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Ovarian torsion
ARTICLE in SEMINARS IN PEDIATRIC SURGERY MAY 2005
Impact Factor: 2.22 DOI: 10.1053/j.sempedsurg.2005.01.003

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Darrell Cass
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Seminars in Pediatric Surgery (2005) 14, 86-92

Ovarian torsion
Darrell L. Cass, MD
From the Michael E. DeBakey Department of Surgery, and Department of Pediatrics, Baylor College of Medicine,
Houston, Texas.
INDEX WORDS
Adnexal torsion;
Children;
Management;
Detorsion;
Oophorectomy

Ovarian torsion is a rare problem in the pediatric age group that must be included in the differential
diagnosis of any girl with abdominal pain or a pelvic or abdominal mass. Clinical presentation is
nonspecific, and diagnosis is based on a high index of suspicion. Ultrasound scan remains the most
useful investigation, but blood flow on Doppler examination does not exclude ovarian torsion. Current
recommendations of treatment strongly support ovary conservation, and macroscopic appearance of the
ovary is not a reliable indicator of the degree of necrosis and potential for ovary recovery. For children
with ovarian torsion, laparoscopic detorsion should be performed with strong consideration of oophoropexy. An underlying ovary lesion such as mature teratoma or functional cyst is found in most cases;
however, the risk of cancer in these patients is extremely low. If there is concern of a mass or underlying
pathology, then follow-up ultrasound, resolution of edema and interval laparoscopic treatment may be
required.
2005 Elsevier Inc. All rights reserved.

Ovarian torsion is rare in the pediatric age group. Of all

cases of ovarian torsion that occur, nearly three-fourths
present during the reproductive years from 20 to 40 years of
age, and few occur in postmenopausal women. Overall,
about 15% of cases occur during infancy and childhood,1
though this percentage is likely higher if the adolescent and
teenage years are included. The actual incidence of ovarian
torsion in children is unknown. However, in 1996 fewer
than 300 cases were found in the worlds literature.2 Moreover, large series from pediatric centers report a case-experience of between 0.3 and 3.5 patients per year.1,3-9 At
Texas Childrens Hospital there are about 7 ovary resections
per year (0.2% of the overall pediatric general surgery case
load), of which 1/3 involve ovarian torsion.8
The purpose of this manuscript is to provide a review of
the pathophysiology, clinical presentation, diagnosis and
management of children with ovarian torsion. Although this

Address reprint requests and correspondence: Darrell L. Cass, MD,

Texas Childrens Hospital Clinical Care Center, Suite 650, 6621 Fannin
St., CC650.00, Houston, TX 77030.
E-mail address: dcass@bcm.edu.

1055-8586/$ -see front matter 2005 Elsevier Inc. All rights reserved.
doi:10.1053/j.sempedsurg.2005.01.003

is a rare diagnosis, it is one that must be considered for all

girls that present with lower abdominal pain or a pelvic
mass. Furthermore, it is a condition for which the treatment
approach has changed significantly. Whereas in the past
most girls with ovarian torsion had resection of the involved
adnexa, currently most should have ovary conservation. It is
my hope that the reader will agree that nearly all children
with ovarian torsion should have detorsion of the involved
ovary and consideration of oophoropexy despite the appearance of the twisted adnexa.

Pathophysiology
As in adults, most children with ovarian torsion have pathology in the involved ovary or tube that likely causes the
abnormal twisting.10-12 In adult series, a causative finding
for adnexal torsion is found in 64% to 82% of cases.10-14 In
large pediatric series, the incidence of underlying ovarian
pathology ranges from 51% to 84%.3,4,8,9 The most frequent
pathologic findings in children with adnexal torsion are
benign cystic teratomas, or hemorrhagic or follicular cysts;

Cass

Ovarian Torsion

Figure 1 Histogram shows the age range at presentation and the

presence of a nonneoplastic cyst or mature teratoma in 49 children
with ovarian torsion.

