Ovarian Torsion

Casandra Cashman, MD, FAAFP Reviewed 06/2017
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Subject: Ovarian Torsion

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BASICS

DESCRIPTION

  • Rotation (complete or partial) of the ovarian vascular pedicle on the long axis. Perhaps more accurately referred to as “adnexal torsion” because the fallopian tube is commonly involved.

  • Torsion can lead to impaired vascular supply to the ovary, potentially progressing to necrosis.

  • Torsion of a normal ovary can occur. However, up to 94% of cases of ovarian torsion involve a mass in the ovary such as a cyst or neoplasm.

  • Adnexal torsion can be a difficult diagnosis, with only 58% diagnosed correctly on first presentation (1).

EPIDEMIOLOGY

PREVALENCE

5th most common gynecologic emergency (2.7%), accounts for 15% of all surgically treated adnexal masses (1

ETIOLOGY

  • Adnexal blood supply comes from both the uterine and ovarian vessels.

  • Torsion commonly cuts off blood supply from one source. However, the ovary often continues to be perfused by the other source.

  • Although the venous drainage from the ovaries is a very low-pressure system, the arterial supply to ovaries is a high-pressure system.

  • Torsion can cause venous drainage to stop, whereas arterial supply into the ovary remains unchanged. This causes congestion and swelling of the ovary but prevents immediate infarction.

  • Increased mass and size of ovary causes increased risk of torsion because the ovary is able to swing on its vascular pedicle more readily.

  • Predominant sex: female only

GENETICS

Congenitally long ovarian ligaments increase mobility of ovaries and fallopian tubes, leading to increased risk of torsion, even in a normal ovary. 

RISK FACTORS

  • ~70% of all torsions occur on the right side, likely because the right utero-ovarian ligament is longer than the left, and the sigmoid colon on the left side decreases the space for movement and torsion of the left ovary (1,2).

  • Ovarian mass is present in up to 81% of cases.

  • Benign masses are more common than ovarian cancers because malignant tumors often invade nearby tissues and/or cause adhesions, therefore decreasing the rate of torsion. Enlarged ovaries, such as polycystic ovaries or those with benign cystic teratomas, are more vulnerable to torsion (2).

  • The rate of malignancy seen with ovarian torsion is between 2% and 15%, with similar numbers reported in pregnancy of between 1% and 8% (2).

  • Patients with ligated uterine tubes, history of laparoscopic hysterectomy, or polycystic ovaries have increased risk of ovarian torsion.

  • Ovarian stimulation (as with fertility treatments) causes an increased risk of torsion due to the increased volume and weight of the ovary.

  • Adnexal torsion occurs in ~1/5,000 pregnancies (3).

GENERAL PREVENTION

  • Diagnosis and treatment of ovarian masses can decrease the rate of torsion. Awareness of the risk of torsion is important for patients undergoing ovarian stimulation for IVF treatments and for patients with known ovarian masses.

  • Certain surgical techniques (such as cystectomy and ovariopexy) used during intervention for ovarian torsion may decrease the risk of future torsion, but these treatments remain controversial (1).

Pregnancy Considerations

  • Of all torsions, 8–25% of cases occur in pregnant patients (2).

  • Signs and symptoms of ovarian torsion in the pregnant patient are similar to those seen in a nonpregnant patient.

  • Rates of torsion have been cited at between 0.6% and 6% in pregnancies obtained by ovarian stimulation, and the rate of torsion increases to between 7.5% and 16% in patients presenting with ovarian hyperstimulation syndrome (1,4).

  • The majority of cases in pregnancy occur in the 1st trimester (1).

  • Reoccurrence is not uncommon, occurring in 19.5% of pregnant patients with torsion.

  • Most commonly, the corpus luteum cyst is the causative etiology of the torsion.

  • Laparoscopic treatment of the torsion is considered safe in pregnancy, with studies reporting between 2% and 5% risk of loss of the pregnancy following surgery, and an 8% rate of preterm labor. In addition, transvaginal cystectomy has also been reported (4).

 
Pediatric Considerations

  • Symptoms of ovarian torsion in the pediatric population are similar to those in adults, including intermittent abdominal pain.

  • ~15% of cases of ovarian torsion occur during infancy and childhood.

  • Ovarian torsion may be present within an incarcerated inguinal hernia; 27% of girls with an incarcerated hernia had ovarian torsion and infarction of their ovaries.

