Ovarian Torsion: How long is too long?
Date First Published:
May 11, 2026
Last Updated:
May 11, 2026
Report by:
Dr. Mackenzie Senior, Emergency Medicine Resident (Queens University Department of Emergency Medicine)
Search checked by:
Dr. Shreyas Shah, Emergency Medicine Resident
Three-Part Question:
In [patients with ovarian torsion presenting to the emergency department] what [time to surgical intervention] is associated with [irreversible necrosis of the ovary]?
Clinical Scenario:
You are working in a community emergency department on a night shift. A 19-year-old female presents to triage with severe lower abdominal pain and vomiting which has progressively worsened for the past 12 hours. She is previously healthy, other than an appendectomy when she was 12 and is currently on no medications other than her Mirena (intrauterine device). After you give her acetaminophen, ketorolac, some morphine and a dose of ondansetron she is more comfortable but still showing signs of discomfort. She has tenderness on palpation in the right lower quadrant and suprapubic region. You are concerned about possible ovarian torsion and would prefer to order a pelvic ultrasound on the patient to identify signs of decreased blood flow to the ovary. Your ultrasound technicians have gone home for the night and you’re wondering if you should call them back in. You know the time cut off for testicular torsion is roughly 6 hours before irreversible necrosis starts to set in, but is the ovary the same?
Search Strategy:
A database search was completed on March 21st 2026, using MEDLINE (1974 – 2026) via the Ovid interface with the following search terms: [(exp Ovarian Torsion/ or ovarian torsion.mp) OR (adnexal torsion.mp) OR (Tubo-ovarian torsion.mp)] AND [Time.mp OR Duration.mp OR Delay.mp OR Length.mp ]. No date or language filters were used in this search.
Search Details:
Studies were included if they met the following criteria:
- Included patients had ovarian torsion/adnexal torsion
- The study measured a temporal relation to symptoms (either onset, time to intervention, admission to OR, etc)
- The study reported outcomes associated with necrosis/nonviable tissue
- The study compared the relationship between timing and necrosis/nonviability
Studies were excluded if they:
- Were case reports
- Involved neonatal cases
- Involved alternative reasons for oophorectomy irrelevant of necrosis (e.g., neoplasm )
- Included patients had ovarian torsion/adnexal torsion
- The study measured a temporal relation to symptoms (either onset, time to intervention, admission to OR, etc)
- The study reported outcomes associated with necrosis/nonviable tissue
- The study compared the relationship between timing and necrosis/nonviability
Studies were excluded if they:
- Were case reports
- Involved neonatal cases
- Involved alternative reasons for oophorectomy irrelevant of necrosis (e.g., neoplasm )
Outcome:
The initial search returned 367 papers. We screened an initial 353 articles, which we found did not meet the inclusion criteria described above. A further 7 articles were excluded based on the following: 2 articles were excluded due to being case reports, 2 were excluded for including neonatal cases in the study population, and the final 3 articles were excluded due to outcomes measuring alternative reasons for oophorectomy. We included 7 papers in the analysis, which we deemed were applicable to the question and met our review criteria.
