Stephanie Cizek, MD

STEPHANIE M. CIZEK, MD, completed a fellowship in pediatric and adolescent gynecology and is now a clinical assistant professor in the Department of Obstetrics and Gynecology at Stanford School of Medicine in California.

Torsion of adnexal structures (including torsion of the ovary, fallopian tube, or both) is the fifth most common gynecologic emergency.

 It can occur at any age, although it is more likely in individuals 10 years and older, with an average being age 30 years.

 It is the sixth most common pediatric surgical emergency and is estimated to affect 5 of ever 100,000 individuals aged 1 to 20 years; 16% of pediatric torsion cases will occur prior to age 1 year.

 It can also occur in pregnant women, women post hysterectomy, and postmenopausal women.

(Printed with permission from Paula Hillard, MD, and Elsevier.)

Both pediatric and adult patients are at risk for delayed or missed diagnosis of torsion. The main presenting symptoms of adnexal torsion are abdominal pain and nausea. Torsion pain is classically intermittent, leaving some patients clinically well appearing in between pain episodes. Imaging, particularly the presence of vascular flow to the adnexa, can provide false reassurance that torsion is not present. Providers may erroneously ascribe torsion pain to a “ruptured cyst” or “hemorrhagic cyst.” Finally, particularly in the pediatric and adolescent population, gynecologic etiologies of pain are often not considered.

PID, pelvic inflammatory disease; STI, sexually transmitted infection.

The presence of symptoms such as diarrhea, dysuria, abnormal vaginal discharge, and vulvovaginal pain/itching are not typical for torsion (

 In neonates, torsion typically presents with nonspecific symptoms such as inconsolability or feeding intolerance, and the infant may have an abdominal mass on examination.

Vomiting may be a good positive predictor of torsion. In a study of pediatric torsion, 83% of premenarchal patients and 100% of postmenarchal patients with a confirmed surgical diagnosis of torsion presented with vomiting as well as abdominal pain.

In all patients, a pelvic exam should be performed judiciously and is not necessary to diagnose torsion (

 Pelvic exams may be most informative for sexually active patients to help distinguish pelvic inflammatory disease (which can also present as adnexal tenderness) from torsion (typically pain is worst in 1 adnexum and a mass may be palpable). In young or premenarchal patients, an external exam is needed if vulvar pathology or imperforate hymen are suspected.

. Laboratory Evaluation for Adnexal Torsion

If malignancy is suspected, then serum tumor markers should be ordered, even if urgent surgical management is performed. Young patients are more likely to have a germ or stromal cell tumor and should have a quantitative β-human chorionic gonadotropin test, as well as tests for α-fetoprotein, lactate dehydrogenase, and inhibin A and inhibin B (

 All patients (any age) should have a cancer antigen 125 test if there is concern about malignancy.

Pelvic ultrasound: Ultrasound is first line in the diagnosis of torsion and should be performed urgently in the emergency department setting when torsion is considered.

 Although transvaginal pelvic ultrasound results in better imaging of the adnexa, transabdominal ultrasound is typically used in the pediatric and adolescent presexually active population. A full bladder for transabdominal ultrasound may be difficult in patients with developmental delay or in young children.

 These may be good second-line diagnostic tools; however, both have limited differences in sensitivity/specificity compared with ultrasound, may delay evaluation, and may incur higher cost.

 CT is less preferred in pediatric patients because it involves ionizing radiation.

. Imaging Findings Concerning for Adnexal Torsion

In a 2020 review, the addition of color Doppler imaging to ultrasound slightly improved both sensitivity and specificity but was not statistically significant.

 The presence of Doppler arterial and/or venous flow does not rule out a diagnosis of torsion, because patients with normal vascular flow per imaging may still have torsion (up to 60% in one study) (

Figure 2. Whirlpool sign on CT scan (arrow). This patient had bilateral paratubal cysts and right adnexal torsion on laparoscopy. 

Pediatric and adolescent patients are more likely to have torsion in the absence of an ovarian cyst (up to 46%) compared with adults.

 In the absence of an adnexal mass, the only imaging finding may be volume differences from associated ovarian tissue edema of the torsed ovary or because a larger ovary itself may be a nidus for torsion.

 Volume differences are common and in torsion are typically notably significant (at least 2.5 times greater volume in the torsed ovary).

 Providers should use caution against overinterpreting volume differences in the setting of an adnexal mass: If there is a cyst, there is naturally a volume difference between the ovaries.

Surgery is the gold standard. The definitive diagnosis and the management of adnexal torsion is done with urgent surgery, typically using laparoscopy. Approximately 50% of patients taken to the operating room because of concern for torsion will have torsion found intraoperatively.

