Successful ovarian preservation in adolescent adnexal torsion with a 720-degree twist: a case description

A 16-year-old female presented with sudden, constant, severe pain in the left lower abdomen that developed immediately after exercise approximately one day prior. The pain was non-radiating and non‑colicky and was accompanied by mild nausea. The symptoms later partially resolved before her arrival at the hospital. Ultrasound showed bilateral ovaries—the left ovary was slightly enlarged and showed no detectable blood flow on color Doppler imaging ( Figure 1A ). A cyst measuring approximately 9.0 cm × 6.6 cm × 9.0 cm was observed in the left adnexal region, with a thin wall, clear fluid content, and peripheral blood flow signals ( Figure 1B ). Adjacent to the cyst, a heterogeneous hyperechoic area measuring 2.0 cm × 1.8 cm × 1.8 cm was observed, with peripheral blood flow showing the “whirlpool sign” ( Figure 1C ). The ultrasound findings were suggestive of a left adnexal cyst with possible torsion. Laboratory findings were normal. The patient denied any history of sexual activity, pregnancy, fertility treatment, dysuria, contraceptive use, polycystic ovary syndrome, endometriosis, prior ovarian cysts, or previous surgery. Ultrasound and pathological images. (A) Ultrasound showed both ovaries; the left ovary was slightly enlarged with no detectable blood flow. (B) Ultrasound revealed a cyst in the left adnexal region. (C) Ultrasound showed the “whirlpool sign”. (D) Pathology of the left adnexal mass confirmed a serous cyst (hematoxylin & eosin stain, 100×). The patient underwent emergency laparoscopic exploration. Intraoperatively, the uterus, right ovary, and right fallopian tube appeared normal. The left ovary was dark red, and a cyst approximately 9 cm in diameter containing clear fluid was observed in the left paraovarian region. The left fallopian tube and ovarian pedicle had undergone three turns. After detorsion, blood supply to the left ovary recovered. The cyst was completely excised and removed. Pathological examination revealed a serous cyst ( Figure 1D ). The patient recovered well postoperatively. At follow-up 4.5 years after surgery, the patient remained asymptomatic, and ultrasound showed no abnormalities in the preserved left ovary. All procedures in this study were performed in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the patient’s legal guardians for the publication of this article and the accompanying images. A copy of the written consent form is available for review by the editorial office of this journal.

Adnexal torsion is defined as the rotation of the ovary or fallopian tube around the vascular pedicle, leading to impaired ovarian blood supply ( 1 ). Because its clinical manifestations, including acute abdominal pain, nausea, and vomiting, are nonspecific, it can be easily confused with other causes of acute abdomen such as appendicitis and acute gastroenteritis, leading to misdiagnosis or delayed treatment ( 2 ). Clinical studies have confirmed that early diagnosis and prompt surgery are key to successful treatment, restoring ovarian blood supply and preserving ovarian function ( 3 ). This article reports the case of a 16-year-old girl who developed left adnexal torsion with three turns after exercise and underwent emergency surgical intervention with successful ovarian preservation. This case provides a reference for the diagnosis and treatment of adnexal torsion in adolescents.

Adnexal torsion can occur at any age. Because its clinical presentation is nonspecific and can be confused with appendicitis or gastroenteritis, delays in diagnosis and treatment are common. In adolescents, gynecological conditions are particularly likely to be overlooked, increasing the risk of misdiagnosis and delayed treatment ( 1 ). In the present case, the patient developed sudden severe abdominal pain after exercise; however, the pain had partially subsided at the time of presentation, further increasing the diagnostic difficulty. Pelvic ultrasound revealed a heterogeneously arranged, spiral-like echogenic structure adjacent to the adnexal cyst, and color Doppler showed a “whirlpool sign” (red-and-blue whirlpool flow)—a characteristic feature of adnexal torsion ( 4 ), providing a key imaging basis for early diagnosis. The patient received timely surgery, resulting in successful detorsion and ovarian preservation. Previous studies have shown that the ultrasound “whirlpool sign” has a specificity of over 90% for the diagnosis of adnexal torsion ( 4 ). Thus, sonographers should perform multiplanar, wide‑range scanning, particularly in patients with large adnexal cysts, to minimize the risk of missed diagnosis. In the present case, the 9-cm paraovarian cyst served as an anatomical trigger for adnexal torsion. Paraovarian cysts originate from embryological remnants and are located in the mesosalpinx between the ovary and fallopian tube; this free structure predisposes the cyst to displacement during exercise. This patient underwent surgery approximately 24 hours after symptom onset, and ovarian blood supply recovered rapidly after detorsion. Previous studies have shown that delays in diagnosis and treatment increase the risk of oophorectomy ( 5 ), whereas timely surgical intervention can achieve ovarian salvage rates exceeding 97% ( 6 ). This case reaffirms the value of early intervention. A key distinguishing feature of this case is that, although preoperative ultrasound showed a slightly enlarged left ovary with no detectable blood flow on imaging, suggesting possible ovarian ischemia, timely surgical detorsion still resulted in successful preservation of ovarian function. This finding challenges the notion that the absence of ovarian blood flow on imaging inevitably indicates irreversible damage; rather, it supports prompt surgical exploration and detorsion, even in the absence of preoperative Doppler signals. Intraoperatively, the left ovary appeared dark red; however, blood supply recovered quickly after detorsion, and no abnormalities were detected on follow‑up. Previous studies have shown that intraoperative ovarian appearance alone is insufficient to determine the reversibility of ovarian function, as most ovaries regain function after detorsion ( 3 , 7 ). Therefore, even when the ovary appears ischemic, detorsion should be prioritized over direct excision.

Early diagnosis and timely surgery are key to successful ovarian preservation in patients with adnexal torsion. Even in cases with a high degree of torsion and an ischemic‑appearing ovary, detorsion should be attempted whenever feasible. Paraovarian cysts are an important trigger for adnexal torsion in adolescents, and cyst excision after detorsion may help reduce the risk of recurrence. Clinicians and radiologists should maintain a high index of suspicion for adnexal torsion in adolescent patients to avoid irreversible damage to ovarian function due to misdiagnosis or delayed treatment.

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