Gynecology Book

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Ovarian Torsion

Aka: Ovarian Torsion
  1. Epidemiology
    1. Accounts for 2-3% of acute surgical emergencies (fifth most common gynecologic emergency)
    2. More common in young women (peaks at ages 20 to 30 years)
    3. Torsion occurs outside the reproductive age range and in pregnancy
      1. Torsion occurs in pediatric patients (15% of cases) and Postmenopause (15% of cases)
      2. Ovarian Torsion in pregnancy accounts for 20% of cases
  2. Pathophysiology
    1. Partial or complete rotation of ovarian pedicle
      1. Results in lymphatic and venous engorgement in partial rotation
      2. Results in ischemia or infarction in complete rotation
    2. Typically unilateral and more commonly right sided
    3. Typically both the ovary and the fallopian tube are involved in the torsion
    4. Enlarged ovary or mass is most common predisposing factor
      1. However, girls prior to Puberty with Ovarian Torsion typically have normal ovaries
  3. Risk Factors
    1. No risk factors in 25% of patients
    2. Enlarged Ovary
    3. Adnexal Mass
      1. Benign ovarian growths (especially dermoid tumors) have an 11% risk of Ovarian Torsion
      2. Ovarian Cancer has only a 2% risk of Ovarian Torsion
    4. Pregnancy
      1. Related to Adnexal displacement (especially between weeks 6 to 14)
    5. Ovulation induction (Infertility management)
    6. Prior pelvic surgery (including Tubal Ligation)
      1. Adhesions may act at pivot points for torsion
  4. Symptoms
    1. Symptoms are initially non-specific
    2. Lower Abdominal Pain (often right sided)
      1. Abrupt onset in only 60% of cases
      2. Severe, progressive unilateral lower Abdominal Pain or Pelvic Pain
      3. Pain is sharp and stabbing in >70% of cases, but may be cramping pain in others
      4. Pain radiates into the thigh or low back
      5. Pain may be intermittent if partial torsion occurs with spontaneous resolution
    3. Nausea or Vomiting
    4. Low grade fever may be present
  5. Signs
    1. Abdominal exam
      1. Frequently benign Abdomen in early cases
      2. Peritoneal signs suggest a longer standing Ovarian Torsion
    2. Pelvic exam (bimanual exam)
      1. Very low sensitivity and Specificity
      2. Uterus may be shifted toward the affected side
      3. Palpable, tender Adnexal Mass in 50% of cases
  6. Labs
    1. Urinalysis
    2. Urine Pregnancy Test
  7. Imaging: Pelvic Ultrasound with color doppler
    1. Findings
      1. Large edema at ovary in partial Ovarian Torsion
      2. Free pelvic fluid is less common in Ovarian Torsion
      3. Hyperechogenic foci suggest hemorrhagic changes in the ovary
      4. Hypoechogenic foci suggest ovarian edema
      5. Cystic, clotted areas suggest infarction
    2. Efficacy
      1. Early studies suggested 93% for Ultrasound abnormality in Ovarian Torsion
      2. More recent studies show variable Test Sensitivity 35-85%
      3. Surprisingly Ultrasound is not appreciably better than CT in identifying Ovarian Torsion
      4. Swenson (2014) Eur J Radiol 83(4): 733-8 +PMID:24480106 [PubMed]
    3. Precautions
      1. Vascular flow on color doppler Ultrasound does not exclude partial Ovarian Torsion
      2. Pelvic Ultrasound need not be done after CT Abdomen specifically to exclude Ovarian Torsion
        1. Ultrasound does not add significant information not seen on CT
      3. Ultrasound is sufficient in low to moderate suspicion for torsion cases
        1. Laparoscopy is the only definitive diagnostic tool in high suspicion cases
  8. Differential Diagnosis
    1. See Abdominal Pain Causes
    2. See Pelvic Pain Causes
    3. Appendicitis
    4. Bowel Obstruction
    5. Gastroenteritis
    6. Ruptured Ovarian Cyst
    7. Ectopic Pregnancy
    8. Pelvic Inflammatory Disease
    9. Nephrolithiasis
  9. Precautions
    1. Consider Ovarian Torsion in any woman with lower Abdominal Pain
      1. Do not delay surgical Consultation if high level of suspicion
      2. Ultrasound does not have high enough Test Sensitivity to completely exclude torsion
  10. Evaluation
    1. High level of suspicion for Ovarian Torsion
      1. Consult Gynecology early
      2. Pelvic Ultrasound (normal result does not exclude high suspicion Ovarian Torsion)
    2. Low to moderate suspicion for Ovarian Torsion
      1. Pelvic Ultrasound is sufficient to evaluate for Ovarian Torsion
      2. CT Abdomen (if done to exclude other causes) is also sufficient to evaluate for torsion
        1. Reflex to pelvic Ultrasound is not needed after CT unless dictated by pathology seen on CT
    3. Intermittent Torsion
      1. Pelvic Ultrasound may show normal blood flow
      2. However, intermittent torsion is typically accompanied by Adnexal Mass seen on Ultrasound
  11. Management
    1. Gynecologic emergency
      1. Requires prompt diagnosis and treatment for optimal surgical management and ovarian salvage
    2. Diagnostic laparoscopy if Ovarian Torsion suspected
      1. Often requires conversion to laparotomy if Ovarian Torsion is present
      2. Untwisting and salvage of ovary is safe if no findings suggestive of a necrotic ovary
      3. Oophorectomy is recommended for an infarcted ovary due to the risk of Venous Thromboembolism
  12. References
    1. Delaney in Herbert (2016) EM:Rap 16(5): 5-6 [PubMed]
    2. Houry (2001) Ann Emerg Med 38:156-9 [PubMed]
    3. Martin (2006) CJEM 8(2):126-9 [PubMed]
    4. Pena (2000) Fertil Steril 73:1047-50 [PubMed]

Torsion of ovary (C0149952)

Definition (NCI) Twisting of the ovary resulting in the cutoff of the blood supply to the ovary. It may develop in an enlarged or normal ovary and in the vast majority of cases is unilateral. Signs and symptoms include acute lower abdominal pain, nausea, vomiting, and fever.
Concepts Anatomical Abnormality (T190)
SnomedCT 156002009, 13595002
English ovarian torsion (diagnosis), ovarian torsion, ovary torsion, torsed ovary, torsion ovary, torsion of ovary, Ovarian Torsion, Torsion of ovary, Ovarian torsion, Torsion of ovary (disorder), ovary; torsion, torsion; ovary
Spanish torsión del ovario, torsión del ovario (trastorno), torsión de ovario, torsión de ovario (trastorno), Torsión de ovario, Torsión ovárica, torsión ovárica
Czech Torze vaječníku, Ovariální torze
Dutch eierstoktorsie, ovariumtorsie, ovarium; torsie, torsie; ovarium
French Torsion ovarienne, Torsion de l'ovaire
German Torsion des Eierstocks
Hungarian Az ovarium torsioja, Ovarium torsio
Italian Torsione ovarica, Torsione dell'ovaio
Japanese 卵巣茎捻転, ランソウケイネンテン, 卵巣捻転, ランソウネンテン
Portuguese Torção do ovário
Sources
Derived from the NIH UMLS (Unified Medical Language System)


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