If I'm Late, the Ovary May Die - Torsion of ovarian cysts

5.30 pm. I was on my way home, driving.

"Hi Dr, I'd like to refer a case of suspected ovarian torsion. The patient is Lisa, a 30-year-old nulliparous woman who presented with a sudden onset of severe lower abdominal pain this morning. A CT scan of the abdomen and pelvis revealed bilateral ovarian cysts. She is in significant pain—we initially administered fentanyl, but due to persistent severe pain, morphine was also required."

"Thanks, I'll review her. Please keep her nil by mouth. She will most likely need emergency surgery as soon as possible."

Ovarian torsion is a gynaecological emergency. Every minute matters. If I'm late, the ovary may not survive.

I rushed back to the hospital. It was rush hour in KL, and the traffic crawled. Every red light felt longer than usual. All I could think was, I hope I'm not too late.

I went to see the patient. She was lying in bed, visibly distressed. Despite multiple doses of strong painkillers, she was still in severe pain. She was grimacing, drenched in sweat, and clearly struggling. I could only imagine how excruciating the pain must have been.

After introducing myself, I clarified her history and reviewed her CT scan results.

A CT scan image of the abdomen and pelvic region. It showed bilateral ovarian cysts.

"Miss, the scan shows that you have cysts on both ovaries. The cyst on the right has caused the ovary to twist. This is called ovarian torsion."

It is not easy to explain this, and it is even harder when the patient is in severe pain.

The ovary is a female reproductive organ roughly the size of an almond. When an ovarian cyst develops, the ovary enlarges. In this patient, both ovarian cysts measured approximately 15 cm. The ovary is supplied by blood vessels. When a large cyst is present, the ovary, together with the cyst, can twist on its supporting structures. This twisting blocks the blood supply to the ovary. If the blood supply is cut off for too long, the ovary can become permanently damaged.

"Because of this, you'll need surgery to untwist the ovary and remove the cyst as soon as possible."

"When will I be going for the operation?" she asked.

"I'm planning to do it as soon as possible," I replied. "I'll contact the anaesthetist and arrange for the operating theatre. However, if there are more urgent emergencies ahead of you, we may have to wait our turn."

In most hospitals, only one emergency operating theatre is available after normal working hours. As a result, emergency surgeries are prioritised according to how urgent and life-threatening they are.

While waiting for her turn, her pain remained severe despite repeated doses of analgesia. Additional pain relief had to be administered, but everyone knew that medication alone would not solve the problem. The only definitive treatment was surgery.

12am

She was finally called.

Torsion of the right ovarian cyst - the blood supply was cut off, and the ovary appeared black.

The photo above shows the right ovarian cyst. After the ovary was untwisted, blood flow returned (a process known as reperfusion). As the ovary regained its blood supply and appeared viable, I was able to perform a cystectomy—removing only the cyst while preserving the ovary.

Left cyst - without torsion.

The left ovarian cyst was not twisted. I performed a cystectomy on the left as well.

The surgery went well. The patient was discharged 2 days after surgery.

Most ovarian cysts remain silent and cause no symptoms—until a complication like ovarian torsion happens. In general, the larger the cyst, the higher the risk of the ovary twisting.