There is no duration of symptoms that reliably predicts ovarian viability. In one study with a median time of 16 hours from symptom onset to surgery, follow-up ultrasound showed normal follicular development in 91% of previously torsed ovaries.

 In another study, patients with viable-appearing ovaries had a median time from presentation to diagnosis of 12 hours, and a median time from symptom onset to presentation of 3 days.

 The lymphatic and venous obstructions are thought to occur prior to arterial blood flow obstruction, and some “loose” or “partial” torsion cases may have intermittent arterial blood flow, making it difficult to correlate pain onset with timing of true tissue ischemia.

 In a comparison of ovarian to testicular torsion, patients with suspected ovarian torsion waited 2.5 times as long for diagnostic imaging and 2.7 times as long to be taken to the operating room, and the salvage rate for the affected gonad was 14% for ovarian torsion and 30% for testicular torsion.

Key Points in Management of Adnexal Torsion

 The benefit of urgent surgical management when torsion is suspected is salvage of viable tubal and/or ovarian tissue, and improvement in patient pain. In select situations, such as a patient who is a poor surgical candidate, then after careful informed consent and shared decision-making discussion, medical management of pain without surgery (or with delayed, planned surgery) may be considered or even
recommended (

There is strong support for retaining torsed ovaries in situ even in the setting of gross signs of necrosis. Even an ovary appearing necrotic may continue to function, as measured by follicular development on ultrasound.

 Concerns regarding the increased risk of venous thromboembolism with detorsion or infection if necrotic tissue is left in situ have not been substantiated.

Concern for malignancy is also often cited as a cause for oophorectomy, particularly in the pediatric population because at least 10% of pediatric ovarian masses are thought to be malignant.

However, a recent large study found only a 1.8% malignancy rate among pediatric patients with ovarian torsion.

 A large multicenter study found that patients 10 years and younger (particularly those < 3 years old), those with public insurance, and those with chronic medical conditions were all more likely to undergo oophorectomy at the time of torsion, suggesting that many factors may play into surgical decision-making.

Can oophoropexy prevent recurrence of torsion?

Peripheralization of follicles (hypoechoic rim) around the edematous stroma of the right ovary (outlined with dots). This patient had a right paratubal cyst and right adnexal torsion on laparoscopy.

Recurrence is thought to be approximately 5% to 6%. Patients who initially had torsion of a normal ovary have the highest rates of recurrence (15% vs
3% in one study examining recurrence of idiopathic torsion vs torsion in the presence of an adnexal mass).

The role of oophoropexy in preventing recurrence of torsion is controversial. Oophoropexy aims to reduce the risk of torsion either by fixing the ovary to a structure in the pelvis or shortening the utero-ovarian ligament. There are scant data comparing different oophoropexy techniques, which makes interpretation of efficacy data difficult. Recurrent torsion rates after oophoropexy are estimated to be between 9% and 17%. Because recurrence is highest in torsion of a normal ovary, this population, along with other patients at higher risk (those with bilateral torsion, recurrent torsion, prior oophorectomy, or anatomic risk factors such as long infundibulopelvic ligaments) may potentially benefit most from oophoropexy.

A swift and accurate diagnosis of torsion requires a high index of suspicion, effective communication, and continuing education of all specialties involved. Gynecology and emergency department providers should keep torsion high on the differential and understand that imaging does not provide definitive evidence against torsion. Operating room staff and anesthesiologists should be aware of the urgent nature of torsion and the intermittent nature of symptoms that may make a patient appear less “urgent” for surgery. Overall, it is recommended that all providers keep torsion high on their differential. 

1. Childress KJ, Dietrich JE. Pediatric ovarian torsion. 

. 2017;97(1):209-221. doi:10.1016/j.suc.2016.08.008

2. Adnexal torsion in adolescents: ACOG Committee Opinion No, 783. 

. 2019;134(2):e56-e63. doi:10.1097/AOG.0000000000003373

3. Robertson JJ, Long B, Koyfman A. Myths in the evaluation and management of ovarian torsion. 

. 2017;52(4):449-456. doi:10.1016/j.jemermed.2016.11.012

4. Schwartz BI, Huppert JS, Chen C, Huang B, Reed JL. Creation of a composite score to predict adnexal torsion in children and adolescents. 

. 2018;31(2):132-137. doi:10.1016/j.jpag.2017.08.007

5. Brandt ML, Helmrath MA. Ovarian cysts in infants and children. 

. 2005;14(2):78-85. doi:10.1053/j.sempedsurg.2005.01.002

6. Wattar B, Rimmer M, Rogozinska E, Macmillian M, Khan KS, Al Wattar BH. Accuracy of imaging modalities for adnexal torsion: a systematic review and meta-analysis. 