however, paratubal cysts, cystadenoma, and hydrosalpinx

are also found. Beaunoyer and colleagues from Ste-Justine
Hospital in Montreal have provided the largest single-institution series of children with ovarian torsion.3 They reported 76 children with 80 episodes of confirmed torsion
over a 23-year period from 1980 to 2002. The mean age of
the girls was 10 years, with a range of 3 months to 18 years.
In this series, 51.2% of girls had underlying ovarian abnormalities, which included simple ovarian cyst in 23.7%,
teratoma in 19.7%, cystadenoma in 7.9%, and hydrosalpinx
in 2.6%. In that institution, as in most, no cases of ovarian
torsion have been associated with malignancy. In our institution, of 49 children that had resection for ovarian torsion
in the last 19 years, 54% of excised ovaries showed underlying pathology (Figure 1).15 Mature teratomas were found
in 27%, functional cysts in 27%, and no malignant tumors
were found.
Malignancy may be associated with ovarian torsion in
1.1% to 2% of adult patients.10-13,16-18 However, the incidence of malignancy in children with ovarian torsion is even
lower. With extensive review of the literature, I have been
able to find only two children with torsion of a cancerous
ovary, and in both instances the diagnosis was suspected
preoperatively and the lesion was dysgerminoma. The first
child is not well described except that the beta human
chorionic gonadotropin level (-HCG) was found to be
elevated preoperatively and the disease was confined to the
ovary.4 The second child is a 5-year-old girl who presented
with a painful, huge abdominal mass and markedly elevated tumor markers.19 Intraoperatively, torsion was discovered incidentally.
Why benign ovarian tumors cause torsion more commonly than malignant tumors is unknown. In one study
involving all age groups, it was found that the rate of torsion
for a malignant tumor was 1.1 cases per 100 patients,

87
whereas the rate for a borderline tumor was 9.7, and a
benign tumor was 14.3.18 Indeed, 3% to 16% of patients
with mature teratoma of the ovary present with torsion, and
in one series 21% had torsion.20,21 In our experience, 15 of
34 (44%) children who had resection for ovarian torsion had
a mature teratoma in the involved ovary.8 Whether malignant tumors have a lower rate of torsion because they have
more tendency toward local invasion and inflammation, and
thus adherence to surrounding structures, remains speculative.18
Torsion is also a common complication of ovarian cysts
(Figure 2).4 Functional ovarian cysts in children usually
develop as a result of perturbed hormonal stimulation. This
usually occurs during two peak periods: the fetal period and
first year of life, and around the time of menarche. Ovarian
cyst formation in the latter period is associated with changes
in gonadotropin release, and during the initiation of menstruation up to 20% of girls may have multicystic and
enlarged ovaries.22 These functional (follicular and corpus
luteal) cysts enlarge during the menstrual cycle, but usually
resolve within several months. Most data suggest that the
risk of torsion correlates with the size of an ovarian cyst,
and the risk is higher for cysts greater than 4 to 5 cm in
size.23-27 Some authors have suggested that the risk of
torsion correlates better with hypermobility of the adnexa,
and the length and laxity of the ovarian suspensory ligaments.24,28 However, this prognostic factor is not helpful in
deciding the role for surgery in these patients, since it is a
finding that can only be made intraoperatively. The treatment of a fetus, neonate or child with an ovarian cyst has not
been clearly defined (discussed by Drs. Brandt and
Helmrath in this edition of the Journal). It is clear that
operation is indicated for those children with symptoms
related to the ovarian pathology, or those that have a persistent lesion that does not resolve on follow-up ultrasound.

Figure 2 Intraoperative photograph of a patient with ovarian

torsion. The adnexa has twisted 720. The ovary is black and
necrotic in appearance, and there is an underlying follicular cyst.
(Color version of figure is available online.)

