Overview
Definition:
Ovarian torsion is a surgical emergency characterized by the twisting of the ovary around its supporting ligaments, compromising its blood supply
This can lead to ischemia, infarction, and potential loss of ovarian function.
Epidemiology:
Ovarian torsion is a rare but significant cause of acute pelvic pain in adolescents and young women, accounting for approximately 3% of gynecologic emergencies
It can occur at any age, but is most common in reproductive-aged women, with a peak incidence in those aged 20-30 years
In adolescents, it is a leading cause of adnexal torsion
Predisposing factors include ovarian cysts, particularly those larger than 5 cm, previous ovarian surgery, and rapid hormonal changes.
Clinical Significance:
Early diagnosis and prompt surgical intervention are crucial to salvage ovarian tissue and preserve fertility
Delayed management can result in ovarian necrosis, necessitating oophorectomy and leading to long-term consequences like infertility and hormonal imbalances
Understanding the nuances of diagnosis, especially with ultrasound, and the surgical approach for detorsion is paramount for pediatricians and gynecologists preparing for DNB and NEET SS examinations.
Clinical Presentation
Symptoms:
Sudden onset of severe, unilateral lower abdominal or pelvic pain, often colicky in nature
Nausea and vomiting are common, usually occurring shortly after the onset of pain
Some patients may report intermittent pain due to partial or intermittent torsion
Fever is usually absent unless secondary infection or necrosis occurs
Associated symptoms can include vaginal spotting or abnormal bleeding, though less common
The pain can be sudden and excruciating, leading to the patient presenting to the emergency department in distress.
Signs:
Tenderness on abdominal palpation, typically localized to the affected lower quadrant
Guarding and rebound tenderness may be present, mimicking appendicitis or other acute abdominal conditions
A palpable adnexal mass may be felt during bimanual pelvic examination, though it may be absent or difficult to detect in obese patients or those with significant pain and guarding
Vital signs may be normal initially, but tachycardia and mild hypotension can occur due to pain and dehydration.
Diagnostic Criteria:
There are no definitive diagnostic criteria solely based on clinical presentation
Diagnosis relies heavily on a combination of clinical suspicion, physical examination findings, and imaging
A high index of suspicion is essential in any adolescent female presenting with acute, severe pelvic pain
The presence of an ovarian cyst on imaging in a patient with suggestive symptoms significantly increases the probability of torsion
Definitive diagnosis is often made intraoperatively.
Diagnostic Approach
History Taking:
A detailed history is critical
Ask about the onset, duration, character, and location of pain
Inquire about associated symptoms like nausea, vomiting, fever, and any vaginal bleeding
Previous episodes of similar pain or known ovarian cysts are important red flags
A history of prior pelvic surgery or gynecological conditions can also be relevant
Assess for any recent changes in menstrual cycle
Rule out other causes of acute abdominal pain like appendicitis, ectopic pregnancy, or urinary tract infection.
Physical Examination:
Perform a complete abdominal examination, including inspection, palpation, percussion, and auscultation
Look for signs of peritonitis
A gentle bimanual pelvic examination is essential to assess for adnexal tenderness, masses, and cervical motion tenderness
However, be cautious not to exacerbate pain
In premenarchal girls, a rectovaginal or perineal examination may be necessary to assess pelvic structures
Always assess vital signs for stability.
Investigations:
Pelvic ultrasound with Doppler is the imaging modality of choice
Key ultrasound findings suggestive of torsion include an enlarged ovary (>5 cm in diameter), stromal edema, peripheral displacement of follicles, a heterogeneous echotexture, and absence or diminished arterial and venous flow on Doppler imaging
A "whirlpool sign" on Doppler, representing twisted vascular pedicle, is highly specific
However, preserved Doppler flow does not exclude torsion, as arterial supply may be maintained even with venous congestion
Laboratory tests include a complete blood count (CBC) to assess for infection and a urine pregnancy test in sexually active adolescents to rule out ectopic pregnancy
Urinalysis and urine culture to rule out urinary tract infection.
Differential Diagnosis:
The differential diagnosis is broad and includes appendicitis, ectopic pregnancy, pelvic inflammatory disease (PID), ruptured ovarian cyst, functional ovarian cyst, urinary tract infection, ureteric colic, gastrointestinal issues (e.g., gastroenteritis, constipation), and musculoskeletal pain
Differentiating ovarian torsion can be challenging due to overlapping symptoms
The presence of a palpable mass or characteristic ultrasound findings often helps distinguish it from other conditions.
Management
Initial Management:
Immediate resuscitation with intravenous fluids is indicated for dehydration and pain management
Analgesics, such as opioids or NSAIDs, are crucial for pain control
Antiemetics can be given for nausea and vomiting
If the patient is hemodynamically unstable, further resuscitation is required
Surgical consultation should be obtained promptly.
