A 14-year-old girl presents to ED with sudden-onset, severe right lower abdominal pain that started six hours ago. She has vomited twice and describes the pain as intermittent but worsening. On examination, she is tachycardic but afebrile, with tenderness in the right iliac fossa and mild guarding. Urinalysis is negative for infection, and a pregnancy test is negative. With ovarian torsion high on your differential, you escalate urgently to gynaecology and arrange an ultrasound to assess ovarian blood flow.
We are always taught to consider testicular torsion in any young male with abdominal pain. How often do you see posters reminding you to think about ovarian torsion in a female with abdominal pain? Missing both diagnoses are never events, but ovarian torsion is not discussed nearly as often and is arguably more challenging to diagnose.
You might think it will be obvious when the patient walks in. The classic picture of a patient with ovarian torsion is an acute history coupled with abnormal observations, severe distress and signs of peritonism with emesis. Unfortunately, paediatric patients do not always present classicly. While you dip a urine to rule out UTI, DKA and pregnancy, take bloods, speak to the general surgical registrar to rule out appendicitis and scramble to get an ultrasound before the close of play, the clock is ticking on the lifespan of that ovary…
Adolescents can present a diagnostic challenge, particularly when it comes to conditions that overlap between paediatrics and adult medicine. Teenage girls, in particular, sit in that grey zone—technically classified as “women of childbearing age” but often still viewed through a paediatric lens. This article explores a tricky diagnosis, highlighting key considerations when assessing adolescent patients.
Adolescents aren’t always the most forthcoming with their history, even when you take a structured HEEEAADSSS approach. Engaging them requires carefully navigating human factors—balancing rapport, trust, and time pressures. Beyond the clinical picture, there are crucial considerations to keep in mind: safeguarding, risk-taking behaviours, confidentiality, and consent. These elements are always in play, adding layers of complexity to the assessment of this unique patient group.
We don’t encounter gynaecological presentations every day in the paediatric emergency department. Many chronic gynaecological conditions follow the primary care referral pathway, meaning we may not feel as confident when faced with acute presentations.
With that in mind, let’s refresh our understanding of ovarian torsion—a time-sensitive diagnosis that we need to keep on our radar. We’ll revisit what ovarian torsion is, how to recognise it, which investigations can support our diagnosis, and what definitive management looks like.
Anatomy and Pathophysiology
The ovaries sit deep within the pelvis, positioned on either side of the uterus and close to the fallopian tubes. They are supported by two key ligaments:
- The suspensory ligament anchors the ovary to the pelvic wall and houses essential blood vessels.
- The ovarian ligament connects the ovary directly to the uterus.
Understanding this anatomy is crucial when considering ovarian torsion, as it helps explain why and how torsion occurs and the potential consequences for ovarian perfusion.
The ovary benefits from a dual blood supply, receiving oxygenated blood from:
- The ovarian artery arises directly from the abdominal aorta.
- The uterine artery is a branch of the internal iliac artery, which anastomoses with the ovarian artery to provide additional perfusion.
However, when the suspensory ligament twists, this vascular supply becomes compromised. The twisting of the ovarian pedicle can initially obstruct venous and lymphatic drainage, leading to ovarian congestion, oedema, and eventually ischaemia if arterial flow is also impaired. This is the underlying mechanism of ovarian torsion, a time-critical gynaecological emergency that requires prompt recognition and intervention.
Understanding the associated anatomy and pathology is key when considering ovarian torsion, as it is often linked to underlying adnexal abnormalities. The most commonly associated pathologies include:
- Benign cystic teratomas (dermoid cysts)
- Follicular cysts
- Cystadenomas
However, not all cases of torsion involve an ovarian mass. In fact, up to 25% of children with ovarian torsion have no identifiable pathology. In these cases, factors such as increased intra-abdominal pressure or anatomical variations (e.g., increased tubal mobility or a longer infundibulopelvic ligament) may contribute to the torsion.
Post-pubertal cases, on the other hand, are more likely to be associated with an underlying ovarian mass, which increases the risk of torsion by altering the weight and balance of the ovary within the pelvis. This highlights the importance of considering both anatomical and pathological factors when evaluating a patient with suspected torsion.
Presentation
Ovarian torsion is an important but often overlooked cause of abdominal pain in children and adolescents. It accounts for approximately 2.7% of all paediatric abdominal pain cases and ranks as the fifth most common gynaecological emergency.
The condition tends to occur at two distinct peaks:
- The neonatal period
- Adolescence, with a mean age of 14.5 years
Recognising torsion in these age groups is crucial, as delays in diagnosis can lead to ovarian necrosis and loss of function. Given its rarity and overlap with more common causes of abdominal pain, it requires a high index of suspicion in young female patients presenting with acute, unilateral pelvic or lower abdominal pain.
Ovarian torsion has a broad spectrum of presentations, ranging from dramatic to deceptively subtle.
