Compare conditions

Put any two — or three — conditions side by side, adult or pediatric, to spot the look-alike differences fast, row by row.

Ovarian Torsion

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In one line

·The ovary twists on its own stalk, kinking its blood vessels and starving itself of oxygen.

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Normal physiology

·Each ovary hangs in the pelvis on a ligament called the utero-ovarian ligament and the infundibulopelvic (IP) ligament (also called the suspensory ligament of the ovary). The IP ligament carries the ovarian artery (which brings oxygen-rich blood from the aorta) and the ovarian vein (which drains old blood back toward the heart). The ovary also sits near the fallopian tube. Normally the ovary is about the size of an almond and weighs roughly 10 grams, so it hangs still and doesn't spin.

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What goes wrong

·Something makes the ovary grow bigger and heavier than normal—most often a cyst (a sac of fluid inside the ovary), a benign tumor, or swelling during pregnancy or fertility treatment. The extra weight tips the balance, and the ovary rotates on its ligament, twisting the blood vessels inside. Veins (which have thin walls and low pressure) collapse first, so blood keeps flowing in through the artery but can't drain out through the vein. The ovary swells with trapped blood. As pressure builds, the artery kinks shut too, and oxygen stops arriving. Without oxygen, ovarian tissue begins to die within hours.

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Hallmark signs

·Sudden, sharp pain on one side of the lower belly
·Pain that comes and goes in waves, then becomes constant
·A lump or mass you can feel in the lower belly or pelvis
·Severe nausea and vomiting
·Fever (in some cases)
·Pain that gets worse with movement or activity
·History of a known ovarian cyst or mass
·Torsion during pregnancy or after fertility treatment

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Red flags · escalate now

·Sudden, severe one-sided lower belly pain in a girl or young woman — do not assume it is a kidney stone, urinary infection, or pelvic infection without imaging the ovaries.
·Pain plus vomiting that does not stop — the ovary may be dying and needs surgery within hours.
·Fever with one-sided belly pain and a known ovarian cyst or mass — the tissue may already be dead (necrotic) and at risk for infection or rupture.

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Workup

·Pelvic ultrasound with color Doppler
·Urine or serum beta-hCG (pregnancy test)
·Complete blood count (CBC) with white blood cell differential
·Urinalysis
·Serum lactate
·CT scan of the abdomen and pelvis with IV contrast (if ultrasound is unclear or the diagnosis is in doubt)

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Treatment

·Emergency gynecology consultation and urgent laparoscopy with detorsion (untwisting the ovary)
·IV crystalloid fluids (normal saline or lactated Ringer's) and anti-nausea medication (ondansetron 4–8 mg IV or metoclopramide 10 mg IV)
·IV opioid pain medication (morphine 2–4 mg IV or hydromorphone 0.5–1 mg IV, repeated as needed)
·Cystectomy (removing the cyst) or drainage of the mass that caused the ovary to twist, performed during the same surgery
·Oophoropexy (stitching the ovary to the pelvic sidewall) if the surgeon thinks torsion will happen again
·Oophorectomy (surgical removal of the ovary) if the ovary is black, dead (necrotic), and unsalvageable

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NCLEX trap

·A cyst can make the ovary bigger and heavier, which makes it easier to twist. If pain comes on suddenly and is sharp and severe, ovarian torsion is the real danger — the cyst did not cause the pain, the twist did. The ovary is rotating on its stalk (the bundle of blood vessels and ligaments that holds it in place), and that rotation cuts off the blood supply. You need imaging (pelvic ultrasound with Doppler) right now, not watchful waiting.
·Ovarian torsion does not cause fever in the early hours. Fever only shows up late, after the ovary has been starved of blood long enough that tissue starts to die and infection sets in. In the first few hours, your clues are sudden, severe one-sided pelvic pain plus nausea and vomiting — often the patient vomits at the exact moment the pain hits. If you wait for fever or a high white count, you have already lost the chance to save the ovary.
·Ovarian torsion can happen on the right or the left ovary. Always ask about a history of ovarian cysts, pregnancy (which can make cysts grow), and whether the pain came on all at once with instant nausea. Appendicitis pain typically starts vague and around the belly button, then moves to the right lower belly over hours. Ovarian torsion pain is sharp, starts suddenly on one side (right or left lower pelvis), and stays in that spot from the very beginning.
·Nausea in ovarian torsion is a symptom of the twist — the ovary and its stalk are packed with nerves, and when they twist the body reacts with intense nausea and vomiting. The real problem is starved blood flow (ischemia) (the ovary is not getting blood). Only emergency surgery to untwist the ovary will restore blood flow. Treating the nausea alone and waiting means the ovary will die within hours.
·Even an ovary that looks dark or purple from lack of blood can recover if you untwist it quickly — especially in children and young women. The goal of surgery is to untwist the ovary and secure it with a stitch (called oophoropexy) so it cannot twist again. You only remove the ovary if it is truly dead: black, cold, and does not bleed when you nick it. Saving the ovary preserves fertility and hormone production.
·Pregnancy actually increases the risk of ovarian torsion because the hormone hCG (human chorionic gonadotropin, made by the placenta) can stimulate the ovaries to form a corpus luteum cyst, which makes the ovary heavier and more likely to twist. Sudden, sharp, one-sided pelvic pain in pregnancy is ovarian torsion until proven otherwise — not round ligament pain or normal cramping. Get a pelvic ultrasound with Doppler immediately.

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