Background <p>Approximately 50% of isolated fallopian tube torsion cases and 5%-10% of tubo-ovarian torsion cases involve an ipsilateral paraovarian cyst. This study aimed to describe the clinical features of paraovarian cyst torsion including isolated fallopian tube torsion and tubo-ovarian torsion and to identify factors associated with delayed surgical intervention.</p> Methods <p>In this retrospective cohort study, we included adult women with surgically confirmed adnexal torsion and a coexisting ipsilateral paraovarian cyst at Peking University Third Hospital between January 2012 and December 2024. Group differences were analysed using independent samples t-tests, Mann–Whitney U tests and chi-square or Fisher’s exact tests. Multiple comparisons of clinical features were adjusted using the Benjamini–Hochberg method with a pre-specified false discovery rate threshold of 0.10. Logistic regression was performed to identify factors associated with a surgical decision-making interval exceeding 12&#xa0;h after emergency department presentation.</p> Results <p>This study included 142 patients, with 66.2% diagnosed with isolated fallopian tube torsion and 33.8% with tubo-ovarian torsion. The mean diameter of paraovarian cysts was significantly larger in the tubo-ovarian torsion group than in the isolated fallopian tube torsion group (7.4 [5.9, 9.4] vs. 5.3 [4.4, 6.2] cm, q &lt; 0.001). Among patients presenting with acute abdominal pain, the tubo-ovarian torsion group had a higher incidence of identifiable precipitating factors (OR = 3.61, 95%CI: 1.48–8.82, q = 0.040). This group also showed a trend toward a higher incidence of abdominal tenderness (OR = 2.33, 95% CI: 1.01–5.39, q = 0.075) and gastrointestinal symptoms such as nausea and/or vomiting (q = 0.060). However, no significant differences were observed in other pain-related characteristics, including pain severity and radiation patterns. Delayed surgical decision-making (&gt; 12&#xa0;h) occurred at more than 2.4 times the rate in the isolated fallopian tube torsion group (31.5% vs. 13.0%), though this association was of borderline statistical significance (q = 0.060). Logistic regression identified a paraovarian cyst diameter ≤ 6&#xa0;cm, along with white blood cell count less than 10 × 10⁹/L, as independent factors associated with surgical decision-making duration exceeding 12&#xa0;h.</p> Conclusions <p>Patients with isolated fallopian tube torsion complicating a paraovarian cyst typically present with smaller cysts and subtler clinical manifestations. Smaller paraovarian cyst diameter and lower white blood cell count were associated with delayed surgical intervention.</p>