a suspicion of malignancy, which is rare Recent case series demonstrate increasing surgical conservation rate as evidence of the rarity of complications and good clinical outcomes with the conservative approach Detorsion without cystectomy, ovarian biopsy, or oophoropexy is generally recommended to avoid long-term effects on fertility Concerns about the appearance of the ovary have previously influenced surgical decisions, but multiple studies have shown that the intraoperative appearance of the ovary does not predict ovarian viability and that conservative therapy is not associated with increased morbidity or poor outcomes Torsion involving normal-appearing ovaries has been associated with an increased risk of ipsilateral recurrence in both pre- and postmenarcheal females, while torsion due to pathology (such as functional ovarian cysts) is not Clinical Considerations Clinical Recognition Torsion can occur in both pre- and postmenarcheal girls and may involve normal ovaries or adnexal containing pathology, like ovarian or paraovarian cysts Adnexal torsion can be a difficult diagnosis to make, given that the clinical picture can overlap with other more common abdominal diagnoses, such as appendicitis Most patients with adnexal torsion will present with acute onset of lower abdominal or pelvic pain; the location of the pain can vary in younger children, as the ovaries can be located higher in the abdomen than in adult women, but symptoms are almost universally unilateral Additional symptoms may include nausea, vomiting, fever, and symptoms referable to the urinary tract Many patients report constant pain, although the pain can be intermittent Clinical Assessment Female patients presenting with acute onset of abdominal pain should be assessed with a complete history, physical examination, and pregnancy risk assessment for postmenarcheal patients, which can start to narrow the broad differential diagnosis Because studies suggest that right-sided adnexal torsion is more common than left-sided, many patients will need to be evaluated concurrently for adnexal torsion and appendicitis Additional diagnoses to consider include nephrolithiasis, mesenteric adenitis, intussusception (in the younger patient), pregnancy (including ectopic pregnancy in the older patient), and urinary tract infection, to name several Most patients present with 24 hours or more of severe, intermittent, and nonradiating pain, and commonly report nausea, vomiting, and abdominal tenderness on examination While laboratory studies can assist in the diagnosis of other entities causing abdominal pain, when there is high suspicion