 93 per cent of macroscopically infarcted-appearing ovaries recover follicular function after detorsion, as confirmed by subsequent ultrasound and ovulation induction response. The feared thromboembolic complication from twisting back a darkened ovary has not materialised in clinical series. RANZCOG C-Gyn 14 and eTG both reflect this evidence by recommending detorsion as the preferred approach. Oophorectomy is reserved for frankly necrotic tissue that disintegrates on handling, or for postmenopausal women where underlying malignancy is a concern (approximately 10 to 22 per cent of postmenopausal adnexal torsion cases harbour malignancy per Schmeler et al 2010, compared with less than two per cent in paediatric series).

Bertozzi et al (J Pediatr Surg 2017) provides the strongest evidence for oophoropexy — fixing the ovary to the pelvic wall to prevent recurrence — in paediatric cases of normal-ovary torsion, where recurrence rates without pexy run at approximately 6 to 11 per cent. Evidence in adult cases is less clear (case series only; no RCT), and oophoropexy is not standard practice when an obvious cyst was the precipitant and has been removed.

For torsion in pregnancy, Asfour et al (2015) and Schmeler et al (2010) confirm that laparoscopic detorsion is safe across all trimesters in experienced hands, with good outcomes for both ovarian preservation and pregnancy continuation.

C. Australian operations — MBS, referral pathway, and the GP role

The GP’s role is recognition and immediate escalation, not investigation or watchful waiting.

Immediate actions:

1. IV access (16–18G); IV crystalloid 250–500 mL if dehydrated or haemodynamically concerning; nil by mouth in anticipation of theatre
2. Analgesia: IV paracetamol 1 g plus IV opioid (morphine 0.1 mg/kg titrated, or fentanyl 25–50 micrograms IV) per AMH — adequate analgesia does not mask the diagnosis and reduces the sympathetic stress response
3. Antiemetic: ondansetron 4 mg IV or wafer, or metoclopramide 10 mg IV per AMH
4. Draw bloods at IV access: FBC, UEC, CRP, lipase, group and hold, quantitative βhCG
5. Telephone the on-call gynaecology team before sending the patient — communicate “suspected ovarian torsion, needs emergency laparoscopy” rather than “abdominal pain for review”
6. Document the time of pain onset (this is the torsion clock that guides surgical urgency)

MBS items (MBS Online): GP consultation item 23/36/44; urgent pelvic ultrasound with Doppler item 55070 plus supplementary transvaginal item 55065; CT abdomen and pelvis item 56412 if required; FBC item 65070; UEC item 66509; emergency operative laparoscopy (in-hospital specialist) item 35691.

Post-operative follow-up: wound review at one to two weeks; pelvic ultrasound at six to twelve weeks to confirm ovarian recovery; fertility consultation if the patient has a single remaining ovary, recurrent torsion, or pre-existing subfertility.

Suppression of recurrent functional cysts — the combined oral contraceptive pill, vaginal ring, or LNG-IUD may reduce the risk of functional cyst formation and recurrence after detorsion. This decision is made in conjunction with the treating gynaecologist at post-operative follow-up and depends on the patient’s fertility plans and the nature of the original precipitating lesion.

Medico-legal context: delayed diagnosis of ovarian torsion with resultant ovarian loss is a recognised source of medical negligence claims in Australia. Documentation of presentation time, examination, differential diagnosis including ectopic pregnancy, and time-to-escalation is essential. An ultrasound report of normal Doppler should be noted but should not be used to close the diagnosis if clinical suspicion remains — document the reasoning if proceeding to transfer despite a normal scan.

D. Integrative and lifestyle considerations

Ovarian torsion is a surgical emergency with no non-surgical treatment. Integrative considerations apply only in prevention, peri-operative recovery, and post-operative psychological support.

Education is the single most impactful non-surgical intervention. Women with known ovarian cysts, active IVF cycles, or prior torsion episodes should be explicitly counselled: sudden severe one-sided pelvic pain means going to the emergency department the same hour, not waiting to see if it settles. Every hour of delay reduces the probability of ovarian salvage. This conversation is most effective when delivered at the time of diagnosing an ovarian cyst or commencing an IVF cycle, not at the time of torsion.

Peri-operative pelvic floor physiotherapy is appropriate for any persistent post-laparoscopy abdominal wall pain or dyspareunia that develops after surgery.

Psychological support: emergency surgery with fertility implications can trigger significant anxiety and adjustment difficulties. A Mental Health Care Plan (items 2715 and 2717) and Better Access psychology referral are appropriate if distress persists beyond four weeks post-operatively. PANDA provides perinatal anxiety and depression support for women who experience torsion during pregnancy.