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| When Is It Too Late? Ovarian Preservation and Duration of Symptoms in Ovarian Torsion Adams, K., Ballard, E., Amoako, A., Khalil, A., Baartz, D., Chu, K., & Tanaka, K. 2022 Australia | All women diagnosed in 10-year period at Royal Brisbane and Women’s Hospital, Australia, with surgically confirmed ovarian torsion (N=86) | Single centre retrospective cohort study | Duration from symptom onset to emergency department presentation and its association with surgical outcome | The median time from symptom onset to emergency department presentation was significantly longer in patients who underwent oophorectomy (26.0 hours) compared to those who had conservative surgery (6.0 hours) (p<0.001). | Relatively small sample size (N=86) Single center retrospective study No postoperative follow up data to understand whether irreversible necrosis was appropriately identified leading to concerns for misclassification of outcome Difficult to assess the exact onset of symptoms creating concerns for misclassification of exposure[Kd1 |
| Duration from emergency department triage to surgery and its association with surgical outcome | The median time from triage to surgery was significantly longer in the oophorectomy group (11.0 hours) compared to the. conservative group (5.5 hours) (p=0.010). | ||||
| Time's a tickin': When should surgical intervention occur in ovarian torsion? Byrne M, Loszko A, Wirth K 2026 USA | Women aged 1-17 with preoperative diagnosis of ovarian torsion (N=34) Conducted at the University of Rochester Medical Center (Golisano Children's Hospital) covering April 2015 June 2024. | Single centre retrospective cohort study | Identification of an optimal time cutoff (symptom onset to operating room) associated with ovarian preservation vs. loss | Receiver Operating Characteristics curve analysis identified 34.7 hours from symptom onset to operating room had a sensitivity 77% and specificity 67% for surgical oophorectomy / postoperative adnexal loss. | Small sample size- n-=34 Single centre retrospective design High exclusion rate, concerns of selection bias in the types of individuals/cases evaluated Difficult to assess the exact onset of symptoms, creating concerns for misclassification of exposure |
| Odds of adnexal organ loss based on symptom duration thresholds | Patients with symptom-to-operating room duration ≥34 hours had 6.67 times higher odds of adnexal loss vs. those <34 hours (95% CI 1.38–32.28;). | ||||
| Ovarian torsion: can we save the ovary? Novoa, M., Friedman, J. & Mayrink, M. Arch 2021 USA | All ages admitted to the hospital with suspected ovarian torsion (N= 49) Conducted at a large academic teaching hospital (Mount Sinai Medical Center, Miami Beach, FL) January 2014 – December 2018. | Single centre retrospective cohort study | Association between time from symptom onset to surgery and histopathological findings (necrosis, hemorrhage/congestion, normal tissue) | An association was found between longer surgical delay and necrosis on histopathology (p<0.05). All 6 patients with confirmed necrosis on histopathology had surgery more than 24 hours after pain onset. Not all patients operated on after 24 hours developed necrosis | Small sample size- n=42 Single center retrospective study design Lack of blinding between symptom duration and choice of intervention creates concerns for incorporation bias. Difficult to assess the exact onset of symptoms creating concerns for misclassification of exposure |
| Acute Adnexal Torsion: Is Immediate Surgical Intervention Associated with a Better Outcome? Odelia Yaakov, Eran Ashwal, Ofer Gemer, Yoav Peled, Victoria Kapustian, Ahmet Namazov, Ram Eitan, Haim Krissi; 2022 Isreal | Aged 18-45 hospitalized with surgically confirmed ovarian torsion (N=220) Conducted at two university-affiliated hospitals in Israel (Barzilai University Medical Center and Rabin Medical Center) From January 2000- December 2015 | Multi-centre retrospective cohort study | Rate of macroscopic adnexal ischemia (defined as blue-black appearance at surgery) comparing early surgical intervention (<6 hours from admission) vs. late surgical intervention (6–24 hours from admission) | No statistically significant difference in the rate of macroscopic adnexal ischemia between the early and late surgery groups (48% vs. 40%; p=0.30). | Retrospective study No postoperative follow up data to understand whether irreversible necrosis was appropriately identified leading to concerns for misclassification of outcome |
| Ovarian Salvage With Prompt Surgical Intervention for Adnexal Torsion: Does Timing Matter? Avila A, Motta M, Schechter D, Samuels S, Jaramillo I, Whitehouse J, Neville HL, Levene T. 2024 USA | Non-neonatal pediatric patients with diagnosis of ovarian torsion who had surgical correction (N=88) Conducted at Joe DiMaggio Children's Hospital (Memorial Healthcare System), Hollywood, FL From March 2014- April 2021 | Single centered retrospective cohort study | Rate of ovarian loss (defined by radiographic evidence on postoperative ultrasound) comparing patients who underwent surgery within vs. beyond 60 minutes of diagnosis | No statistically significant difference in ovarian loss between patients who had surgery within 60 minutes vs. beyond 60 minutes of diagnosis (80.6%(n=54) vs 75.0%(n=3), p=0.62). | Small sample size Single center retrospective design Difficult to assess the exact onset of symptoms creating concerns for misclassification of exposure |