88
It is possible that laparoscopic or image-guided aspiration,
or laparoscopic fenestration or cystectomy may help to
minimize the risk of torsion in girls with large cysts or
persistent cysts. Recently, Bagolan has shown that for cysts
5 cm prenatal aspiration is safe and increases the rate of
spontaneous resolution, and thus may decrease the risk of
torsion.24 However, in this study no data were presented to
demonstrate long-term function of the involved ovary. The
role of aspiration and treatment of a fetus, infant or child
with an ovarian cyst merits further study with a prospective
randomized design.
Adnexal torsion may occur in girls and women with no
underlying adnexal pathology. There are several theories
that have been proposed to explain this process: (1) excess
mobility of the adnexa due to an abnormally long fallopian
tube, mesosalpinx, or mesoovarium; (2) adnexal venous
congestion due to constipation, sigmoid distention, pregnancy, or premenarchal hormonal activity; and (3) jarring
movement of the body in the presence of a small infantile
uterus and a relatively large ovary.29,30 Adnexal torsion is
more common on the right side than on the left, with a ratio
of about 3:2.30,31 The increased risk of right-sided torsion
may be explained by the increased amount of space on the
right side compared with the sigmoid-filled left pelvis, hypermobility of the cecum and ileum on the right, and the
increased likelihood that a patient with right lower quadrant
pain will have more thorough investigation due to concerns
about appendicitis.32
Spontaneous adnexal torsion may occur prenatally or in
the neonatal period. In many instances this may be due to an
underlying follicular cyst or tumor, but in some instances
the underlying adnexa may have no apparent lesion. When
this process occurs it may be asymptomatic and lead to
congenital absence or spontaneous disappearance of the
adnexa. In addition, autoamputation may occur in which
there is a free floating, often partially calcified cystic mass
in the abdomen and a missing ovary on one side.24,33
Asynchronous bilateral ovarian torsion has been described, and occurs even in children with no underlying
adnexa pathology.3,34-40 It is likely that these patients have
underlying anatomic variations that put them at increased
risk of ovarian torsion. Oophoropexy should be strongly
considered in patients with adnexal torsion and no underlying pathologic abnormality, particularly in those that
present with left-sided torsion as the first event.3

Clinical presentation and diagnosis

The diagnosis of adnexal torsion is often difficult, and in
some reports ovary torsion was diagnosed preoperatively in
only 37% to 50% of cases.6,9,10 Children may present with
ovarian torsion at any age, but it is most common in the
perimenarchal and early teenage years (Figure 1).3,4,8 In
children with torsion there are often significant delays between the onset of symptoms and hospital presentation, and

