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Ovarian and fallopian tube torsion

Marc R Laufer, MD
Section Editors
Howard T Sharp, MD
Deborah Levine, MD
Deputy Editor
Sandy J Falk, MD, FACOG


Ovarian torsion refers to the complete or partial rotation of the ovary on its ligamentous supports, often resulting in impedance of its blood supply. It is one of the most common gynecologic emergencies and may affect females of all ages [1]. The fallopian tube often twists along with the ovary; when this occurs, it is referred to as adnexal torsion. Prompt diagnosis is important to preserve ovarian and/or tubal function and to prevent other associated morbidity. However, making the diagnosis can be challenging because the symptoms are relatively nonspecific.

Isolated torsion of the fallopian tube is less common, but may also occur and adversely impact tubal function [2]. Tubal torsion may occur either in the mid-portion of the tube itself or around the ligamentous supports of the tube.

Torsion of paratubal or paraovarian cysts may also occur [3,4].

This topic will focus mainly on ovarian torsion, but isolated fallopian tube torsion and torsion of paratubal or paraovarian cysts will also be reviewed. An overview of the approach to an adnexal mass and to acute pelvic pain is discussed separately. (See "Approach to the patient with an adnexal mass" and "Evaluation of acute pelvic pain in women".)


The ovary is suspended by the infundibulopelvic ligament (also referred to as the suspensory ligament of the ovary), and is not fixed, but may be positioned lateral and/or posterior to the uterus, depending upon the position of the patient. The infundibulopelvic ligament is a fold of the broad ligament that is attached laterally to the pelvic sidewall. The ovarian vessels, which originate in the upper abdomen, travel through the infundibulopelvic ligaments. Other support structures of the ovary include the utero-ovarian ligament, which attaches the ovary to the uterus, and the broad ligament, one area of which is the mesovarium.

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Literature review current through: Nov 2017. | This topic last updated: Jun 01, 2017.
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  1. McWilliams GD, Hill MJ, Dietrich CS 3rd. Gynecologic emergencies. Surg Clin North Am 2008; 88:265.
  2. Schrager J, Robles G, Platz T. Isolated fallopian tube torsion: a rare entity in a premenarcheal female. Am Surg 2012; 78:118.
  3. Muolokwu E, Sanchez J, Bercaw JL, et al. The incidence and surgical management of paratubal cysts in a pediatric and adolescent population. J Pediatr Surg 2011; 46:2161.
  4. Said MR, Bamigboye V. Twisted paraovarian cyst in a young girl. J Obstet Gynaecol 2008; 28:549.
  5. Celik A, Ergün O, Aldemir H, et al. Long-term results of conservative management of adnexal torsion in children. J Pediatr Surg 2005; 40:704.
  6. Germain M, Rarick T, Robins E. Management of intermittent ovarian torsion by laparoscopic oophoropexy. Obstet Gynecol 1996; 88:715.
  7. Buss JG, Lee RA. Sequential torsion of the uterine adnexa. Mayo Clin Proc 1987; 62:623.
  8. Beaunoyer M, Chapdelaine J, Bouchard S, Ouimet A. Asynchronous bilateral ovarian torsion. J Pediatr Surg 2004; 39:746.
  9. Huchon C, Fauconnier A. Adnexal torsion: a literature review. Eur J Obstet Gynecol Reprod Biol 2010; 150:8.
  10. Littman ED, Rydfors J, Milki AA. Exercise-induced ovarian torsion in the cycle following gonadotrophin therapy: case report. Hum Reprod 2003; 18:1641.
  11. Liu YP, Shih SL, Yang FS. Sudden onset of right lower quadrant pain after heavy exercise. Am Fam Physician 2008; 78:379.
  12. Yancey LM. Intermittent torsion of a normal ovary in a child associated with use of a trampoline. J Emerg Med 2012; 42:409.
  13. Kokoska ER, Keller MS, Weber TR. Acute ovarian torsion in children. Am J Surg 2000; 180:462.
  14. Albayram F, Hamper UM. Ovarian and adnexal torsion: spectrum of sonographic findings with pathologic correlation. J Ultrasound Med 2001; 20:1083.
