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Ovarian Torsion Case Discussion: Doppler, Detorsion, Fertility [ Case Discussion ](https://mdster.com/blog?category=case-discussion) Ovarian Torsion Case Discussion: Doppler, Detorsion, Fertility ================================================================ A board-focused review of acute pelvic pain when preserved arterial flow should not reassure you [ MDster Editorial Team ](https://mdster.com/about) · Mar 18, 2026 · 6 min read · 102 [ Reviewed by Dr. Ali Ragab, MBBCH, MSc, MCAI ](https://mdster.com/medical-reviewers/dr-ali-ragab) [Editorial Policy](https://mdster.com/editorial-policy) | [Corrections Policy](https://mdster.com/corrections) [ Board Review ](https://mdster.com/blog?tag=board-review) [ Obstetrics & Gynecology ](https://mdster.com/blog?tag=obstetrics-gynecology) [ Case Discussion ](https://mdster.com/blog?tag=case-discussion) [ Gynecology ](https://mdster.com/blog?tag=gynecology) [ Ovarian Torsion ](https://mdster.com/blog?tag=ovarian-torsion) [ Acute Pelvic Pain ](https://mdster.com/blog?tag=acute-pelvic-pain) Share this article Share this post A 24-year-old nulligravid patient arrives with 6 hours of abrupt right lower quadrant pain, vomiting, mild leukocytosis, a negative urine β-hCG, and a tender 6-cm adnexal mass. TVUS shows a 7-cm enlarged ovary with peripheral follicles, heterogeneous stroma, absent venous flow, and preserved arterial waveforms. This is the classic trap: the Doppler is not reassuring. In a reproductive-age patient, the task is not to prove torsion radiographically; it is to decide whether delay will cost ovarian function. [\[1\]](#cite-1 "Reference [1]") Working the differential ------------------------ DiagnosisWhy it stays on the list**Adnexal torsion**Sudden unilateral pain, vomiting, adnexal mass, enlarged edematous ovary, peripheral follicles, and abnormal venous flow make this the leading diagnosis. [\[1\]](#cite-1 "Reference [1]")**Hemorrhagic cyst or rupture**Can cause acute pain and free fluid, but usually does not produce the same enlarged, torsed-appearing ovary. [\[2\]](#cite-2 "Reference [2]")**Ectopic pregnancy**Always considered in reproductive-age patients with acute pelvic pain, even when this case is made unlikely by a negative urine β-hCG. [\[2\]](#cite-2 "Reference [2]")**Tubo-ovarian abscess**Fever, leukocytosis, and an adnexal mass overlap, but the tempo and ultrasound pattern are less convincing here. [\[2\]](#cite-2 "Reference [2]")**Appendicitis**Right-sided pain, nausea, leukocytosis, and rebound can look identical early on. [\[3\]](#cite-3 "Reference [3]") What pushes torsion to the top is the physiologic pattern. The ovary usually twists around the infundibulopelvic and utero-ovarian ligaments; venous and lymphatic outflow are compromised first, producing congestion, stromal edema, ovarian enlargement, and peripherally displaced follicles before arterial inflow disappears. Risk rises when a mass exceeds 5 cm, and right-sided torsion is more common. The ovarian vessels running in the suspensory or infundibulopelvic ligament are the key vascular structures at risk. [\[1\]](#cite-1 "Reference [1]") > **Clinical Pearl:** Preserved arterial flow means the ovary may still be salvageable; it does **not** exclude torsion. [\[1\]](#cite-1 "Reference [1]") Why preserved arterial flow is the trap --------------------------------------- Board questions love the phrase preserved arterial waveforms because it tempts overinterpretation. Current ACOG guidance is explicit: there are no clinical or imaging criteria sufficient to confirm the diagnosis preoperatively, and Doppler flow alone should not guide decision-making. The explanation is straightforward—torsion may be partial or intermittent, and arterial perfusion can persist because the ovary has dual supply from the ovarian and uterine arteries. Consequently, absent venous flow with an enlarged ovary is more than enough to keep torsion at the top of the list and move toward urgent laparoscopy. [\[1\]](#cite-1 "Reference [1]") In the operating room: salvage first ------------------------------------ The operation is both diagnostic and therapeutic. If suspicion is high, the threshold for diagnostic laparoscopy should be low, because delay correlates with lower ovarian preservation rates. Once inside the abdomen, detorse first and then reassess. The ovary may remain blue-black and dramatically congested after untwisting; that appearance is a poor test of viability. Current consensus favors laparoscopic detorsion and preservation of adnexal structures regardless of gross color, with oophorectomy reserved for the rare ovary that is frankly necrotic, gelatinous, and literally falling apart. Importantly, systematic review data found no evidence of thromboembolic harm after detorsion and no reliable relationship between gross appearance and long-term ovarian function. [\[1\]](#cite-1 "Reference [1]") Management of the associated cyst is where nuance matters. If there is a benign-appearing cyst with a clean plane, cystectomy at the index operation is reasonable. However, in