Overview
Definition:
Ovarian torsion is a surgical emergency characterized by the twisting of the ovary around its supporting ligaments, compromising its blood supply.
Epidemiology:
It is a rare but critical condition in pediatrics, often associated with ovarian masses, which are frequently benign in this age group
Incidence is highest in reproductive-aged women, but it can occur at any age, including infancy.
Clinical Significance:
Prompt diagnosis and surgical intervention are crucial to salvage ovarian tissue and preserve fertility
Delay can lead to ovarian necrosis, loss of ovarian function, and potential future infertility.
Clinical Presentation
Symptoms:
Sudden onset of severe, unilateral lower abdominal pain
Nausea and vomiting are common
The pain may be intermittent initially, becoming constant
Fever is usually absent unless secondary infection occurs.
Signs:
Tenderness on abdominal palpation, often localized to one side
Rebound tenderness and guarding may be present if peritonitis has developed
A palpable adnexal mass may be present
Vital signs may be normal initially but can show tachycardia and hypotension with significant pain or hemorrhage.
Diagnostic Criteria:
No strict diagnostic criteria exist
diagnosis is primarily clinical and supported by imaging
Suspicion arises with sudden onset severe unilateral pelvic pain, especially in the presence of an adnexal mass.
Diagnostic Approach
History Taking:
Detailed pain history: onset, character, radiation, duration, associated symptoms (nausea, vomiting, fever, urinary or bowel symptoms)
Previous episodes of similar pain
Menstrual history
History of ovarian cysts or masses
Family history of gynecologic conditions.
Physical Examination:
General assessment: vital signs, hydration status
Abdominal examination: inspection, palpation for tenderness, masses, rigidity, rebound tenderness
Pelvic examination: speculum and bimanual examination to assess for cervical motion tenderness, adnexal tenderness, or masses
In infants and premenarchal girls, a rectal examination may be more informative.
Investigations:
Complete blood count (CBC) may show leukocytosis
Urinalysis to rule out urinary tract infection
Pregnancy test (in sexually active females)
Pelvic ultrasound (transabdominal and transvaginal if feasible) is the cornerstone, assessing ovarian size, stromal edema, follicular pattern, and presence of Doppler flow (absent or diminished flow suggests torsion)
MRI may be useful if ultrasound is equivocal
Laparoscopy is diagnostic and therapeutic.
Differential Diagnosis:
Appendicitis
Pelvic inflammatory disease (PID)
Ovarian cyst rupture or hemorrhage
Ectopic pregnancy
Urinary tract infection (UTI)
Kidney stones
Gastroenteritis
Meckel's diverticulitis.
Management
Initial Management:
Pain control with intravenous analgesics (e.g., morphine, fentanyl)
Intravenous fluids for hydration
Antiemetics to manage nausea and vomiting
Broad-spectrum antibiotics if signs of infection or peritonitis are present.
Medical Management:
Primarily supportive
No specific medical management for torsion itself
the goal is prompt surgical intervention.
Surgical Management:
Laparoscopy is the preferred approach
The ovary is detorsed (untwisted) counterclockwise (if right ovary) or clockwise (if left ovary) to restore blood flow
Ovarian cystectomy or salpingo-oophorectomy is performed if a large or suspicious mass is present
If the ovary appears necrotic after detorsion, it may be removed, but conservative attempts to save viable ovarian tissue are prioritized
Oophoropexy (fixing the ovary to the pelvic wall) may be considered in cases of recurrent torsion or in young patients with elongated utero-ovarian ligaments, though its long-term efficacy is debated.
Supportive Care:
Continuous monitoring of vital signs and pain levels
Postoperative pain management
Gradual resumption of oral intake
Monitoring for signs of complications such as infection, bleeding, or bowel dysfunction.
Complications
Early Complications:
Ovarian necrosis
Hemorrhage
Infection
Postoperative ileus
Adnexal abscess.
Late Complications:
Infertility due to loss of ovarian tissue or function
Chronic pelvic pain
Adhesions
Recurrent torsion
Ovarian failure.
Prevention Strategies:
Prompt diagnosis and surgical intervention to salvage the ovary
Management of predisposing conditions like large ovarian cysts.
Prognosis
Factors Affecting Prognosis:
Duration of torsion before intervention
Degree of ovarian compromise
Presence of ovarian mass
Associated complications like necrosis or infection.
Outcomes:
If treated promptly (within hours of symptom onset), ovarian salvage rates are high, and fertility can be preserved
Delayed treatment significantly increases the risk of ovarian loss
Long-term outcomes are generally good with successful salvage.
Follow Up:
Regular follow-up is essential to monitor ovarian function, assess for recurrent torsion, and evaluate for any late complications
This includes serial pelvic examinations and ultrasounds
In pediatric patients, close collaboration with pediatric endocrinologists may be necessary if ovarian function is compromised.
Key Points
Exam Focus:
Ovarian torsion is a surgical emergency
Sudden unilateral pelvic pain with nausea/vomiting is classic
Ultrasound with Doppler is the primary imaging modality
Prompt surgical detorsion is key to ovarian salvage and fertility preservation.
Clinical Pearls:
Always consider ovarian torsion in the differential diagnosis of acute abdominal pain in girls and young women, even without typical risk factors
Untwist counterclockwise for right ovary, clockwise for left
Aim to preserve the ovary unless clearly necrotic and irreparable.
Common Mistakes:
Delaying surgical intervention due to diagnostic uncertainty
Over-reliance on Doppler findings alone, as flow can be present even in torsion
Failure to consider torsion in premenarchal girls or infants
Inadequate pain management during the diagnostic and management phases.