Posted: 26/07/2022
Ovarian torsion, also known as adnexal torsion, is a condition that arises when an ovary - a small female reproductive organ located on either side of the pelvis - or fallopian tube - the long ducts that connect each ovary to the uterus - become twisted, resulting in a blockage of blood flow to the ovary.
While it is relatively uncommon, it is serious and must be treated quickly to prevent permanent damage to the ovary, which can result in a loss of fertility and an increased risk of infection. For the best chance of salvaging the ovary, it is generally thought that the time from torsion to surgery should be less than 36 hours.
Ovarian torsion arises when the ovary is unstable. This can occur for a variety of reasons, but established risk factors include:
Because ovarian torsion can have permanent consequences if not treated quick enough, it is considered a surgical emergency. It is therefore important to know the signs and symptoms.
The most common symptoms are:
It is important to note that not all of these symptoms will occur in every case of ovarian torsion. Equally, you may notice the similarity of some of the symptoms of ovarian torsion to those associated with other conditions, such as appendicitis and gastroenteritis. Unfortunately, these factors together make missed and delayed diagnosis of the condition relatively common.
Diagnosing the condition without surgery is very difficult. While ultrasounds, CT scans and blood tests can be used to gather information that may point towards an enlarged ovary, which is a consequence of ovarian torsion, they are not conclusive. Therefore, where ovarian torsion is suspected, it is vital that the person concerned is taken for surgery as soon as possible, to definitively confirm or rule out the diagnosis and, if confirmed, for treatment.
If ovarian torsion is detected, there are two treatment options available; both require surgery. Which treatment option is taken will depend on two factors: (i) whether the patient wishes to retain their fertility; and (ii) the extent of any dead (necrotic) ovarian tissue which has arisen due to loss of blood flow.
The most common and preferred option is to detort the ovary or fallopian tube. This preserves normal ovarian function and fertility, but risks the retention of necrotic ovarian tissue. However, even in the presence of severe necrotic ovarian tissue, the ovary is able to recover following detorsion, which makes this option the preferred method of treatment.
The second option is to remove the ovary - known as an oophorectomy - and sometimes part of the fallopian tube as well - known as a salpingo-oophorectomy. This may affect the patient’s fertility but will ensure all necrotic ovarian tissue is removed. This option is preferred by clinicians where the patient is not concerned with preserving their fertility, as retained necrotic ovarian tissue can become infected, which could result in worrying complications, such as an abscess or peritonitis.
Interestingly, the female reproductive system is able to cope with only one ovary and two fallopian tubes, or with one ovary and one fallopian tube, so long as the remaining ovary and fallopian tube are patent (not injured). The fallopian tube on the side of the missing ovary is actually able to pick up an egg from the opposite ovary allowing for normal fertility in most cases. However, studies have shown that removal of one ovary is likely to bring forward the date of menopause.
Unfortunately, in cases where there is damage to the corresponding ovary, such as cysts, or to the fallopian tube, such as hydrosalpingitis, fertility will be affected by removal of the torted ovary and/or fallopian tube.
Sadly, ovarian torsion clinical negligence claims are something we see relatively regularly at Penningtons Manches Cooper. These often arise from delays in diagnosis of torsion following admission to A&E. Further, medical professionals do not always appreciate the emergency nature of such a presentation once torsion has been confirmed. The longer the torsion is left the greater the likelihood that removal will be necessitated.
We often see cases where surgeons have removed the torted ovary and/or the fallopian tube even in the absence of necrotic tissue. As discussed above, this can have devastating consequences for women, particularly those who do not have children or have not completed their families when the corresponding ovary/fallopian tube are damaged.
We recently acted for a client X, who was aged 39 at the time of her ovarian torsion. X suffered a sudden onset of pain in the right lower side of her stomach, was physically sick, and consequently attended her local A&E. She described being doubled over in pain and unable to walk. X was admitted to hospital with concern over possible appendicitis - a common misdiagnosis with ovarian torsion. She remained an inpatient for three days until an ultrasound scan was undertaken and a diagnosis of ovarian torsion made. Our client was discharged from hospital to have an outpatient MRI scan. She was forced to seek a private medical opinion and, ultimately, surgery. Sadly, her right ovary had become necrotic and died, and was unable to be saved. She underwent a salpingo-oophorectomy, two months after attending A&E.
It was alleged that there was a failure to diagnose and treat within the 36-hour window which would have saved the ovary and fallopian tube.
The hospital trust denied liability in full. However, after protracted discussions and disclosure of our expert evidence, settlement was reached.
We also recently acted for another client Y, who was 31 at the time of her ovarian torsion. She attended A&E due to stabbing right sided abdominal pain. A diagnosis of renal/ureteric colic was made, and she was referred to urology. The following day a CT scan was performed, which showed a large cystic mass on her right ovary. The following day Y was referred to a gynaecologist and an ultrasound scan was performed which confirmed ovarian torsion but, importantly, showed good blood flow to the ovary. Four days after admission to hospital, Y underwent a salingo-oophorectomy despite the ovary being patent.
It was alleged that there was a delay in diagnosis and a delay in performing surgery. Further, we alleged that there was no need to remove the ovary and fallopian tube given there was no evidence of necrosis.
Again, there was reluctance on behalf of those representing the hospital trust to make any admissions of wrongdoing. This led again to protracted discussions and disclosure of our expert evidence, before settlement was finally reached on a commercial basis.
Emily Reville, senior associate in the clinical negligence team, who represented both clients, commented: “There appears to be a reluctance on behalf of NHS trusts to recognise the signs and symptoms of ovarian torsion and to appreciate the need for urgent treatment. Women, particularly those like X and Y, who are young and do not have children, are being failed in these circumstances, resulting in the loss of both ovaries and fallopian tubes unnecessarily. Both women were fortunate to maintain their fertility. Other women are less fortunate where there are pre-existing problems with the remaining ovary and/or fallopian tube.
“It is very disappointing that those representing the NHS trusts in claims like these appear to be reluctant to address the failures in care and make admissions of liability, despite an eventual willingness to agree a settlement.”
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