Seminars in Pediatric Surgery, Vol 14, No 2, May 2005

from hospital presentation to operative intervention.3,4,11
The most likely explanation for these difficulties is the
nonspecific nature of the symptoms and signs associated
with this diagnosis. The differential diagnosis of abdominal
pain in children with ovarian torsion includes appendicitis,
kidney stone, incarcerated hernia, mesenteric adenitis, pelvic inflammatory disease, gastroenteritis and ectopic pregnancy. The rare nature of this condition, the difficulty in
obtaining an accurate history, and the higher, intraabdominal location of the tubes and ovaries in young children
contribute to the challenges of making an accurate diagnosis
of ovarian torsion in pediatric patients.
The most common symptoms of children with ovarian
torsion are pain, nausea and vomiting. Although nearly all
children with ovarian torsion have pain, not all have the
classic history of sudden onset pain, followed by colicky
persistent pain. In fact, some report radiation of the pain to
the flank, groin or back, a characteristic more typical of
patients with renal colic or pancreatitis. Interestingly, when
a careful history is taken most girls report a history of
similar pain, suggesting the possibility of intermittent ovarian torsion.5,6,40 This finding was highlighted by Way more
than 50 years ago.41
There are some features in clinical presentation that may be
helpful in distinguishing ovarian torsion from other diagnostic
possibilities. In children with ovarian torsion, nausea and vomiting usually are coincident with the onset of pain, whereas
with appendicitis these symptoms usually follow the pain onset
by several hours. Furthermore, children with a ruptured ovarian cyst generally have less severe symptoms, and nausea and
vomiting are less frequent. In contrast, girls with an ectopic
pregnancy generally have more severe pain and have an elevated -HCG level. Pelvic inflammatory disease is usually
associated with more gradual onset of symptoms, and patients
with a kidney stone generally have costovertebral angle pain
and tenderness.4 In our series of patients with ovarian torsion,
acute abdominal pain and vomiting were found in 74% and
65%, respectively.8
Tenderness, the palpation of a mass, and fever are the
most common signs found in children with ovarian torsion.
Whereas fever is common in girls with appendicitis, it is
less common with ovarian torsion, and may be associated
with more advanced cases and a higher risk of tissue necrosis.42
Ovarian torsion may present in an incarcerated inguinal
hernia. Merriman reviewed 71 cases of irreducible herniae
in girls and found that in 82% the hernias contained ovaries,
and 11 had torsion.43 In this group the median age was 8
weeks, and only 7 girls were over 1 year of age. Of these 11
girls with ovarian torsion, 5 had salpingo-oophorectomy
because the ovary appeared necrotic and 6 had ovary preservation. Furthermore, in a review of a large series of
children undergoing inguinal hernia repair, Boley found that
27% of girls with incarcerated hernia had ovarian torsion
and infarcted ovaries.44 In this series, 2 girls with a known
mass in the hernia sac appeared to develop torsion while

Cass

Ovarian Torsion

awaiting repair. For female infants with an inguinal hernia

and a mass, repair should be timely to minimize the small
risk of torsion, strangulation and ovary loss. For those
infants with erythema and tenderness, repair should be urgent to minimize the extent of ovary infarction.43,44
Laboratory tests that may be useful in the evaluation of
a girl with abdominal pain and possible ovarian torsion
include urinalysis, urine pregnancy test, and complete blood
count. If an ovarian mass is detected or there is sonographic
evidence for an ovarian tumor, then serologic tumor markers including alpha fetoprotein (FP), and HCG should be
sent.
With regard to imaging, occasionally plain x-rays can be
helpful. For patients with vomiting, plain films may help to
diagnose bowel obstruction. For girls with ovarian torsion,
a mass effect may be seen, and calcifications may suggest a
mature teratoma.3,45
Abdominopelvic ultrasound scan remains the most useful investigation, especially with the use of Doppler to
improve the diagnostic accuracy. The most common sonographic findings in girls with ovarian torsion are an enlarged
ovary, or an echogenic mass with nonvisualization of the
ipsilateral ovary.3,4 Fluid in the cul-de-sac is a late finding
and usually associated with hemorrhagic ovarian tissue. The
finding of a unilaterally enlarged ovary containing dilated,
peripherally located cysts is a pattern that occurs in up to
66% of patients with ovarian torsion.46-48 It is important to
note that the presence of vascular flow does not exclude
torsion, though it has accounted for delays in treatment in
some reports.40,45,49 Doppler US scan is operator dependent,
and it may be difficult to differentiate background noise
from true flow.50,51 Absent blood flow with Doppler suggests arterial occlusion; however, this finding is not common. Pena found only 4 of 10 patients with surgically
proven ovarian torsion had decreased or absent flow on
preoperative US.45 Similarly, Stark found absent flow in
only 5 of 15 patients.48 It is likely that venous obstruction
and thrombosis resulting from torsion leads to congestion,
edema and symptoms before arterial thrombosis and ovarian
necrosis occurs. Alternatively, it is possible that some arterial flow is preserved due to a dual ovarian arterial blood
supply, or there is intermittent torsion and the ovary is not
twisted at the time of the study.52
In situations in which an ultrasound is not available, CT
scan may be useful to find an ovarian mass, and to help
exclude other causes of lower abdominal pain. However,
ultrasound is preferred to image the ovaries, and does not
expose the child to radiation.

