Ovarian torsion is caused by twisting of the ligaments that support the adnexa, cutting off blood flow to the organ. Urgent surgical intervention is required. Ovarian torsion is a process that occurs when the ovary twists above the ligaments that support it in the adnexa. The fallopian tube is often twisted with the ovary, in these cases it is called adnexal torsion. The ovary is supported by multiple structures in the pelvis. One ligament from which it is suspended is the infundibulopelvic ligament (suspensory ligament of the ovary). It connects the ovary to the side wall of the pelvis. This ligament also contains the major ovarian vessels. The ovary is also connected to the uterus by the utero-ovarian ligament. The ovary has a dual blood supply from the ovarian arteries and the uterine arteries. Twisting of these ligaments can lead to venous congestion, edema, compression of arteries and eventually loss of blood supply to the ovary. This can cause a constellation of symptoms, including severe pain when the blood supply is compromised. The condition can lead to necrosis, ovarian loss and infertility if not identified early. The main risk factor for ovarian torsion is an ovarian mass with a diameter of 5 cm or more. The mass increases the risk of the ovary rotating around the axis of the two ligaments that hold it in a suspended state. This twist prevents venous outflow and ultimately arterial inflow. In a study of torsions confirmed by surgery, 46% were associated with neoplasm (malignant growths) and 48% were associated with cysts. Of these masses, 89% were benign and 80% of patients were under the age of 50. Therefore, women of reproductive age are at the greatest risk of torsion. Torsion can also occur in childhood. Pregnancy, as well as patients undergoing infertility treatment, are at high risk of torsion due to enlarged ovarian follicles. Torsion occurs in women of all age groups, but is most common in women of childbearing age. Only 20% of patients with ovarian torsion are premenstrual and 50% of them have normal ovaries. The majority of women of reproductive age with torsion had a benign ovarian mass. Pregnancy is also an independent risk factor for torsion. Symptoms of ovarian torsion may include: Nausea; Severe pelvic pain; Vomiting; Fever; Abnormal bleeding. Diagnosing a torsion can be challenging because the symptoms are similar to those of other conditions, including: Kidney stones; Appendicitis; Urinary tract infection; Gastroenteritis. The treatment for ovarian torsion is surgical detorsion. In women of reproductive age, an attempt should be made to save the ovary and determine its viability. Most often, the approach to surgery should be laparoscopic and involves direct visualization of a twisted ovary. Assessment of viability is primarily through visualization. the dark onean enlarged ovary with hemorrhagic lesions may have compromised blood flow. After detorsion, the ovaries are found to be functional in more than 90% of patients who have undergone detorsion. This is assessed by the appearance of the adnexa on ultrasound, including ovarian follicular development. Therefore, adnexa-sparing surgery is the treatment of choice. Rarely, if the ovary appears necrotic and gelatinous beyond possible salvage, the surgeon may choose to perform a salpingo-oophorectomy. The surgeon may also perform a cystectomy if a benign cyst is present. If the cyst appears malignant or if the woman is postmenopausal, salpingo-oophorectomy is the treatment of choice. References: 1. Mahonski S, Hu KM. Female Nonobstetric Genitourinary Emergencies. Emerg Med Clin North Am. 2019 Nov;37(4):771-784. [ PubMed ] 2. Varras M, Tsikini A, Polyzos D, Samara Ch, Hadjopoulos G, Akrivis Ch. Uterine adnexal torsion: pathologic and gray-scale ultrasonographic