Adnexal Torsion

• Think torsion in any female with sudden onset unilateral lower abdominal/pelvic pain, especially with nausea and vomiting.
• Pregnancy, known ovarian cysts or assisted reproduction increase risk.
• Early diagnosis and theatre access preserve ovarian function and fertility.

1. Assess ABC and vitals; treat pain and nausea early. Establish IV access and monitoring.
2. Do a pregnancy test (urine or serum β-hCG) in all reproductive-age patients.
3. Take focused history (onset, character, radiation, associated vomiting, prior cysts/surgery, fertility treatment).
4. Perform abdominal and pelvic examination (if appropriate and safe); assess for guarding, adnexal tenderness or mass.
5. Order baseline tests: FBC, CRP, U&E, group & save / crossmatch as per local protocol.
6. Arrange pelvic ultrasound with Doppler if rapidly available, but do not delay gynae review if suspicion is high.
7. Make the call: if clinical suspicion of torsion → urgent gynae consult for diagnostic laparoscopy.
8. Keep patient NBM, provide IV fluids, analgesia, antiemetics, and prepare for theatre.

Always consider and rapidly exclude other causes of acute pelvic or lower abdominal pain:

• Ectopic pregnancy (tubal rupture, haemoperitoneum).
• Ruptured or haemorrhagic ovarian cyst.
• Pelvic inflammatory disease / tubo-ovarian abscess.
• Appendicitis (especially right lower quadrant pain).
• Renal colic (loin to groin pain, haematuria).
• Degenerating fibroid.
• Urinary tract infection, bowel obstruction or colitis.

• Pregnancy test: mandatory in all reproductive-age females with pelvic pain.
• FBC, CRP/ESR, U&E, LFTs as indicated; group & save or crossmatch if surgery likely.
• Urinalysis to assess for UTI or haematuria.
• STI swabs if pelvic infection suspected.

Ultrasound (Preferred Modality)

• Transvaginal US (where appropriate) or transabdominal in younger or pregnant patients.
• Findings suggestive of torsion:
  • Unilateral enlarged ovary (>4 cm) with peripheral follicles (“string of pearls”).
  • Ovarian or adnexal mass/cyst.
  • Free pelvic fluid.
  • Twisted vascular pedicle (“whirlpool sign”) if visible.
  • Reduced or absent venous/arterial flow on Doppler – but arterial flow may be preserved early.

CT or MRI may be used if the diagnosis is uncertain or US is unavailable, but they must not delay surgical review in clinically suspicious cases.

Initial ED Measures

• ABC assessment, oxygen if indicated, continuous monitoring for unstable patients.
• IV access with appropriate cannula size; send bloods and group & save / crossmatch.
• Keep patient NBM in anticipation of surgery.
• Analgesia: paracetamol, NSAIDs (if not contraindicated), opioids for severe pain as required.
• Antiemetics for nausea/vomiting.
• IV fluids if dehydrated or vomiting.

Definitive Management

• Urgent gynae consultation – this is a surgical emergency requiring prompt laparoscopy or laparotomy.
• Diagnostic laparoscopy allows:
  • Detorsion and ovarian salvage (even if ovary appears dusky or cyanotic – often recovers).
  • Cystectomy or fixation (oophoropexy) where appropriate.
  • Oophorectomy only if ovary clearly non-viable or malignancy suspected.
• Avoid multiple pelvic examinations, which add little and increase discomfort.

Adolescents & Children

• High index of suspicion with acute lower abdominal pain and vomiting.
• History may be limited – rely heavily on examination and US.
• Ovarian preservation is a priority for future fertility and endocrine function.

Pregnancy

• Torsion is more common in early pregnancy – corpus luteum cysts and enlarged ovaries are risk factors.
• US is safe in pregnancy; avoid delay in surgical management.
• Most procedures can be performed laparoscopically with appropriate obstetric input.

Post-menopausal Women

• Ovarian torsion less common but more likely associated with a neoplasm.
• Higher suspicion for malignancy; management decisions often involve definitive surgery (oophorectomy) rather than simple detorsion.

• Any patient with suspected adnexal torsion should be admitted for surgical management – discharge is inappropriate if torsion is on the differential and not ruled out.
• Document:
  • Onset and characteristics of pain.
  • Risk factors and examination findings.
  • US findings (and limitations) if done.
  • Time of gynae consultation and agreed plan.

Patient Counselling (When Stable)

• Explain that torsion threatens blood supply to the ovary and may require urgent surgery.
• Reassure that surgery aims to preserve fertility where possible, but sometimes removal of the ovary is necessary.
• Discuss recurrence risk and the need to seek care urgently in future if similar symptoms recur.

Teamwork: good communication between ED, gynae, anaesthetics and theatre teams is key to minimising delay and preserving ovarian function.