  • Children with torsion and no underlying ovarian pathology had an 11.4% risk of asynchronous torsion of the other ovary.

  • Incidence of underlying ovarian pathology in children with torsion ranges from 64% to 82%, with the most common pathologic findings being benign cystic teratomas or hemorrhagic or follicular cysts.

  • Rate of malignancy among torsed ovaries in children is 1.8%.

 

ASSOCIATED CONDITIONS

Pregnancy and ovarian stimulation 

DIAGNOSIS

HISTORY

  • The most common symptom is pelvic pain (96%). This is often sudden and intense. When pain begins >10 hours prior to surgery, risk of necrosis is increased (1,2).

  • Pain is localized to the involved side but may radiate across the lower pelvis.

  • Associated nausea and vomiting for 42–85% of patients

  • High fever is not typical. Tachycardia may or may not be present.

  • Pain may subside or resolve in an unresolved torsion due to necrosis of pain fibers.

  • Detection of ovarian cysts on prenatal US and/or MRI is increasing; this may help identify patients who are at risk for torsion as children. Ovarian cysts are the most commonly encountered intra-abdominal mass in females in utero.

PHYSICAL EXAM

  • Adnexal mass is found in 41–70% of cases. Unilateral pain is typical, with or without peritoneal signs.

  • Bilateral adnexal pain during vaginal exam found in 26% of cases (1).

DIFFERENTIAL DIAGNOSIS

  • Ruptured ovarian cyst

  • Ectopic pregnancy

  • Appendicitis

  • Endometriosis

  • Mittelschmerz

  • UTI

  • Pelvic inflammatory disease

  • Diverticulitis

  • Ureteral calculi

TESTS

INITIAL TESTS

  • No lab work required for diagnosis

  • CBC: Leukocytosis may be present but does not correlate with necrosis (1).

  • Interleukin-6, tumor necrosis factor-α is under investigation as possible markers.

  • US is perhaps the most useful for evaluation of possible torsion, with an accuracy of 74%, but negative ultrasound does not rule out torsion.

  • Sonographic appearance of ovarian torsion was associated with normal laparoscopic findings in 6% of cases.

  • Doppler imaging may show decreased or absent venous or arterial flow, but this is not correlated with ovarian viability.

  • Another study reports loss of venous blood flow was noted in 81.3% of patients with confirmed torsion (2).

  • MRIs and CTs are not routinely used and carry an increased cost compared to US or clinical diagnosis; however, when the clinical picture is unclear, these are often the first tests carried out (usually evaluating for other causes of pain) (3).

  • Ovarian Torsion Composite Index (OT-CI) scoring system may be helpful in pediatric patients; scores >3 had 100% sensitivity and 65% specificity, scores >5 had 100% specificity (5)[C].

CONSIDERATIONS

Definitive diagnosis of adnexal torsion is by direct visualization with surgery—either with a laparotomy or laparoscopy. 

DIAGNOSTIC PROCEDURES/SURGERY

  • Both a laparotomy and laparoscopy are diagnostic and therapeutic.

  • A laparoscopy is preferred due to shorter recovery time and complication rates.

TREATMENT

GENERAL MEASURES

Surgery is the definitive treatment of choice. 

MEDICATION

  • Medication is not a first- or second-line treatment for ovarian torsion.

  • Pain relief can be obtained with medication; however, surgical detorsion is the only definitive treatment.

SURGERY

  • Torsion must be evaluated by either a laparoscopy or laparotomy.

  • Conservative treatment involves untwisting the adnexa (detorsion), and it is now the accepted treatment of choice for children and women of reproductive age. Blue-black appearance of the ovary is common, yet 91–93% will recover follicular function after detorsion. Removal of the affected adnexa is recommended if the patient is postmenopausal or if the ovary is completely replaced by pathologic lesion.

  • Previously, the affected ovary was always removed for fear that detorsing the ovary could cause a thromboembolic event secondary to release of a thrombus from the adnexal veins. However, recent studies have shown the rate of pulmonary embolus associated with torsion to be 0.2% and not increased after untwisting of the adnexa.

  • If, during the initial procedure, ovarian cancer is suspected, frozen sections should be obtained to allow confirmation of malignancy.

  • Ovariopexy or plication of the utero-ovarian ligament has been proposed by some and is occasionally performed on the contralateral side as well (1).

INPATIENT CONSIDERATIONS

  • A patient should remain in the hospital until torsion has been resolved, pain has been controlled, patient is ambulating on her own, and she is able to maintain a regular diet.