a severely edematous, friable ovary, forcing the cystectomy can turn a salvageable ovary into an oophorectomy. ACOG therefore allows detorsion alone, with or without drainage of a large simple cyst, followed by repeat ultrasonography in 6 to 12 weeks. Interestingly, pediatric cohort data suggest that immediate cystectomy does not appear to worsen short-term ovarian morphology, so either strategy can be defensible when technically sound. Clinical judgment dictates which risk is greater in front of you: recurrence or iatrogenic tissue loss. [\[1\]](#cite-1 "Reference [1]") Clinical application -------------------- Counseling before surgery should be direct. The primary goal is ovarian salvage. Removal is a contingency, not the plan, and should occur only if the adnexa are truly unsalvageable. Patients also deserve perspective: retrospective reproductive-outcome data are reassuring overall, with no clear signal that surgically treated torsion reduces later live birth potential. Even if unilateral oophorectomy becomes necessary, the contralateral ovary is usually sufficient for ongoing hormonal function and fertility. [\[1\]](#cite-1 "Reference [1]") Recurrence prevention is more controversial than many exam answers imply. ACOG notes a recurrence rate generally in the 2% to 12% range, higher in torsion of a normal adnexa, and does **not** support routine oophoropexy after a first episode. In practice, fixation is most defensible after recurrent torsion, bilateral events, or obvious ligamentous laxity. Available cohort data suggest that no single fixation technique has proved clearly superior, and recurrence can still occur after pexy. The classic benign neoplastic lead point for torsion remains the mature cystic teratoma or dermoid. [\[1\]](#cite-1 "Reference [1]") Key Points for Board Exams -------------------------- - **Torsion is a surgical diagnosis**; a reassuring Doppler study does not rule it out. [\[1\]](#cite-1 "Reference [1]") - **Venous compromise precedes arterial compromise**, explaining ovarian enlargement, edema, and peripheral follicles with persistent arterial flow. [\[3\]](#cite-3 "Reference [3]") - **Masses larger than 5 cm** materially increase torsion risk. [\[1\]](#cite-1 "Reference [1]") - **Detorse first, judge later**; a dark ovary can recover and should not be removed for color alone. [\[1\]](#cite-1 "Reference [1]") - **Cystectomy is optional at the index surgery** if edema makes ovarian injury more likely. [\[1\]](#cite-1 "Reference [1]") - **Routine oophoropexy after a first event is not established standard care**. [\[1\]](#cite-1 "Reference [1]") Conclusion ---------- The high-yield lesson is simple: in suspected ovarian torsion, preserved arterial flow should increase urgency, not complacency. Think physiologically, operate early, detorse generously, and preserve ovarian tissue whenever possible. That approach is not just board-correct; it is the fertility-sparing standard reflected in the best available guidance as of March 2026. [\[1\]](#cite-1 "Reference [1]") References (9) ------------------ 1. 1. [ www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2019/08/adnexal-torsion-in-adolescents ](https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2019/08/adnexal-torsion-in-adolescents) [↩](#cite-ref-1-1 "Back to text") 2. 2. [ pubmed.ncbi.nlm.nih.gov/37895407 ](https://pubmed.ncbi.nlm.nih.gov/37895407/) [↩](#cite-ref-2-1 "Back to text") 3. 3. [ pubmed.ncbi.nlm.nih.gov/28884300 ](https://pubmed.ncbi.nlm.nih.gov/28884300/) [↩](#cite-ref-3-1 "Back to text") 4. 4. American College of Obstetricians and Gynecologists. Committee Opinion No. 783: Adnexal Torsion in Adolescents. Obstet Gynecol. 2019. 5. 5. Ssi-Yan-Kai G, Rivain AL, Trichot C, et al. What every radiologist should know about adnexal torsion. Emerg Radiol. 2018;25(1):51-59. 6. 6. Dasgupta R, Renaud E, Goldin AB, et al. Ovarian torsion in pediatric and adolescent patients: A systematic review. J Pediatr Surg. 2018;53(7):1387-1391. 7. 7. Silberstein T, Freud A, Baumfeld Y, et al. Influence of ovarian torsion on reproductive outcomes and mode of delivery. Front Med (Lausanne). 2024;11:1370409. 8. 8. Akdam A, Bor N, Fouks Y, et al. Recurrent Ovarian Torsion: Risk Factors and Predictors for Outcome of Oophoropexy. J Minim Invasive Gynecol. 2022;29(8):1011-1018. 9. 9. Yagur Y, Klein A, Tiosano L, et al. Comparative outcomes of oophoropexy techniques in preventing recurrent adnexal torsion. Arch Gynecol Obstet. 2025;312(4):1317-1325. Next step Build confidence in OB/GYN with focused practice -------------------------------------------------- - Labor & delivery + postpartum essentials - Gynecology, screening, and common procedures - Review weak topics and improve faster [ Start practicing ](https://mdster.com/user/dashboard) [ Explore Obstetrics & Gynecology ](https://mdster.com/speciality/obstetrics-gynecology) [ View pricing ](https://mdster.com/pricing) [ Explore features ](https://mdster.com/features) No credit card required. Full access to all features. No commitment. Cancel anytime. 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