Some patients will present with acute, severe lower abdominal pain, often with nausea, vomiting, or even signs of bowel obstruction. Others may have a more insidious onset, with grumbling pelvic pain, mild tachycardia, or vague lower abdominal discomfort—the kind of patient who sits quietly in the waiting room, compensating well. Constipation and dysuria can also be atypical presenting features, adding to the diagnostic challenge.
It’s also worth considering the human factors at play. Parental anxiety may amplify concerns, while an adolescent’s reluctance to disclose symptoms can make the history more difficult to interpret.
The bottom line? If you’ve thought about ovarian torsion in a young female with lower abdominal pain, you’re already ahead. It’s a step closer to making the diagnosis and ensuring that investigations are directed appropriately—because early recognition is key to preserving ovarian function.
Investigations
Ovarian torsion is primarily a clinical diagnosis. If your suspicion is high, don’t delay—start the appropriate referrals and escalate early while arranging investigations in parallel. The challenge lies in its nonspecific presentation, meaning blood tests and imaging are often used to support, rather than confirm, the diagnosis.
Can Blood Tests Help?
No single blood test reliably predicts torsion. However, certain findings may raise concern:
- Elevated CRP and leukocytosis can occur due to ovarian ischaemia and the physiological stress response.
- A high neutrophil-to-lymphocyte ratio (NLR) has been suggested as a potential marker, but its role remains uncertain.
That said, normal bloods do not exclude torsion, so don’t be falsely reassured by unremarkable inflammatory markers. The key takeaway? If torsion is on your differential, keep it on your radar and escalate accordingly.
Ultrasound: The First-Line Imaging for Ovarian Torsion
Transabdominal ultrasound is the imaging modality of choice for suspected ovarian torsion. It has a higher sensitivity than CT, avoids radiation exposure, and provides key sonographic clues to support the diagnosis.
Key Ultrasound Findings in Ovarian Torsion:
- “Whirlpool sign” – twisted vascular pedicle of the adnexa
- Medially displaced ovary – due to the twisting motion
- Ovarian enlargement – secondary to venous and lymphatic congestion
- Oedema and the “follicular ring sign” – peripheral displacement of follicles with surrounding hyperechoic oedema
- Increased echogenicity – a sign of stromal congestion
What About Doppler Flow?
Absent Doppler flow is significantly associated with torsion, but its presence does not rule it out. The degree of vascular compromise depends on how the ovary twists:
- Initially, venous and lymphatic outflow are compromised before arterial supply is affected.
- In early or intermittent torsion, Doppler flow may still be present, meaning normal flow does not exclude torsion.
Bottom Line: Clinical Suspicion Drives Diagnosis
While ultrasound can strongly suggest torsion, only laparoscopy can definitively confirm it. If torsion is a concern, early involvement of the gynaecology team is essential to facilitate urgent decision-making. Delays can lead to ovarian necrosis and loss of function—so trust your clinical judgement and escalate appropriately.
The Role of MRI in Ovarian Torsion
MRI, particularly T2-weighted sequences, can provide valuable information on ovarian viability, with the potential to predict necrosis. In a small retrospective study, an MRI scoring system was proposed, based on hypointense signals in key anatomical sites, which reflect reduced blood flow. These included:
- The ovarian stroma
- Areas around the follicle
- The cyst wall
- The twisted pedicle
A hypointensity score of 2 or more had the highest diagnostic accuracy for predicting ovarian necrosis.
However, the logistics of MRI in an acute setting present a major limitation. Access to MRI, particularly out of hours, can be challenging in a busy hospital environment, making it less practical for emergency diagnosis. Despite this, MRI could play a role in triaging cases and assessing the extent of ovarian necrosis, providing additional information while avoiding radiation exposure in females of reproductive age.
While ultrasound remains the first-line imaging modality, MRI may be a useful adjunct in cases where the diagnosis is uncertain or when there is concern about ovarian viability.
While MRI may provide detailed tissue characterisation, CT remains the more readily available imaging modality in an emergency setting. A small retrospective study reviewing CT scans of 31 patients with ovarian torsion suggested that the degree of torsion may influence the likelihood of necrosis, with torsion angles of less than 360 degrees being less likely to result in irreversible damage.
However, the exact timeframe for ovarian necrosis remains unclear. Various factors—including imaging findings, torsion angle, and patient demographics (such as older reproductive age)—have been suggested to influence the degree of ischaemic injury, but no single predictor is definitive.
Ovarian Ischaemia
Ovarian ischaemia in torsion is influenced by multiple factors, and there is no absolute predictor of necrosis. This underscores the importance of:
- Early recognition and prompt escalation
- Rational use of available imaging modalities based on local resources and clinical urgency
- Close communication with radiology and surgical teams
- A low threshold for intervention, especially when the clinical suspicion is high
Ultimately, time is ovarian function—early gynaecology involvement and timely surgical decision-making remain the cornerstone of management.
Emergency Department (ED) Management of Suspected Ovarian Torsion
1. Prioritising Patient Stability and Referral
- Early referral to the surgical team is essential – this is a time-critical diagnosis, and delays can lead to ovarian necrosis.