Medical Management:
Medical management is not the primary treatment for ovarian torsion
Once torsion is suspected, surgical intervention is the mainstay
However, in select cases with low suspicion and minimal findings, conservative management with close observation might be considered, but this is rarely appropriate in adolescents with suspected torsion
Pain management with IV analgesics is a critical component of supportive care.
Surgical Management:
Surgical detorsion is the definitive treatment
Laparoscopy is the preferred approach due to its minimally invasive nature, allowing for visualization, detorsion, and potential cystectomy or cystectomy
The goal is to untwist the ovary to restore blood flow
If a cyst is present, it should be deroofed or excised if it is the suspected cause
If the ovary appears viable after detorsion, it should be conserved and, if a cyst was removed, the remaining ovarian cortex may be sutured to reduce the risk of recurrence
Ovarian fixation (oophoropexy) may be considered in cases with a history of torsion or significant risk factors
If the ovary is necrotic or irreparable, oophorectomy may be necessary.
Supportive Care:
Postoperatively, patients require adequate pain control, intravenous fluids, and monitoring for complications
Antibiotics may be initiated if there was significant intra-abdominal contamination or evidence of infection
Monitoring for ovarian viability and function is important
Education regarding signs of recurrence and importance of follow-up is crucial.
Complications
Early Complications:
Hemorrhagic infarction of the ovary if detorsion is delayed, leading to ovarian necrosis and potential oophorectomy
Pelvic infection or abscess formation can occur secondary to ischemic ovarian tissue
Adhesions can form post-operatively, potentially leading to chronic pelvic pain or bowel obstruction
Damage to adjacent structures during surgery is a rare but possible complication.
Late Complications:
Reduced fertility or infertility if ovarian tissue is lost or damaged
Premature ovarian insufficiency or early menopause if bilateral ovarian torsion occurs or if sufficient functional ovarian tissue is compromised
Chronic pelvic pain can persist due to adhesions or ovarian damage
Recurrence of ovarian torsion, especially if the underlying predisposing factor (e.g., cyst) is not addressed.
Prevention Strategies:
Prompt diagnosis and surgical detorsion to preserve ovarian viability
Addressing predisposing factors such as large or symptomatic ovarian cysts through surgical management (e.g., cystectomy)
In cases with high risk of recurrence, considering ovarian fixation during surgery
Patient education about recognizing symptoms of torsion and seeking immediate medical attention is vital.
Prognosis
Factors Affecting Prognosis:
The most critical factor is the duration of torsion and the time to definitive surgical intervention
The viability of the ovary at the time of detorsion directly impacts future ovarian function and fertility
The presence and size of an underlying ovarian cyst or mass also influence the prognosis
Factors such as the degree of ischemia and the development of complications like infection also play a role.
Outcomes:
With prompt diagnosis and successful detorsion, the ovary can often be preserved, leading to a good prognosis for ovarian function and future fertility
Successful detorsion can result in resolution of pain and nausea
In cases where the ovary is necrotic, oophorectomy may be required, leading to a reduced number of viable ovaries
Long-term outcomes depend on the extent of ovarian damage and whether fertility is preserved.
Follow Up:
Patients should undergo regular follow-up with their gynecologist to monitor ovarian health and assess for recurrence
This typically involves clinical assessment and serial pelvic ultrasounds, especially in the immediate post-operative period and if a cyst was managed conservatively
Monitoring for menstrual irregularities and signs of premature ovarian insufficiency is important in the long term
Counseling regarding future fertility considerations is also recommended.
Key Points
Exam Focus:
Ovarian torsion is a surgical emergency in adolescents presenting with sudden, severe unilateral pelvic pain, nausea, and vomiting
Ultrasound with Doppler is the key diagnostic tool, looking for an enlarged ovary, stromal edema, and absent/diminished flow, though preserved flow does not exclude torsion
Prompt surgical detorsion via laparoscopy is crucial to save the ovary and preserve fertility
Necrotic ovaries may require oophorectomy.
Clinical Pearls:
Maintain a high index of suspicion for ovarian torsion in any adolescent female with acute pelvic pain, even if the pain is intermittent or there are GI symptoms
Always consider ovarian torsion in the differential diagnosis of acute abdominal pain in this population
Do not rely solely on Doppler flow on ultrasound
grayscale findings and clinical correlation are paramount
Aggressive pain control is essential
Consider ovarian fixation in cases with high recurrence risk.
Common Mistakes:
Delayed diagnosis due to misinterpreting symptoms as non-gynecological (e.g., appendicitis, UTI)
Reliance on normal Doppler flow to exclude torsion
Inadequate pain management
Delaying surgical consultation
Not addressing predisposing factors like ovarian cysts adequately
Performing ovarian cystectomy without proper assessment of ovarian viability post-detorsion.