  15. Servaes S, Zurakowski D, Laufer MR, et al. Sonographic findings of ovarian torsion in children. Pediatr Radiol 2007; 37:446.
  16. McGovern PG, Noah R, Koenigsberg R, Little AB. Adnexal torsion and pulmonary embolism: case report and review of the literature. Obstet Gynecol Surv 1999; 54:601.
  17. Shukunami K, Nishijima K, Orisaka M, et al. Acute abdomen in a Jehovah's witness with chronic anemia. Am J Emerg Med 2004; 22:242.
  18. Abolmakarem H, Tharmaratnum S, Thilaganathan B. Fetal anemia as a consequence of hemorrhage into an ovarian cyst. Ultrasound Obstet Gynecol 2001; 17:527.
  19. Chapron C, Capella-Allouc S, Dubuisson JB. Treatment of adnexal torsion using operative laparoscopy. Hum Reprod 1996; 11:998.
  20. Cunnion KM, Dolan MA, Sonnino RE. Case records of the Medical College of Virginia: a 10-year-old girl presenting with an acute onset of abdominal pain. Pediatr Emerg Care 1996; 12:52.
  21. Pryor RA, Wiczyk HP, O'Shea DL. Adnexal infarction after conservative surgical management of torsion of a hyperstimulated ovary. Fertil Steril 1995; 63:1344.
  22. Hibbard LT. Adnexal torsion. Am J Obstet Gynecol 1985; 152:456.
  23. Bouguizane S, Bibi H, Farhat Y, et al. [Adnexal torsion: a report of 135 cases]. J Gynecol Obstet Biol Reprod (Paris) 2003; 32:535.
  24. Varras M, Tsikini A, Polyzos D, et al. Uterine adnexal torsion: pathologic and gray-scale ultrasonographic findings. Clin Exp Obstet Gynecol 2004; 31:34.
  25. Oltmann SC, Fischer A, Barber R, et al. Cannot exclude torsion--a 15-year review. J Pediatr Surg 2009; 44:1212.
  26. Pansky M, Smorgick N, Herman A, et al. Torsion of normal adnexa in postmenarchal women and risk of recurrence. Obstet Gynecol 2007; 109:355.
  27. Houry D, Abbott JT. Ovarian torsion: a fifteen-year review. Ann Emerg Med 2001; 38:156.
  28. White M, Stella J. Ovarian torsion: 10-year perspective. Emerg Med Australas 2005; 17:231.
  29. Kirkham YA, Lacy JA, Kives S, Allen L. Characteristics and management of adnexal masses in a canadian pediatric and adolescent population. J Obstet Gynaecol Can 2011; 33:935.
  30. Chinchure D, Ong CL, Loh AH, Rajadurai VS. Neonatal ovarian cysts: role of sonography in diagnosing torsion. Ann Acad Med Singapore 2011; 40:291.
  31. Sakala EP, Leon ZA, Rouse GA. Management of antenatally diagnosed fetal ovarian cysts. Obstet Gynecol Surv 1991; 46:407.
  32. Heling KS, Chaoui R, Kirchmair F, et al. Fetal ovarian cysts: prenatal diagnosis, management and postnatal outcome. Ultrasound Obstet Gynecol 2002; 20:47.
  33. Tsafrir Z, Hasson J, Levin I, et al. Adnexal torsion: cystectomy and ovarian fixation are equally important in preventing recurrence. Eur J Obstet Gynecol Reprod Biol 2012; 162:203.
  34. Eitan R, Galoyan N, Zuckerman B, et al. The risk of malignancy in post-menopausal women presenting with adnexal torsion. Gynecol Oncol 2007; 106:211.
  35. Lee RA, Welch JS. Torsion of the uterine adnexa. Am J Obstet Gynecol 1967; 97:974.
  36. Cohen A, Solomon N, Almog B, et al. Adnexal Torsion in Postmenopausal Women: Clinical Presentation and Risk of Ovarian Malignancy. J Minim Invasive Gynecol 2017; 24:94.
  37. Ozcan A, Mumusoglu S, Gokcu M, et al. Differentiated therapy in pre- and postmenopausal adnexal torsion based on malignancy rates: A retrospective multicentre study over five years. Int J Surg 2016; 29:95.
