Ovarian torsion

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Background

  • Ovarian torsion is the rotation of the ovary and portion of the fallopian tube on the supplying vascular pedicle. It is also referred to as adnexal torsion and tubo-ovarian torsion.
  • Occurs in females of all ages
    • Most common in reproductive age adults
    • In children: most common in 9-14 yrs old
  • Ovarian cysts (usually > 4cm) and neoplasms account for 94% of cases in adults.[1] However in children they are only less common in children.
  • Torsion more common on the right, sigmoid tends to stabilize the left
  • In children hypermobility of the ovary many be the primary cause of torsion.
  • Dual blood supply from oarian and uterine arteries.

Pathophysiology

Torsion occurs from either of the two causes:

  1. Hypermobility of the ovary
  2. Adnexal mass
  • Cysts greater than 4cm more likely to torse[2]
  • Absence of ovarian Doppler flow is highly specific for torsion, but normal Doppler flow does not completely exclude torsion

Clinical Features

  • Nausea/vomiting (70%)
  • Sudden and sharp pain in the lower abdomen (59%)
    • Can be intermittent
    • Commonly occurs simultaneously with vomiting
  • Fever (<2%)

Differential Diagnosis

RLQ Pain

LLQ Pain

Evaluation

Although the gold standard is direct visualization in the operating room ultrasound is generally the first diagnostic test performed. The ovary can torse intermittently so high clinical suspicion is need, especially in the setting of a negative ultrasound.

Pelvic exam

  • May not have Adnexal TTP or adnexal mass.

Ultrasound

Findings suggestive of torsion may include:

  • Diminished or absent blood flow in the ovarian vessels[3]
    • 2/3 of patients with ovarian torsion have had normal blood flow.
  • Ovarian mass > 3 cm may be clue
  • Enlarged ovarian volume
    • MC finding
  • Loss of echogenicity
  • Peripherally displaced follicles with hyperechoic central stroma
  • Midline ovary
  • Pelvic free fluid
  • An infarcted ovary may have a more complex appearance with cystic or hemorrhagic degeneration
  • Whirlpool sign of twisted vascular pedicle may be seen but rare[3]

CT Abd/Pelvis

  • CT will not diagnose torsion
  • CT may be used to rule out other possible causes of lower abdominal pain; also exclude presence of pelvic mass

Management

  • Emergent OB/GYN consult in ED
    • May consider if high suspicion despite negative US.
  • Surgical detorsion is required to prevent ovarian necrosis. If the ovary become necrotic there is a high risk of infection.
    • Salvage rate may be high even if prolonged time [4]

See Also

References

  1. Amirbekian S et al. Ultrasound Evaluation of Pelvic Pain. Radiol. Clin. North Am. 2014;52 (6): 1215-1235
  2. M.L. Brandt et al. Surgical indications in antenatally diagnosed ovarian cysts J Pediatr Surg, 26 (1991), pp. 276–282
  3. 3.0 3.1 Lee EJ et-al. Diagnosis of ovarian torsion with color Doppler sonography: depiction of twisted vascular pedicle. J Ultrasound Med. 1998;17 (2): 83-9.
  4. Anders JF, Powell EC. Urgency of evaluation and outcome of acute ovarian torsion in pediatric patients. Arch Pediatr Adolesc Med. 2005;159:532–535