- Consider appropriate bay allocation – is the patient stable enough for a standard cubicle, or do they need closer monitoring in a bay near the nursing station or resus?
2. Initial Resuscitation and Investigations
- Insert two large-bore cannulae
- Take pre-operative bloods, including:
- Venous or arterial blood gas (for lactate and metabolic status)
- Full blood count (FBC)
- Renal function and electrolytes (U&Es)
- Liver function tests (LFTs)
- Amylase (to exclude pancreatitis)
- C-reactive protein (CRP) (to assess for inflammation)
- Clotting profile
- Group and save (in case of surgical intervention)
- Beta-HCG (to exclude pregnancy-related causes)
- Obtain a urine sample for urinalysis and pregnancy testing
- Consider STI screening (chlamydia and gonorrhoea swabs) if pelvic inflammatory disease is a differential
3. Fluid and Symptom Management
- Start intravenous fluids (IVF) as appropriate
- If the patient is vomiting or dehydrated, consider a fluid bolus (especially if lactate is raised).
- Administer intravenous anti-emetics
4. Pain Management
- Follow the WHO pain ladder, escalating as needed for the patient’s age and clinical status.
- Never underestimate the power of IV paracetamol – it is an effective first-line analgesic and should be given early.
- Consider opioids if the pain is severe, particularly if the patient is distressed or struggling to tolerate oral medications.
Surgical Management of Ovarian Torsion
In paediatric and adolescent patients, fertility preservation is a key priority when managing ovarian torsion. Surgical options include:
- Laparoscopic oophorectomy – removal of the ovary, typically reserved for cases where the ovary is non-viable or associated with significant pathology.
- Detorsion (ovarian salvage surgery) – untwisting the ovary and preserving the ovarian tissue, which is now the preferred approach in most cases where feasible.
In recent years, surgical management has significantly changed. Detorsion is now the first-line procedure for most paediatric and adolescent cases. This shift is based on growing evidence that even an ischaemic-appearing ovary can recover function post-detorsion, particularly in younger patients.
What Influences the Surgical Decision?
- Degree of ischaemia observed during surgical exploration
- Presence of an associated mass or significant adnexal pathology
- Risk of malignancy (although rare in children, it remains a consideration)
Detorsion is the preferred option, given the potential for ovarian function recovery. Early recognition and escalation are critical to ensuring that young patients have the best chance at ovarian salvage and preserved reproductive potential.
Pelvic ultrasound reveals a significantly enlarged right ovary with peripheral follicular displacement and a “whirlpool sign”, raising strong suspicion for ovarian torsion. The gynaecology team takes her to theatre for urgent laparoscopy, where a torsed but viable ovary is successfully detorsed. Post-operatively, she recovers well, and a follow-up scan confirms ongoing ovarian perfusion, preserving her future fertility.
Conclusion
Whilst ovarian torsion is a rare presentation in the paediatric population, confident and timely diagnosis is critical to avoid the catastrophic consequences on the future fertility of that young person.
In the future, scoring systems could be developed to predict paediatric ovarian torsion by combining clinical, laboratory, and radiographic findings to support the diagnosis.
Is there a potential role for POCUS to detect free fluid in the pelvis, facilitate an urgent gynaecological referral, or add more weight to your ultrasound request?
Much remains to be developed in the field of paediatric gynaecological emergencies and often the diagnosis is tricky.
References
Gibson E & Mandy H (2023) “Anatomy: Abdomen & Pelvis, Ovary”, In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK545187/
Sanfilippo J.S, Mansuria S.M, Donnellan N.M (2015) “Surgical problems in the paediatric patient”, Clinical Gynaecology, 2nd edition, p578-579.
Rousseau V, Massicot R, Darwish AA, Sauvat F, Emond S, Thibaud E, Nihoul-Fekete C (2008) “Emergency management and conservative surgery of ovarian torsion in children: a report of 40 cases”, 21(4):201-6, PMID: 18656074.
Renganathan, R., Subramaniam, P., Deebika, S. et al. Scoring system for predicting ovarian necrosis in adnexal torsion using an ultra-short optimized MRI protocol. Abdom Radiol 48, 2122–2130 (2023). https://doi.org/10.1007/s00261-023-03886-1
Aziz D, Davis V, Allen L, Langer JC (2004) “Ovarian torsion in children: is oophorectomy necessary?” J Pediatr Surg, 39(5):750-3, PMID: 15137012.
Moro F, Bolomini G, Sibal M, Vijayaraghavan S.B, Venkatesh P, Pasciuto T, Mascilini F, Pozzati F, Leone F.P.G, Josefsson H, Epstein E, Guerriero S, Scambia G, Valentin L, Testa A.C (2020) “Imaging in gynecological disease (20): clinical and ultrasound characteristics of adnexal torsion” Ultrasound in Obstetrics & Gynecology, 56 (6): p934-943.