| 83% of all patients had surgery more than 60 minutes from diagnosis (median 116 minutes), yet overall ovarian loss remained low (4.6%) | |||||
| Association between duration of symptoms prior to presentation and ovarian loss | |||||
| Patients with ovarian salvage had a significantly shorter duration of symptoms prior to presentation (24 hours v 96 hours; p=0.02), | |||||
| Association between total time from symptom onset to surgery and ovarian loss | |||||
| Patients with ovarian loss had a longer mean time from symptom onset to surgery (43.8 hours vs. 24.8 hours), though this did not reach statistical significance (p not reported as significant). | |||||
| Adnexal torsion in adolescents: prompt diagnosis and treatment may save the adnexa Ben-Arie, A., Lurie, S., Graf, G., & Insler, V. 1995 Isreal | Aged 9-19 hospitalized for lower abdominal pain with eventual diagnosis of ovarian torsion (N=13) Conducted at Kaplan Hospital, Rehovot, Israel Covering January 1988 – June 1993 | Single centered retrospective cohort study | Association between time from hospital admission to surgery and operative outcome | Conservative management/no ischemia group time from admission to surgery 8 +/- 5 hours versus oophorectomy/ischemia group time 18 +/- 9 hours (p=0.03) | Small sample size Single center retrospective cohort study Lack of blinding between symptom duration and choice of intervention creates concerns for incorporation bias. |
| Urgency of Evaluation and Outcome of Acute Ovarian Torsion in Pediatric Patients Anders, Jennifer F, and Elizabeth C Powell 2005 USA | Pediatric patients aged 3-15 with surgically confirmed ovarian torsion N= 22 Conducted at Chicago’s Children’s Memorial Hospital, USA Covering October 1987- April 2003 | Single centered retrospective cohort study | Association between duration of symptoms prior to initial examination and ovarian salvage | Mean duration of symptoms prior to initial examination was identical in both groups (76 hours), with no statistically significant difference (salvaged: 1–144 hours; non-salvaged: 2–336 hours; CI 95%). | Small sample size n=22 Single centered retrospective study Lack of blinding between symptom duration and choice of intervention creates concerns for incorporation bias. Difficult to assess the exact onset of symptoms creating concerns for misclassification of exposure bias |
| Association between time from initial examination to operative intervention and ovarian salvage | Mean time from initial examination to operative intervention was 10.8 hours in the salvaged group and 21.2 hours in the non-salvaged group. Although this difference was not statistically significant (95% CI −5 to 26 hours), | ||||
| Among those operated on within 8 hours of initial examination, the salvage rate was 43%; within 24 hours, 33%; and beyond 24 hours, 0%. All six ovarian salvages occurred within 24 hours of initial examination. |
Author Commentary:
There are a limited number of published articles addressing ovarian or adnexal torsion. This review demonstrates that substantial gaps remain in understanding the clinical presentation of ovarian torsion. All studies included were retrospective with small sample sizes. This leads to concerns about confounding, generalizability of the data, and overall ability to draw conclusions from the findings in relation to the review question. Prospective multicentre research incorporating additional variables such as pain severity, associated symptoms, comorbidities, imaging findings, and duration of symptoms may provide a more accurate and clinically meaningful understanding of the urgency required for surgical intervention.
Bottom Line:
Though evidence is based on small retrospective studies, earlier surgical intervention is associated with higher rates of ovarian salvage in ovarian torsion.
Level of Evidence:
Level 2: Studies considered were neither 1 or 3
References:
- Adams, K., Ballard, E., Amoako, A., Khalil, A., Baartz, D., Chu, K., & Tanaka, K.. When Is It Too Late? Ovarian Preservation and Duration of Symptoms in Ovarian Torsion
- Byrne M, Loszko A, Wirth K. Time's a tickin': When should surgical intervention occur in ovarian torsion?
- Novoa, M., Friedman, J. & Mayrink, M. Arch. Ovarian torsion: can we save the ovary?
- Odelia Yaakov, Eran Ashwal, Ofer Gemer, Yoav Peled, Victoria Kapustian, Ahmet Namazov, Ram Eitan, Haim Krissi;. Acute Adnexal Torsion: Is Immediate Surgical Intervention Associated with a Better Outcome?
- Avila A, Motta M, Schechter D, Samuels S, Jaramillo I, Whitehouse J, Neville HL, Levene T.. Ovarian Salvage With Prompt Surgical Intervention for Adnexal Torsion: Does Timing Matter?
- Ben-Arie, A., Lurie, S., Graf, G., & Insler, V.. Adnexal torsion in adolescents: prompt diagnosis and treatment may save the adnexa
- Anders, Jennifer F, and Elizabeth C Powell. Urgency of Evaluation and Outcome of Acute Ovarian Torsion in Pediatric Patients