. 2021;128(1):37-44. doi:10.1111/1471-0528.16371

7. Ssi-Yan-Kai G, Rivain AL, Trichot C, et al. What every radiologist should know about adnexal torsion. 

. 2018;25(1):51-59. doi:10.1007/s10140-017-1549-8

8. Breech LL, Hillard PJA. Adnexal torsion in pediatric and adolescent girls. 

. 2005;17(5):483-489. doi:10.1097/01.gco.0000179666.39548.78

9. Hartman SJ, Prieto JM, Naheedy JH, et al. Ovarian volume ratio is a reliable predictor of ovarian torsion in girls without an adnexal mass. 

. 2021;56(1):180-182. doi:10.1016/j.jpedsurg.2020.09.031

10. Joudi N, Adams Hillard PJ. Adnexal torsion in a pediatric population: acute presentation with question of chronicity. 

. 2022;268:82-86. doi:10.1016/j.ejogrb.2021.11.435

11. Piper HG, Oltmann SC, Xu L, Adusumilli S, Fischer AC. Ovarian torsion: diagnosis of inclusion mandates earlier intervention. 

. 2012;47(11):2071-2076. doi:10.1016/j.jpedsurg.2012.06.011

12. Casey RK, Damle LF, Gomez-Lobo V. Isolated fallopian tube torsion in pediatric and adolescent females: a retrospective review of 15 cases at a single institution. 

. 2013;26(3):189-192. doi:10.1016/j.jpag.2013.02.010

13. Melcer Y, Sarig-Meth T, Maymon R, Pansky M, Vaknin Z, Smorgick N. Similar but different: a comparison of adnexal torsion in pediatric, adolescent, and pregnant and reproductive-age women. 

. 2016;25(4):391-396. doi:10.1089/jwh.2015.5490

14. Lawrence AE, Minneci PC, Deans KJ. Ovarian masses and torsion: new approaches for ovarian salvage. 

. 2020;67:113-121. doi:10.1016/j.yapd.2020.03.010

15. Oltmann SC, Fischer A, Barber R, Huang R, Hicks B, Garcia N. Pediatric ovarian malignancy presenting as ovarian torsion: incidence and relevance. 

. 2010;45(1):135-139. doi:10.1016/j.jpedsurg.2009.10.021

16. Lipsett SC, Haines L, Monuteaux MC, Hayes K, Michelson KA. Variation in oophorectomy rates for children with ovarian torsion across US children’s hospitals. 

. 2021;231:269-272.e1. doi:10.1016/j.jpeds.2020.12.019

17. Comeau IM, Hubner N, Kives SL, Allen LM. Rates and technique for oophoropexy in pediatric ovarian torsion: a single-institution case series. 

. 2017;30(3):418-421. doi:10.1016/j.jpag.2016.11.006

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Torsion of adnexal structures can occur in pregnant women, women post-hysterectomy, and postmenopausal women.


Adnexal torsion requires careful diagnosis, management

My 12-year-old patient was sitting alone in the exam room when I walked in. Eyes on her phone, she was engrossed in a video of a girl about her age in the middle of a long rant. We listened together to the girl’s tirade against everything from her parents to her school to her boyfriend to pop culture stars. “She seems pretty angry,” I said, to which my patient replied that she knew the girl well and her videos sometimes went on for hours.

In life and in my work, I try to focus on “finding the funny”-the parts of a day that make me laugh. In pediatric gynecology, there are a lot of really great, hilarious moments. A mom reports a “Crayola Seafoam Green” discharge from her child’s vagina, into which the girl had placed a crayon. A laugh-cry moment when a patient sobs to me that her grandmother was given a diagnosis of cancer and “has only 30 or 40 more years to live.” And then there are the nicknames that my patients use to refer to the vulva and vagina. When I first meet them, I try to use their words and hear myself saying 

But some days, the humor is hard to find, and I feel like I want to make a rant video myself. In gynecology, we’re constantly navigating a world that, at best, sends mixed messages to our girls about their worth as human beings, and at worst can feel like a constant assault. In trying to be emotionally present for every patient, we talk easily about sadness or joy. It’s less easy to acknowledge that anger can co-exist with these feelings, maybe because discussing anger means having to discuss its complicated roots. 