Management
The optimal management of ovarian torsion has evolved in
the last 10 years. Whereas early diagnosis and prompt surgical evaluation remain key to optimizing long-term ovary
function, there has been a trend toward increased use of

89
laparoscopy, and significant evidence to support detorsion
and ovary conservation, regardless of the appearance of the
ovary at operation.2,3,5,9,53-59
Classic treatment of adnexal torsion for all age groups
has been resection of an ischemic appearing ovary and/or
fallopian tube. Support for this approach has been: (1) the
concern of malignancy associated with torsed ovaries, (2)
the theoretical risk of thromboembolism from untwisting
torsed ovarian veins, and (3) the belief that a grossly blue
black and hemorrhagic adnexa is irreversibly damaged. Indeed, in older pediatric and adult series and in some current
series, the ovary salvage rate is 0% to 16%.3,4,6,7,10
Way provided one of the earliest descriptions of ovary
detorsion.41 In his paper, he clearly described 2 patients
(among others) that were treated with detorsion of extremely ischemic adnexa. In both, there was evidence of
ovary recovery at salpinography or subsequent direct examination at laparotomy. He states, even unfavourable-looking tumors may be amenable to conservative surgery. In
the last 17 years there has been increasing support for this
hypothesis. In 1987, Vancaillie described a 19-year-old
woman who had detorsion despite a dark blue and markedly
congested appearing gonad.60 The patient also had partial
cystectomy and then oophoropexy by plication of the ovarian ligament. At second look laparoscopy the ovary was
smaller than the contralateral side, but subsequent ultrasound examinations showed normal follicle development.
In 1989, Shalev and colleagues from Chaim Sheba Medical
Center and the Sackler School of Medicine in Tel Aviv
reported 19 patients between 2.5 and 35 years of age that
had detorsion of torsed ovaries despite a purplish black
and nonviable appearance.61 Surprisingly, 15 of 16 patients showed normal ovaries with follicle formation on
follow-up ultrasound examinations. In this series there were
no ovarian neoplasms and no immediate or long-term complications. In 1999, Cohen, from this same institution, reviewed 58 consecutive patients (mean age of 25 years;
including 3 premenarchal girls) that underwent laparoscopic
detorsion of necrotic or ischemic appearing adnexa characterized by marked edema and a black bluish color.62
Twenty-nine patients had cyst aspiration, 9 had cystectomy,
and 1 had associated oophoropexy, but no patient had oophorectomy. Sonographic evidence of ovarian function was
shown in 39 of 42 patients at 6 weeks, and in 54 of 58
patients (93%) by 3 months. Importantly, cystectomy was
attempted in 3 of the 4 patients that had no evidence of
ovarian function at long-term follow-up. Since then, multiple investigators from multiple other institutions have found
similar results.14,63-67 Recently, Oelsner updated the experience at Sheba Medical Center and reviewed the worlds
literature.68 Of 172 patients that had detorsion of torsed
adnexa, 160 (93%) showed evidence of subsequent ovarian
function either by ultrasound, or in some cases with interval
surgical examination. Similar results are accumulating in
children with ovarian torsion.2,5,9,40,54,55,57

