Ovarian torsion

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 women)
• Ovarian cysts (usually > 4cm) and neoplasms account for 94% of cases in adults. However in children they are only less common in children.
• In children hypermobility of the ovary many be the primary cause of torsion.

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
• 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
• Fever (<2%)

Differential Diagnosis

RLQ Pain

• GI
  • Appendicitis
    • Perforated appendicitis
  • Peritonitis
  • Crohn's disease (terminal ileitis)
  • Diverticulitis (cecal, Asian patients)
  • Inguinal hernia
  • Mesenteric ischemia
  • Ischemic colitis
  • Meckel's diverticulum
  • Neutropenic enterocolitis (typhlitis)
• GU
  • Ectopic
  • Endometriosis
  • Kidney stone
  • Mittelschmerz
  • Ovarian cyst
  • Ovarian torsion
  • PID
  • Pyelonephritis
• Other
  • Abdominal aortic aneurysm
  • Epiploic appendagitis
  • Mesenteric lymphadenitis
  • Herpes zoster
  • Psoas abscess
  • Testicular torsion

LLQ Pain

• Diverticulitis
• Kidney stone
• UTI
• Pyelonephritis
• Ectopic pregnancy
• Infectious colitis
• Inflammatory bowel disease (Crohn's Disease, Ulcerative Colitis)
• Inguinal hernia
• Mesenteric ischemia
• Epiploic appendagitis
• Mittelschmerz
• Ovarian cyst
• Ovarian torsion
• PID
• Psoas abscess
• Testicular torsion
• Appendicitis
• Abdominal aortic aneurysm
• Herpes zoster
• Endometriosis
• Colon cancer
• Irritable bowel syndrome
• Small bowel obstruction

Diagnosis

• Ultrasound (sensitivity 46-70%)
  • Diminished or absent blood flow in the ovarian vessels (presence of flow does not r/o)
  • Ovarian mass > 2.5-3 cm
  • Enlarged ovarian volume
  • Loss of echogenicity
  • Edema
  • Free fluid
• CT may be used to r/o other possible causes of lower abdominal pain; also exclude presence of pelvic mass
• Gold standard: direct visualization!

Treatment

• Emergent OB/GYN consult in ED

See Also

• Abdominal pain