  38. Ganer Herman H, Shalev A, Ginath S, et al. Clinical characteristics and the risk for malignancy in postmenopausal women with adnexal torsion. Maturitas 2015; 81:57.
  39. Yousefi Z, Farazestanian M, Mottaghi M, Pourmoghadam N. Ovarian torsion in postmenopausal women and risk of malignancy. J Midwifery Reprod Health 2015; 3:479.
  40. SCHULTZ LR, NEWTON WA Jr, CLATWORTHY HW Jr. Torsion of previously normal tube and ovary in children. N Engl J Med 1963; 268:343.
  41. Anders JF, Powell EC. Urgency of evaluation and outcome of acute ovarian torsion in pediatric patients. Arch Pediatr Adolesc Med 2005; 159:532.
  42. Tsafrir Z, Azem F, Hasson J, et al. Risk factors, symptoms, and treatment of ovarian torsion in children: the twelve-year experience of one center. J Minim Invasive Gynecol 2012; 19:29.
  43. Worthington-Kirsch RL, Raptopoulos V, Cohen IT. Sequential bilateral torsion of normal ovaries in a child. J Ultrasound Med 1986; 5:663.
  44. Davis AJ, Feins NR. Subsequent asynchronous torsion of normal adnexa in children. J Pediatr Surg 1990; 25:687.
  45. Koonings PP, Grimes DA. Adnexal torsion in postmenopausal women. Obstet Gynecol 1989; 73:11.
  46. Johnson TR Jr, Woodruff JD. Surgical emergencies of the uterine adnexae during pregnancy. Int J Gynaecol Obstet 1986; 24:331.
  47. Yen CF, Lin SL, Murk W, et al. Risk analysis of torsion and malignancy for adnexal masses during pregnancy. Fertil Steril 2009; 91:1895.
  48. Bromley B, Benacerraf B. Adnexal masses during pregnancy: accuracy of sonographic diagnosis and outcome. J Ultrasound Med 1997; 16:447.
  49. Schmeler KM, Mayo-Smith WW, Peipert JF, et al. Adnexal masses in pregnancy: surgery compared with observation. Obstet Gynecol 2005; 105:1098.
  50. Gorkemli H, Camus M, Clasen K. Adnexal torsion after gonadotrophin ovulation induction for IVF or ICSI and its conservative treatment. Arch Gynecol Obstet 2002; 267:4.
  51. Shah AA, Likes CE, Price TM. Early polycystic ovary syndrome as a possible etiology of unexplained premenarcheal ovarian torsion. J Pediatr Adolesc Gynecol 2009; 22:265.
  52. Tay J, Parker H, Dhange P, et al. Isolated torsion of the fallopian tube in a patient with polycystic ovarian syndrome (PCOS). Eur J Obstet Gynecol Reprod Biol 2010; 150:218.
  53. Rousseau V, Massicot R, Darwish AA, et al. Emergency management and conservative surgery of ovarian torsion in children: a report of 40 cases. J Pediatr Adolesc Gynecol 2008; 21:201.
  54. Huchon C, Panel P, Kayem G, et al. Does this woman have adnexal torsion? Hum Reprod 2012; 27:2359.
  55. Hamrick HJ, Fordham LA. Ovarian cyst and torsion in a young infant. Arch Pediatr Adolesc Med 1998; 152:1245.
  56. Suita S, Handa N, Nakano H. Antenatally detected ovarian cysts--a therapeutic dilemma. Early Hum Dev 1992; 29:363.
  57. Lee JH, Tang JR, Wu MZ, et al. Ovarian cyst with torsion presenting as a wandering mass in a newborn. Acta Paediatr Taiwan 2003; 44:310.
  58. Schmahmann S, Haller JO. Neonatal ovarian cysts: pathogenesis, diagnosis and management. Pediatr Radiol 1997; 27:101.
  59. Ashwal E, Hiersch L, Krissi H, et al. Characteristics and Management of Ovarian Torsion in Premenarchal Compared With Postmenarchal Patients. Obstet Gynecol 2015; 126:514.