My patient with the friend who makes the angry videos has a lot to be angry about herself. I met her in the Emergency Room when she was
	11 years old and came in with heavy vaginal bleeding from a molar pregnancy. There was no fetus, but a molar pregnancy starts like any other, with sperm. She had been raped. Afterwards, I could find no 11-year-old-appropriate words to describe the abnormal pregnancy to her, to reassure her when she asked me the difference between an abortion and the procedure that she had undergone to remove the tissue from inside her uterus, to explain that the abnormal pregnancy tissue can linger in the body even after treatment, and can return and become like a cancer, requiring months of laboratory monitoring. She was transferred into foster care shortly after discharge from the hospital. When the girl missed one of her lab checks, our social worker learned that she had run away with an older boyfriend. For a brief time, she was sought by the police, and she was eventually found and placed in a locked-down care facility. As far as I know, her rapists have never been locked down, have never been in the hospital undergoing a procedure they didn’t understand, and have never felt the prick of a blood draw every week, then every month.

It seems natural and justified to feel angry for my patients who are in difficult situations borne of violence. When the difficult situation is borne of love, my anger feels less natural and justified, my values more suspect, my role less clear. For example, we cared for a 17-year-old woman who has had multiple major surgeries for a severe congenital reproductive tract malformation. Health-wise, she’s currently doing very well. A member of a religious sect in which marriages are arranged, she is nearing the age of marriage. Her parents and the leader of the sect, all loving people devoted to her happiness, recently had a conference call with the gynecology team. The patient was not on the call, but it was done with her knowledge and permission. The parents and the religious leader requested a formal letter describing in detail the woman’s fertility potential and said that an inability to carry a pregnancy would make my patient potentially un-marriageable. Her fertility potential is meager, and I felt frustrated at the circumstances and at what we were being asked to do. I was lucky to have an amazing attending to talk to about my anger in private. That conversation allowed me to examine my values, find a space where my anger was welcomed-and recognize where it was not-and to grow as a physician.

It can become overwhelming. I’m angry at myths about hymens, and the widespread belief that a pelvic exam or using tampons will break one. At misinformation about what the vulva should look like, so my patients feel uncomfortable about their bodies, unsure who to ask if they are normal. At restrictions on birth control access and insurance coverage, so that my patients can’t all use the medications they need for their painful periods, heavy bleeding, acne, cancer prevention-or yes, for contraception. I am angry about the never-ending stories of sexual abuse and sexual pressure, and the meager number of girls who have access to counseling to help them heal. Add to this a health care system that under-prioritizes the female body. For example, there are operative reports for young girls who have had major urinary and bowel surgeries that don’t mention the vagina and uterus. Girls with menses so heavy they necessitate blood transfusion, yet whose previous providers noted nothing abnormal about their menstrual flow, or maybe didn’t ask. And there are preschoolers treated over and over for yeast infections, even though it’s extremely rare for a yeast infection to occur at that age.

In case you missed it: Why I Chose A MIGS Fellowship

It’s confusing and tragic and it hurts, then it feels unreal, then routine, then almost inevitable (or worse, almost normal). In the #MeToo era, acknowledging anger seems healthy and constructive, but it doesn’t end there. We can move from anger to support to empowerment.  

Our patients show us how to travel this arc, and what it means to support women. This can be most apparent in situations that challenge traditional ideas of womanhood. One of my patients, amenorrheic at age 15, was found to carry an XY genotype. She laughed as she said that when she tried to tell her friends about her karyotype, they thought she was transgender and planning to transition, “and they were so supportive!” (They were still supportive after they learned she was not transitioning). Another patient, a 21-year-old married woman with vaginal cancer, could not have intercourse without bleeding and severe pain. At her request, and with her husband present and participating in the conversation, we discussed other ways they could safely be intimate. The mother of a 2-month-old expected to undergo a bone marrow transplant for a rare genetic disorder met with her gynecologist because the chemotherapy required for the transplant had a high risk of causing her ovaries to stop functioning. This mother was entirely alone, having moved to our city to seek care for her baby, and was staying in the Ronald McDonald house. I marveled at the woman’s strength as she tried to peer into a future that she wasn’t certain would exist for her baby, and how, through it all, she was so appreciative that our medical team was discussing this aspect of her daughter’s health. In addition, she had found a network of supportive parents online that she could talk to openly about fertility, who supported and loved her, and made her feel that she didn’t have to make this decision alone.

In light of how these conversations could have gone for my patients, these stories seem like more than expressions of love: they seem like fighting back.

We work in a job where difficult conversations about sex and fertility occur every day, and serve as guides in a world of conflicting messages where we don’t always know the way ourselves. It’s okay to be angry at how our patients struggle, at the systems around us, at ourselves-make a rant video, write an article, shout it in the streets! Then do what our patients do: fight back with love.

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When an ob/gyn treats young patients exposed to cruelty and confusing messages, it can be tough to overcome anger at the situation.

Stephanie Cizek, MD

Articles

Adnexal torsion requires careful diagnosis, management

Fighting back with love