MedicAlert registration is a practical suggestion for women with recurrent torsion or a single remaining ovary, so that future emergency clinicians have immediate awareness of the adnexal anatomy.

E. Special populations

Premenarchal girls: torsion of a normal ovary — without any underlying cyst — is the dominant pattern in this age group. It is frequently misdiagnosed as gastroenteritis, constipation, or appendicitis. Any premenarchal girl with sudden severe unilateral lower abdominal pain and vomiting requires urgent surgical consideration. Avoid bimanual pelvic examination in premenarchal girls; transabdominal ultrasound is the imaging modality of choice. Oophoropexy of the ipsilateral and often the contralateral ovary is more commonly offered in paediatric centres given the risk of torsion of a normal ovary.

Pregnant women: the clinical features overlap with normal pregnancy discomforts, round ligament pain, and threatened miscarriage, leading to diagnostic delays. Pregnancy does not reduce the urgency of the diagnosis or the threshold for laparoscopy. Obstetric anaesthesia input and tocolysis considerations apply in the second and third trimesters. Inform obstetric teams alongside gynaecology.

IVF patients with OHSS: bilaterally enlarged hyperstimulated ovaries are friable and bleed easily; the operating surgeon should be a reproductive specialist where possible. Conservative management (detorsion without cystectomy) preserves the stimulated ovarian response.

ATSI women in remote and rural settings: regional and remote locations may not have immediate emergency laparoscopic capability. Lower transfer threshold and earlier telephone consultation with tertiary gynaecology is essential. ACCHO partnership for post-discharge follow-up and culturally safe aftercare planning. Jean Hailes for Women’s Health provides culturally inclusive resources.

Postmenopausal women: torsion is uncommon but when it occurs, approximately 10 to 22 per cent of adnexal torsion specimens in this age group contain malignancy. Intra-operative frozen section and staging should be considered. The default of ovarian preservation does not automatically apply — oophorectomy is more frequently appropriate in this age group.

When to escalate

All suspected ovarian torsion is a Category 1 emergency escalation — same hour. Telephone ahead to the gynaecology team and the receiving emergency department before transporting the patient. Do not wait for ultrasound results, blood results, or symptom review before making the call if clinical suspicion is present.

Absolute indicators for escalation without delay: sudden severe unilateral pelvic pain with vomiting in a reproductive-age woman; haemodynamic instability (implies ectopic pregnancy or necrosis and requires even more urgent response); suspected torsion in pregnancy; premenarchal girl with acute abdomen and vomiting.

What this article is and is not

This article summarises Australian and international evidence-based guidance on ovarian torsion to support informed conversations between patients and clinicians. It is for educational purposes and does not constitute medical advice. Ovarian torsion is a medical emergency. Anyone experiencing sudden severe one-sided lower abdominal pain — particularly with vomiting, or if they have a known ovarian cyst, are pregnant, or have recently had IVF — should go directly to the emergency department or call 000.

---

Sources cited

1. RANZCOG C-Gyn 14 — Management of adnexal masses and suspected ovarian malignancy
2. eTG complete — Gynaecological emergencies
3. ACEM — Acute pelvic pain in the emergency department
4. Australian Medicines Handbook — analgesia, antiemetics, antibiotics
5. RACGP — Acute abdominal pain in general practice
6. Houry D, Abbott JT. Ovarian torsion: a fifteen-year review. Ann Emerg Med 2001;38:156-9
7. Cohen Z et al. Laparoscopic detorsion allows sparing of the twisted ischaemic adnexa. 2003
8. Lee EJ et al. Outcomes of ovarian torsion and detorsion. Fertil Steril 2008
9. Servaes S et al. Sonographic findings of ovarian torsion in children. Pediatr Radiol 2007
10. Khalil M et al. Doppler ultrasound in paediatric ovarian torsion. Pediatr Radiol 2013
11. Asfour V et al. Ovarian torsion in pregnancy. Eur J Obstet Gynecol Reprod Biol 2015
12. Galinier P et al. Ovarian torsion — management and ovarian salvage in children. 2008
13. Geimanaite L, Trainavicius K. Ovarian torsion in children. Pediatr Surg Int 2013
14. Bertozzi M et al. Oophoropexy after ovarian detorsion in paediatric patients. J Pediatr Surg 2017
15. Schmeler KM et al. Adnexal masses in pregnancy: surgery compared with observation. Obstet Gynecol 2010
16. Jean Hailes for Women’s Health
17. HealthDirect — Ovarian cysts and torsion
18. PANDA — Perinatal anxiety and depression
19. MBS Online — items 23, 36, 44, 55065, 55070, 56412, 65070, 66509, 35691, 2715, 2717
20. PBS Online — ondansetron, paracetamol, morphine