  60. Pinto AB, Ratts VS, Williams DB, et al. Reduction of ovarian torsion 1 week after embryo transfer in a patient with bilateral hyperstimulated ovaries. Fertil Steril 2001; 76:403.
  61. Sasso RA. Intermittent partial adnexal torsion after electrosurgical tubal ligation. J Am Assoc Gynecol Laparosc 1996; 3:427.
  62. Cohen SB, Wattiez A, Stockheim D, et al. The accuracy of serum interleukin-6 and tumour necrosis factor as markers for ovarian torsion. Hum Reprod 2001; 16:2195.
  63. Daponte A, Pournaras S, Hadjichristodoulou C, et al. Novel serum inflammatory markers in patients with adnexal mass who had surgery for ovarian torsion. Fertil Steril 2006; 85:1469.
  64. Anthony EY, Caserta MP, Singh J, Chen MY. Adnexal masses in female pediatric patients. AJR Am J Roentgenol 2012; 198:W426.
  65. Wilkinson C, Sanderson A. Adnexal torsion -- a multimodality imaging review. Clin Radiol 2012; 67:476.
  66. Ben-Ami M, Perlitz Y, Haddad S. The effectiveness of spectral and color Doppler in predicting ovarian torsion. A prospective study. Eur J Obstet Gynecol Reprod Biol 2002; 104:64.
  67. Vijayaraghavan SB. Sonographic whirlpool sign in ovarian torsion. J Ultrasound Med 2004; 23:1643.
  68. Yaman C, Ebner T, Jesacher K. Three-dimensional power Doppler in the diagnosis of ovarian torsion. Ultrasound Obstet Gynecol 2002; 20:513.
  69. Lee EJ, Kwon HC, Joo HJ, et al. Diagnosis of ovarian torsion with color Doppler sonography: depiction of twisted vascular pedicle. J Ultrasound Med 1998; 17:83.
  70. Nizar K, Deutsch M, Filmer S, et al. Doppler studies of the ovarian venous blood flow in the diagnosis of adnexal torsion. J Clin Ultrasound 2009; 37:436.
  71. Bar-On S, Mashiach R, Stockheim D, et al. Emergency laparoscopy for suspected ovarian torsion: are we too hasty to operate? Fertil Steril 2010; 93:2012.
  72. Valsky DV, Esh-Broder E, Cohen SM, et al. Added value of the gray-scale whirlpool sign in the diagnosis of adnexal torsion. Ultrasound Obstet Gynecol 2010; 36:630.
  73. Vijayaraghavan SB, Senthil S. Isolated torsion of the fallopian tube: the sonographic whirlpool sign. J Ultrasound Med 2009; 28:657.
  74. Mashiach R, Melamed N, Gilad N, et al. Sonographic diagnosis of ovarian torsion: accuracy and predictive factors. J Ultrasound Med 2011; 30:1205.
  75. Born C, Wirth S, Stäbler A, Reiser M. Diagnosis of adnexal torsion in the third trimester of pregnancy: a case report. Abdom Imaging 2004; 29:123.
  76. Haque TL, Togashi K, Kobayashi H, et al. Adnexal torsion: MR imaging findings of viable ovary. Eur Radiol 2000; 10:1954.
  77. Kawakami K, Murata K, Kawaguchi N, et al. Hemorrhagic infarction of the diseased ovary: a common MR finding in two cases. Magn Reson Imaging 1993; 11:595.
  78. Schlaff WD, Lund KJ, McAleese KA, Hurst BS. Diagnosing ovarian torsion with computed tomography. A case report. J Reprod Med 1998; 43:827.
  79. Kimura I, Togashi K, Kawakami S, et al. Ovarian torsion: CT and MR imaging appearances. Radiology 1994; 190:337.
  80. Hiller N, Appelbaum L, Simanovsky N, et al. CT features of adnexal torsion. AJR Am J Roentgenol 2007; 189:124.
  81. Argenta PA, Yeagley TJ, Ott G, Sondheimer SJ. Torsion of the uterine adnexa. Pathologic correlations and current management trends. J Reprod Med 2000; 45:831.