  • IV fluid repletion is often necessary as patients in pain have inadequate oral intake. IV fluid hydration should be maintained in preparation for surgical exploration and treatment.

  • Laparoscopic treatment of ovarian torsion is more commonly done today, and no difference was found in rate of complications; however, patients who underwent laparoscopy had much shorter hospital stays (1).

ONGOING CARE

FOLLOWUP RECOMMENDATIONS

MONITORING

  • Because of more conservative treatments, the rate of repeat torsions is likely to increase.

  • Patients with cystic lesions managed conservatively at the time of torsion diagnosis may require additional surgical intervention if those lesions do not resolve.

  • Ovariopexy is a follow-up option for patients with a single ovary, patients with repeat torsion, or patients with adnexectomy of the contralateral ovary (1).

  • Routine laboratory testing or imaging to confirm return of ovarian function is usually unnecessary.

PROGNOSIS

  • Ovarian function is likely to recover after detorsion.

  • Recurrent torsion of the treated or opposite ovary is possible.

COMPLICATIONS

  • Surgical complications, including infection or hemorrhage

  • Repeat torsion if conservative treatment was performed.

  • Infertility (due to adhesions or removal of ovarian tissue)

  • Peritonitis, systemic infection, and sepsis if ovary becomes necrotic and is not removed

REFERENCES

Huchon C, Fauconnier A. Adnexal torsion: a literature review. Eur J Obstet Gynecol Reprod Biol.  2010;150(1):8–12.  [View Abstract]
Balci O, Icen MS, Mahmoud AS et al. Management and outcomes of adnexal torsion: a 5-year experience. Arch Gynecol Obstet.  2011;284(3):643–646.  [View Abstract]
Wilkinson C, Sanderson A. Adnexal torsion—a multimodality imaging review. Clin Radiol.  2012;67(5):476–483.  [View Abstract]
Hasson J, Tsafrir Z, Azem F et al. Comparison of adnexal torsion between pregnant and nonpregnant women. Am J Obstet Gynecol.  2010;202(6):536.e1–536.e6.  [View Abstract]
King A, Keswani S, Biesiada J et al. The utility of a composite index for the evaluation of ovarian torsion. Eur J Pediatr Surg.  2014;24(2):136–140.  [View Abstract]

ADDITIONAL READING

  • Damigos E, Johns J, Ross J. An update on the diagnosis and management of ovarian torsion. Obstet Gynaecol.  2012;14:229–236.

  • Mashiach R, Melamed N, Gilad N et al. Sonographic diagnosis of ovarian torsion: accuracy and predictive factors. J Ultrasound Med.  2011;30(9):1205–1210.  [View Abstract]

  • Rossi BV, Ference EH, Zurakowski D et al. The clinical presentation and surgical management of adnexal torsion in the pediatric and adolescent population. J Pediatr Adolesc Gynecol.  2012;25(2):109–113.  [View Abstract]

  • Rudser AKE, Rudser K, Patterson RJ et al. Ovarian torsion in pediatric patients: a review of eleven years’ experience. Ann Emerg Med.  2013;62(4):S72.

  • Tsafrir Z, Hasson J, Levin I et al. Adnexal torsion: cystectomy and ovarian fixation are equally important in preventing recurrence. Eur J Obstet Gynecol Reprod Biol.  2012;162(2):203–205.

CODES

ICD10

  • N83.51 Torsion of ovary and ovarian pedicle

  • Q50.2 Congenital torsion of ovary

  • N83.53 Torsion of ovary, ovarian pedicle and fallopian tube

  • N83.52 Torsion of fallopian tube

ICD9

  • 620.5 Torsion of ovary, ovarian pedicle, or fallopian tube

  • 752.0 Anomalies of ovaries

SNOMED

  • 13595002 Torsion of ovary (disorder)

  • 253822004 congenital torsion of ovary (disorder)

  • 198309005 torsion of the ovary and fallopian tube (disorder)

  • 46946009 Torsion of fallopian tube (disorder)

PEARLS

  • Diagnosis of ovarian torsion is frequently missed, so a high clinical suspicion (especially in patients at increased risk) is key.

  • Risk of torsion is increased during pregnancy, especially those obtained by ovarian stimulation.

  • Surgery is both diagnostic and definitive; treatment can be accomplished by either a laparoscopic or open approach.

  • Conservative treatment with detorsion and ovarian preservation is preferred in premenarchal girls and women of reproductive age.

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