Clinical predictors of ovarian torsion in female patients presenting to the emergency department: A Systematic Review
DOI:
https://doi.org/10.65759/e6ccdw65Keywords:
Ovarian torsion, Adnexal torsion, emergency department, acute pelvic pain, clinical predictionAbstract
Background: Ovarian torsion is a gynecologic emergency in which nonspecific symptoms and imperfect imaging complicate early recognition in emergency care. In this study we aimed to analyze original articles on clinical, laboratory, and ultrasound predictors associated with surgically confirmed ovarian or adnexal torsion in females presenting with acute symptoms. Methods: A PRISMA-aligned systematic review framework was constructed for PubMed, Scopus, Web of Science Core Collection, and the Cochrane Library from inception through August 2026. Eligible studies evaluated preoperative predictors of ovarian or adnexal torsion in females assessed in emergency settings and used operative findings as the reference standard. Prediction-model and diagnostic-factor studies were analyzed qualitatively because predictor definitions, thresholds, age groups, and modeling strategies were heterogeneous. Results: Eighteen original studies were included. Recurrent predictors include unilateral or localized pain, nausea or vomiting, shorter symptom duration, leukocytosis or elevated neutrophil-to-lymphocyte ratio, ovarian enlargement or increased ovarian volume ratio, ovarian stromal edema, free pelvic fluid, abnormal ovarian position, and the whirlpool sign. Multivariable and composite models performed better than isolated symptoms, laboratory values, or Doppler findings. Pediatric models integrating age, inflammatory indices, and sonographic morphology reported discrimination in internal validation. Conclusions: Ovarian torsion prediction is strongest when history, examination, inflammatory markers, and ultrasound morphology are integrated.
References
1. Huchon C, Fauconnier A. Adnexal torsion: a literature review. Eur J Obstet Gynecol Reprod Biol. 2010;150(1):8-12. doi:10.1016/j.ejogrb.2010.02.006.
2. Sasaki KJ, Miller CE. Adnexal torsion: review of the literature. J Minim Invasive Gynecol. 2014;21(2):196-202. doi:10.1016/j.jmig.2013.09.010.
3. Rey-Bellet Gasser C, Gehri M, Joseph JM, Pauchard JY. Is It Ovarian Torsion? A Systematic Literature Review and Evaluation of Prediction Signs. Pediatr Emerg Care. 2016;32(4):256-261. doi:10.1097/PEC.0000000000000621.
4. American College of Obstetricians and Gynecologists. Adnexal Torsion in Adolescents: ACOG Committee Opinion No. 783. Obstet Gynecol. 2019;134(2):e56-e63. doi:10.1097/AOG.0000000000003373.
5. Wattar B, Rimmer M, Rogozinska E, et al. Accuracy of imaging modalities for adnexal torsion: a systematic review and meta-analysis. BJOG. 2021;128(1):37-44. doi:10.1111/1471-0528.16371.
6. Bridwell RE, Koyfman A, Long B. High risk and low prevalence diseases: Ovarian torsion. Am J Emerg Med. 2022;56:145-150. doi:10.1016/j.ajem.2022.03.046.
7. Scheier E. Diagnosis and Management of Pediatric Ovarian Torsion in the Emergency Department: Current Insights. Open Access Emerg Med. 2022;14:283-291. doi:10.2147/OAEM.S342725.
8. Huchon C, Staraci S, Fauconnier A. Adnexal torsion: a predictive score for pre-operative diagnosis. Hum Reprod. 2010;25(9):2276-2280. doi:10.1093/humrep/deq173.
9. King A, Keswani S, Biesiada J, Breech L, Crombleholme T, Huppert J. The utility of a composite index for the evaluation of ovarian torsion. Eur J Pediatr Surg. 2014;24(2):136-140. doi:10.1055/s-0033-1343084.
10. Schwartz BI, Huppert JS, Chen C, Huang B, Reed JL. Creation of a Composite Score to Predict Adnexal Torsion in Children and Adolescents. J Pediatr Adolesc Gynecol. 2018;31(2):132-137. doi:10.1016/j.jpag.2017.08.007.
11. Melcer Y, Maymon R, Pekar-Zlotin M, Vaknin Z, Pansky M, Smorgick N. Does she have adnexal torsion? Prediction of adnexal torsion in reproductive age women. Arch Gynecol Obstet. 2018;297(3):685-690. doi:10.1007/s00404-017-4628-x.
12. Melcer Y, Maymon R, Pekar-Zlotin M, Pansky M, Smorgick N. Clinical and sonographic predictors of adnexal torsion in pediatric and adolescent patients. J Pediatr Surg. 2018;53(7):1396-1398. doi:10.1016/j.jpedsurg.2017.07.011.
13. Budhram G, Elia T, Dan J, Schroeder M, Safain G, Schlech W, et al. A Case-Control Study of Sonographic Maximum Ovarian Diameter as a Predictor of Ovarian Torsion in Emergency Department Females With Pelvic Pain. Acad Emerg Med. 2019;26(2):152-159. doi:10.1111/acem.13523.