  82. Pomeranz AJ, Sabnis S. Misdiagnoses of ovarian masses in children and adolescents. Pediatr Emerg Care 2004; 20:172.
  83. McCloskey K, Grover S, Vuillermin P, Babl FE. Ovarian torsion among girls presenting with abdominal pain: a retrospective cohort study. Emerg Med J 2013; 30:e11.
  84. Reed JL, Strait RT, Kachelmeyer AM, et al. Biomarkers to distinguish surgical etiologies in females with lower quadrant abdominal pain. Acad Emerg Med 2011; 18:686.
  85. Oelsner G, Cohen SB, Soriano D, et al. Minimal surgery for the twisted ischaemic adnexa can preserve ovarian function. Hum Reprod 2003; 18:2599.
  86. Bristow RE, Nugent AC, Zahurak ML, et al. Impact of surgeon specialty on ovarian-conserving surgery in young females with an adnexal mass. J Adolesc Health 2006; 39:411.
  87. Harkins G. Ovarian torsion treated with untwisting: second look 36 hours after untwisting. J Minim Invasive Gynecol 2007; 14:270.
  88. Mashiach S, Bider D, Moran O, et al. Adnexal torsion of hyperstimulated ovaries in pregnancies after gonadotropin therapy. Fertil Steril 1990; 53:76.
  89. Bider D, Mashiach S, Dulitzky M, et al. Clinical, surgical and pathologic findings of adnexal torsion in pregnant and nonpregnant women. Surg Gynecol Obstet 1991; 173:363.
  90. Oelsner G, Bider D, Goldenberg M, et al. Long-term follow-up of the twisted ischemic adnexa managed by detorsion. Fertil Steril 1993; 60:976.
  91. Dolgin SE, Lublin M, Shlasko E. Maximizing ovarian salvage when treating idiopathic adnexal torsion. J Pediatr Surg 2000; 35:624.
  92. Aziz D, Davis V, Allen L, Langer JC. Ovarian torsion in children: is oophorectomy necessary? J Pediatr Surg 2004; 39:750.
  93. Shalev J, Goldenberg M, Oelsner G, et al. Treatment of twisted ischemic adnexa by simple detorsion. N Engl J Med 1989; 321:546.
  94. Wang JH, Wu DH, Jin H, Wu YZ. Predominant etiology of adnexal torsion and ovarian outcome after detorsion in premenarchal girls. Eur J Pediatr Surg 2010; 20:298.
  95. Taskin O, Birincioglu M, Aydin A, et al. The effects of twisted ischaemic adnexa managed by detorsion on ovarian viability and histology: an ischaemia-reperfusion rodent model. Hum Reprod 1998; 13:2823.
  96. Styer AK, Laufer MR. Ovarian bivalving after detorsion. Fertil Steril 2002; 77:1053.
  97. Eckler K, Laufer MR, Perlman SE. Conservative management of bilateral asynchronous adnexal torsion with necrosis in a prepubescent girl. J Pediatr Surg 2000; 35:1248.
  98. McHutchinson LL, Koonings PP, Ballard CA, d'Ablaing G 3rd. Preservation of ovarian tissue in adnexal torsion with fluorescein. Am J Obstet Gynecol 1993; 168:1386.
  99. Jones HW, Jones GS. Novak Textbook of Gynecology, 10th ed, Wolters Kluwer Lippincott Williams & Wilkins, Baltimore 1981. p.471.
  100. Zweizig S, Perron J, Grubb D, Mishell DR Jr. Conservative management of adnexal torsion. Am J Obstet Gynecol 1993; 168:1791.
  101. Mathevet P, Nessah K, Dargent D, Mellier G. Laparoscopic management of adnexal masses in pregnancy: a case series. Eur J Obstet Gynecol Reprod Biol 2003; 108:217.
  102. Djavadian D, Braendle W, Jaenicke F. Laparoscopic oophoropexy for the treatment of recurrent torsion of the adnexa in pregnancy: case report and review. Fertil Steril 2004; 82:933.
  103. Bisharah M, Tulandi T. Laparoscopic surgery in pregnancy. Clin Obstet Gynecol 2003; 46:92.
  104. Upadhyay A, Stanten S, Kazantsev G, et al. Laparoscopic management of a nonobstetric emergency in the third trimester of pregnancy. Surg Endosc 2007; 21:1344.
