Ovarian torsion

Complete/partial rotation of ovary on ligamentous supports, resulting in issues with blood supply - can lead to ischaemia

Typically rotates around both suspensory ligament of ovary and utero-ovarian ligament
Fallopian tube twists along with ovary - referred to as adnexal torsion

Aetiologies

Fetus/neonate
Ovarian cysts
Premenarchal girls
Ovarian cysts and neoplasms
Elongated utero-ovarian ligament
Premenopausal women
Ovarian cysts and neoplasms (includes ovarian hyperstimulation syndrome)
Pregnancy
Postmenopausal women
Ovarian cysts and neoplasms

86-95% of patients with torsion have an ovarian mass
- Commonly functional cyst/corpus luteum, or benign neoplasm
Most likely when ovary >5cm diameter
More likely with benign lesions
Most occur in women of reproductive age
Increased risk during pregnancy (corpus luteum)
Increased risk with ovulation induction (hyperstimulation syndrome)
However can occur AT ALL AGES

No specific time duration predictive of ovarian necrosis, however in one case series, mean time from symptom onset to successful salvage was 87 hours, so it's probably not that urgent. (see UTD)
Intermittent torsion is not a/w necrosis
If peritonitis is present, probably more urgent to get to theatre, raises concern for necrosis

USS - sensitivity 46-75%, but quite specific
- Rounded, enlarged, heterogenous appearance (oedema/engorgement/haemorrhage)
- Ovary may be located anterior to uterus rather than normal location lateral or posterior
- Multiple small follicles may be present
- Normal doppler flow does not exclude torsion (can be seen in up to 57% of patients with torsion) but if no flow if present, highly sensitive for torsion
Hcg, fbe, uec
Inflammatory markers generally normal

Gross visual inspection
- dark, enlarged ovary - likely vascular and lymphatic congestion - likely viable
- Necrosis - loss of normal antomical structure, gelatinous, poorly-defined structure