14. Otjen JP, Stanescu AL, Alessio AM, Parisi MT. Ovarian torsion: developing a machine-learned algorithm for diagnosis. Pediatr Radiol. 2020;50(5):706-714. doi:10.1007/s00247-019-04601-3.
15. Hartman SJ, Prieto JM, Naheedy JH, Ignacio RC, Bickler SW, Kling KM, et al. Ovarian volume ratio is a reliable predictor of ovarian torsion in girls without an adnexal mass. J Pediatr Surg. 2021;56(1):180-182. doi:10.1016/j.jpedsurg.2020.09.031.
16. Umasankar N, Howard SM, Tomlin KV. Adnexal Torsion Predictive Tool Maintains Applicability in a Heterogeneous Pediatric Population. J Pediatr Adolesc Gynecol. 2021;34(5):656-661. doi:10.1016/j.jpag.2021.05.002.
17. Meyer R, Meller N, Mohr-Sasson A, Toussia-Cohen S, Komem DA, Mashiach R, Levin G. A clinical prediction model for adnexal torsion in pediatric and adolescent population. J Pediatr Surg. 2022;57(3):497-501. doi:10.1016/j.jpedsurg.2021.03.052.
18. Meller N, Meyer R, Cohen A, Abu-Bandora E, Komem DA, Toussia-Cohen S, et al. A validated predictive model for adnexal torsion pre-operative diagnosis. Arch Gynecol Obstet. 2022;305(4):1069-1077. doi:10.1007/s00404-021-06388-x.
19. Ghimire A, Ghimire S, Shrestha A, Pant SR, Subedi N, Pant PR. Preoperative Neutrophil Lymphocyte Ratio in Prediction of Adnexal Mass Torsion. Obstet Gynecol Int. 2023;2023:3585189. doi:10.1155/2023/3585189.
20. Atia O, Hazan E, Rotem R, Armon S, Yagel S, Grisaru-Granovsky S, et al. A Scoring System Developed by a Machine Learning Algorithm to Better Predict Adnexal Torsion. J Minim Invasive Gynecol. 2023;30(6):486-493. doi:10.1016/j.jmig.2023.02.008.
21. Chen S, Gao Z, Qian Y, Chen Q. Key clinical predictors in the diagnosis of ovarian torsion in children. J Pediatr (Rio J). 2024;100(4):399-405. doi:10.1016/j.jped.2024.01.006.
22. Delgado-Miguel C, Arredondo-Montero J, Moreno-Alfonso JC, San Basilio M, Peña Pérez R, Carrera N, et al. The Role of Neutrophyl-to-Lymphocyte Ratio as a Predictor of Ovarian Torsion in Children: Results of a Multicentric Study. Life (Basel). 2024;14(7):889. doi:10.3390/life14070889.
23. Aiob A, Shushan Marom SB, Gumin D, Lowenstein L, Sharon A. Identifying reliable predictors of ovarian torsion in acute gynecological presentations: A retrospective case-control study. Eur J Obstet Gynecol Reprod Biol. 2025;313:114627. doi:10.1016/j.ejogrb.2025.114627.
24. Boztas AE, Sencan E, Payza AD, Sencan A. An Innovative Machine Learning-Based Algorithm for Diagnosing Pediatric Ovarian Torsion. J Pediatr Surg. 2025;60(9):162417. doi:10.1016/j.jpedsurg.2025.162417.
25. Meng J, Bai G, Xiong J, Tang Y, Liu M, Cai J, et al. Development and validation of a predictive nomogram for pediatric ovarian torsion: a retrospective cohort study. Transl Pediatr. 2026;15(5):186. doi:10.21037/tp-2026-1-0131.
26. Khanzadeh S, Tahernia H, Hernandez J, Sarcone C, Lucke-Wold B, Salimi A, Tabatabaei F. Predictive Role of Neutrophil to Lymphocyte Ratio in Adnexal Torsion: A Systematic Review and Meta-Analysis. Mediators Inflamm. 2022;2022:9680591. doi:10.1155/2022/9680591.
27. Adu-Bredu TK, Arkorful J, Appiah-Denkyira K, Wiafe YA. Diagnostic value of the sonographic whirlpool sign in the diagnosis of ovarian torsion: A systematic review and meta-analysis. J Clin Ultrasound. 2021;49(7):746-753. doi:10.1002/jcu.23021.
28. Mashiach R, Melamed N, Gilad N, Ben-Shitrit G, Meizner I. Sonographic diagnosis of ovarian torsion: accuracy and predictive factors. J Ultrasound Med. 2011;30(9):1205-1210. doi:10.7863/jum.2011.30.9.1205.
29. Shadinger LL, Andreotti RF, Kurian RL. Preoperative sonographic and clinical characteristics as predictors of ovarian torsion. J Ultrasound Med. 2008;27(1):7-13. doi:10.7863/jum.2008.27.1.7.