  105. Crombleholme TM, Craigo SD, Garmel S, D'Alton ME. Fetal ovarian cyst decompression to prevent torsion. J Pediatr Surg 1997; 32:1447.
  106. Alrabeeah A, Galliani CA, Giacomantonio M, et al. Neonatal ovarian torsion: report of three cases and review of the literature. Pediatr Pathol 1988; 8:143.
  107. Bryant AE, Laufer MR. Fetal ovarian cysts: incidence, diagnosis and management. J Reprod Med 2004; 49:329.
  108. Steyaert H, Meynol F, Valla JS. Torsion of the adnexa in children: the value of laparoscopy. Pediatr Surg Int 1998; 13:384.
  109. Crouch NS, Gyampoh B, Cutner AS, Creighton SM. Ovarian torsion: to pex or not to pex? Case report and review of the literature. J Pediatr Adolesc Gynecol 2003; 16:381.
  110. Ozcan C, Celik A, Ozok G, et al. Adnexal torsion in children may have a catastrophic sequel: asynchronous bilateral torsion. J Pediatr Surg 2002; 37:1617.
  111. Grunewald B, Keating J, Brown S. Asynchronous ovarian torsion--the case for prophylactic oophoropexy. Postgrad Med J 1993; 69:318.
  112. Functional ovarian cysts and oral contraceptives. Negative association confirmed surgically. A cooperative study. JAMA 1974; 228:68.
  113. Caillouette JC, Koehler AL. Phasic contraceptive pills and functional ovarian cysts. Am J Obstet Gynecol 1987; 156:1538.
  114. Mishell DR Jr. Noncontraceptive benefits of oral contraceptives. J Reprod Med 1993; 38:1021.
  115. Grimes DA, Godwin AJ, Rubin A, et al. Ovulation and follicular development associated with three low-dose oral contraceptives: a randomized controlled trial. Obstet Gynecol 1994; 83:29.
  116. Holt VL, Cushing-Haugen KL, Daling JR. Oral contraceptives, tubal sterilization, and functional ovarian cyst risk. Obstet Gynecol 2003; 102:252.
  117. Kaleli B, Aktan E, Gezer S, Kirkali G. Reperfusion injury after detorsion of unilateral ovarian torsion in rabbits. Eur J Obstet Gynecol Reprod Biol 2003; 110:99.
  118. Dolgin SE. Acute ovarian torsion in children. Am J Surg 2002; 183:95.
  119. Abeş M, Sarihan H. Oophoropexy in children with ovarian torsion. Eur J Pediatr Surg 2004; 14:168.
  120. Laufer MR, Billett A, Diller L, et al. A new technique for laparoscopic prophylactic oophoropexy prior to craniospinal irradiation in children with medulloblastoma. Adolesc Pediatr Gynecol 1995; 8:77.
  121. Regad, J. Etude anatomo-pathologique de la torsion des trompets uterines. Gynecol Obstet 1933; 27:519.
  122. Comerci G, Colombo FM, Stefanetti M, Grazia G. Isolated fallopian tube torsion: a rare but important event for women of reproductive age. Fertil Steril 2008; 90:1198.e23.
  123. Harmon JC, Binkovitz LA, Binkovitz LE. Isolated fallopian tube torsion: sonographic and CT features. Pediatr Radiol 2008; 38:175.
  124. Krissi H, Shalev J, Bar-Hava I, et al. Fallopian tube torsion: laparoscopic evaluation and treatment of a rare gynecological entity. J Am Board Fam Pract 2001; 14:274.
  125. Kiseli M, Caglar GS, Cengiz SD, et al. Clinical diagnosis and complications of paratubal cysts: review of the literature and report of uncommon presentations. Arch Gynecol Obstet 2012; 285:1563.
  126. Kostov M, Mijović Z, Mihailović D. Giant paraovarian cyst in a child complicated with torsion. Vojnosanit Pregl 2008; 65:843.
  127. Varras M, Akrivis Ch, Polyzos D, et al. A voluminous twisted paraovarian cyst in a 74-year-old patient: case report and review of the literature. Clin Exp Obstet Gynecol 2003; 30:253.