Ovarian Torsion in Normal Ovaries—Diagnostic Challenges and Management

Ovarian torsion is a gynecological emergency caused by rotation of the ovary on its supporting ligaments, leading to compromised blood flow and potential ovarian necrosis if not promptly treated. It is most commonly associated with ovarian enlargement due to cysts or masses, which predispose the ovary to torsion. Although torsion can occur in normal ovaries—particularly in premenarchal girls with elongated infundibulopelvic ligaments—its occurrence in reproductive-aged women is uncommon and sparsely reported in the literature.

This report presents two cases of ovarian torsion involving normal ovaries, highlighting the diagnostic challenges and emphasizing the importance of early surgical intervention.

The first case involved a 19-year-old woman who presented with acute right iliac fossa pain. Pelvic ultrasound demonstrated a normal-sized ovary with preserved Doppler blood flow. Despite reassuring imaging findings, persistent severe pain prompted diagnostic laparoscopy, which revealed a 1.5-turn torsion at the utero-ovarian ligament. Successful detorsion was performed, and the ovary was preserved. The patient had an uneventful postoperative recovery, with follow-up ultrasonography confirming normal ovarian morphology.

The second case involved a 40-year-old woman with a history of hysterectomy, who presented with acute left iliac fossa pain. Ultrasound revealed an enlarged, heterogeneous left ovary measuring 5 × 3.2 × 4.2 cm, with reduced Doppler flow and associated complex free pelvic fluid, raising suspicion for torsion. Emergency laparoscopy confirmed a two-turn torsion of the infundibulopelvic ligament. Despite attempted detorsion, the ovary was nonviable, necessitating left oophorectomy.

These cases demonstrate that ultrasonography and Doppler flow studies may be unreliable in excluding ovarian torsion, particularly in normal ovaries. Diagnostic laparoscopy remains the gold standard for both confirmation and management. Clinicians should maintain a high index of suspicion for ovarian torsion in reproductive-aged women presenting with acute abdominal pain, even in the absence of ovarian masses or definitive imaging findings. Early surgical intervention is crucial to prevent irreversible ovarian damage and to optimize fertility preservation.