90
The intraoperative use of fluorescein may improve ovary
conservation rates as well. McHutchison and colleagues
treated 11 women with adnexal torsion, the youngest of
which was 15 years of age.64 At operation, fluorescein was
administered as a test dose of 1 mL, followed by a bolus of
4 mL, and the ovary was inspected under ultraviolet light.
Nonfluorescent tissue was considered nonviable and removed. In this group, 4 ovaries were untwisted and preserved, 4 had wedge excision of nonfluorescent areas, and 3
were removed resulting in a conservation rate of 72%.
In light of the increased evidence in support of detorsion,
there has been reevaluation of the initial theoretical concerns. Thus far there has been no report of a torsed cancer
that has been treated with detorsion. In addition, there have
been no cases of thromboembolism from a pelvic vein in
these patients. McGovern examined the risk of thromboembolism in patients with adnexal torsion and found 2 proven
cases of pulmonary embolism since 1900, for an incidence
of 0.2%. Interestingly, both cases occurred among 672 patients treated with adnexal resection, and no cases were
found among 309 patients treated with detorsion.
It has become clear that the macroscopic appearance of
the ovary at operation does not correlate well with subsequent ovary recovery and function. Kruger reviewed 31
patients with adnexal torsion, of which 9 were less than 18
years of age.42 Twenty-eight of 31 patients had adnexal
resection, and 3 had detorsion with cystectomy. When the
histology of the specimens was reviewed, 19 patients had
50% tissue necrosis, but 12 patients had no evidence of
necrosis in resected specimens. In this study the presence of
fever preoperatively was associated with an increased risk
of necrosis. In addition, there was a trend toward necrosis
with longer symptom duration. Recently, we have reviewed
the pathology findings of all children who underwent adnexal resection for ovary torsion in the last 20 years.15 In all
cases, the ovary was removed because of a necrotic appearance at the time of surgery. Histologic sections from each
specimen were re-evaluated and a viability index was
assessed based on the percentage of viable tissue (1 0%,
2 1-25%, 3 26-75%, 4 75%). Not surprisingly,
61% showed viable ovarian tissue, and 47% had a viability
index of 3 or 4. Similarly, of ovaries described as black
intraoperatively, 38% showed viable ovarian tissue, and
21% showed an index of 4. Of interest, when the patients
were divided into 2 groups based on the presence or absence
of viable ovarian tissue microscopically, we could find no
differences with regard to the presence of fever, admission
white blood cell count, or the time of symptom onset to
surgical resection.
The ability of ischemic ovarian tissues to recover has
been examined experimentally. Taskin reported a rat model
of ovarian torsion in which adnexa were either twisted three
times and fixed to the pelvic sidewall, or rendered ischemic
by clamps on the ovary vessels.69 Tissues were then examined at different time points following 4- to 36-hour ischemia times. At sacrifice all ischemic adnexa were black

Seminars in Pediatric Surgery, Vol 14, No 2, May 2005

bluish in appearance. However, microscopically greater
than 70% viability was found in all ovaries with up to
24-hour ischemia times. Similarly, when these ischemic
adnexa were untwisted or unclamped and examined 1 week
later, those that had 4- to 24-hour ischemia times appeared
normal, whereas those with 36-hour ischemia appeared
necrotic.
The exact risk of recurrent ipsilateral ovarian torsion or
asynchronous contralateral ovarian torsion is not known,
but it appears to range between 2% and 5%.3,29,68 Likely we
will gain more information about the risk of recurrent ipsilateral ovarian torsion as adnexal salvage rates continue to
increase. In the recent report from Oelsner in which 102
adults had detorsion, 4.9% developed retorsion of ipsilateral
adnexa within the follow-up period (median 4.5 years). Of
76 children with ovarian torsion treated over a 23-year
period at Ste. Justine Hospital, 4 (5%) developed asynchronous bilateral ovarian torsion, and the interval between
episodes ranged from 7 to 30 months.3 For those children
with torsion and no underlying ovarian pathology, the risk
of asynchronous torsion was 11.4%. At our institution, in
those patients who had resections for ovarian torsion, 1 of
49 had asynchronous bilateral torsion (2%).15 There are
multiple other case reports of bilateral asynchronous torsion
in children, many of which had adnexa with no underlying
pathology.29,34-37,39,40,56,70-72
The role of oophoropexy in the treatment of children with
ovarian torsion is not clear. In the past many authors have been
reluctant to recommend oophoropexy in the treatment of these
patients.4 However, an increasing number of authors are now
recommending this approach.3,7,9,34-39,54,56,57,70 These recommendations tend to follow encounters in which children have
been treated for asynchronous bilateral torsion. There are concerns that oophoropexy may damage the ovary or distort the
relationship between ovary follicles and the fallopian tube,
potentially decreasing fertility. Issues about timing of oophoropexy arise and whether it may be worth any risks from a
second anesthetic or operation. On the contrary, there is no
evidence that oophoropexy decreases fertility. In addition,
there are cases in which an ovarian follicle has been thought to
pass through a contralateral fallopian tube to achieve pregnancy. For these reasons, I agree with many practicing pediatric surgeons that oophoropexy is justified in some patients
with ovarian torsion. Whether it is accomplished at the primary
operation for torsion or as a second operation may depend on:
whether there is a contralateral ovary, whether the primary
torsion was of a normal or diseased ovary, whether a second
operation may be required, and perhaps on a surgeons skill
with laparoscopy. Certainly, if one ovary has been removed,
every effort should be made to preserve the contralateral gonad.
There are several techniques that have been described to
achieve oophoropexy. In patients with a long utero-ovarian
ligament, plication or shortening of the ligament may be performed. In this technique a permanent suture is placed
through the utero-ovarian ligament at the ovarian insertion,

Cass

Ovarian Torsion

through the mid-portion of the ligament in the opposite direction, and then back through the ligament at its uterine origin.35
Other methods include: fixation of the ovary to the pelvic
sidewall,37,73 plication of the utero-ovarian ligament to the
round ligament,74 plication of the utero-ovarian ligament,36,71
and fixation of the ovary to the uterine serosa.30 In cases of
massive edema of the ovary, wedge resection has been recommended.75 Laparoscopic techniques are described.36 It is possible that different techniques should be used in different patients based on the size and relationship of the ovary to the
uterus, fallopian tube and pelvic sidewall. Preservation of the
proximity of the ovary to the fimbriae of the tube should be
considered. The impact of oophoropexy on subsequent fertility
merits further study.
A high index of suspicion is critical to the evaluation and
management of children with ovarian torsion. Lower abdominal pain, nausea and vomiting, a history of previous episodes
of similar pain, low grade fever and tenderness should increase
concern and prompt sonographic evaluation. If the ultrasound
shows abnormalities, such as an enlarged ovary or an enlarged
ovary with reduced blood flow, then serologic tumor markers
(FP, HCG) should be sent to complete the workup. When
there is concern about torsion, these results will not be available preoperatively; however, they may be useful later depending on the operative findings. Patients should then proceed
promptly to operation, and in most cases a laparoscopic procedure is preferred. In all cases the ovary should be detorsed.
If there is no significant edema or ischemia and an underlying
lesion is found, then cystectomy, tumorectomy, or cyst aspiration may be considered. In all cases, even those with very
large teratomata, there is a rim of normal ovary at the hilum
that can be preserved. In patients with no underlying ovarian
pathology or those with abnormally long ovarian ligaments,
oophoropexy should be considered for both the involved and
contralateral ovary. However, if there is significant edema and
hemorrhage within the gonad, then further procedures should
be avoided to minimize the risk of damage to the ovary. If there
is any suspicion of malignancy based on ultrasound or operative findings (theoretically possible, though not reported), if
there is concern about the correct approach, or if the involved
gland is significantly inflamed or ischemic, then there should
be no hesitancy to detorse the ovary alone. The patient should
have tumor markers reviewed and follow-up ultrasound examinations. If the tumor markers are elevated, then the patient
requires reoperation with a cancer approach (described by Dr.
van Allman in this edition of the Journal). If the tumor markers
are normal and a lesion persists on follow-up ultrasound, then
interval laparoscopy and tumorectomy or cystectomy, and possible oophoropexy should be performed after the edema has
resolved in 6 to 8 weeks.

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