Ovarian torsion: Difference between revisions
(Strip excess bold)
 
(13 intermediate revisions by 5 users not shown)
Line 1: Line 1:
==Background==
==Background==
*Ovarian torsion is the rotation of the ovary and portion of the fallopian tube on the supplying vascular pedicle
*Rotation of the ovary around its vascular pedicle (infundibulopelvic and utero-ovarian ligaments)
*Referred to as adnexal torsion and tubo-ovarian torsion
*Compromises venous/lymphatic drainage first → edema → eventual arterial compromise → ischemia and necrosis
*Occurs in females of all ages
*'''5th most common gynecologic emergency'''
**Most common in reproductive age adults
*Accounts for ~3% of all gynecologic emergencies
**In children, it is most common in 9-14 years of age
*Most common in reproductive-age women (20-40 years)
**Risk factors:
*Risk factors:
***Ovarian mass
**Ovarian mass >5 cm (most common risk factor; dermoid cysts particularly prone)
***Fertility treatments
**Ovarian hyperstimulation syndrome (fertility treatment)
*Ovarian cysts (usually > 4 cm) and neoplasms account for 94% of cases in adults<ref>Amirbekian S et al. Ultrasound Evaluation of Pelvic Pain. Radiol. Clin. North Am. 2014;52 (6): 1215-1235</ref>
**Pregnancy (especially first trimester; corpus luteum cysts)
*Torsion more common on the right, as the sigmoid colon tends to stabilize the left
**Prior tubal ligation (increases ovarian mobility)
*In children, hypermobility of the ovary many be the primary cause of torsion
**Long utero-ovarian ligament
*Dual blood supply from ovarian and uterine arteries
*Right side more common than left (sigmoid colon may limit left ovarian mobility)
 
*Can occur in prepubertal girls (often without predisposing mass — normal ovary)
===Pathophysiology===
Torsion occurs from either of two causes:
#Hypermobility of the ovary
#Adnexal mass
*Cysts greater than 4 cm are more likely to torse<ref>M.L. Brandt et al. Surgical indications in antenatally diagnosed ovarian cysts J Pediatr Surg, 26 (1991), pp. 276–282</ref>
*Absence of ovarian Doppler flow is highly specific for torsion, but normal Doppler flow does not completely exclude torsion


==Clinical Features==
==Clinical Features==
*[[Nausea/vomiting]] (70%)
*Sudden onset, severe, unilateral lower abdominal/pelvic pain (most common presentation)
*Sudden and sharp pain in the lower abdomen (50%)<ref>Houry, D. and Abbott, J.T. Ovarian torsion: a fifteen-year review. Ann Emerg Med. 2001; 38: 156–159.</ref>
*Pain may be intermittent (intermittent torsion/detorsion)
**Can be intermittent and insiduous, especially in those with history of cysts, PCOS<ref>Damigos, E., Johns, J., and Ross, J. An update on the diagnosis and management of ovarian torsion. Obstet Gynaecol. 2012; 14: 229–236.</ref>
*Nausea and vomiting (present in 70% — may be prominent)
**Commonly occurs simultaneously with vomiting
*Low-grade [[fever]] (late finding suggesting necrosis)
**May occur for days to months intermittently before diagnosis is made<ref>Sasaki, K.J. and Miller, C.E. Adnexal torsion: review of the literature. J Minim Invasive Gynecol. 2014; 21: 196–202.</ref>
*Adnexal tenderness on bimanual exam; palpable adnexal mass in ~50%
*Up to 30% have no tenderness on bimanual exam<ref>Houry, D. and Abbott, J.T. Ovarian torsion: a fifteen-year review. Ann Emerg Med. 2001; 38: 156–159.</ref>
*May mimic [[appendicitis]], [[renal colic]], or [[ectopic pregnancy]]
*Most adults with ovarian torsion have abnormal or enlarged ovaries that serves as lead point for torsion, but torsion is more likely to occur in normal sized ovaries in pediatrics<ref>Anders, J.F. and Powell, E.C. Urgency and evaluation and outcome of acute ovarian torsion in pediatric patients. Arch Pediatr Adolesc Med. 2005; 159: 532–535.</ref>
*Peritoneal signs are late and suggest necrosis
**More than 50% of cases have no palpable adnexal mass<ref>Houry, D. and Abbott, J.T. Ovarian torsion: a fifteen-year review. Ann Emerg Med. 2001; 38: 156–159.</ref>
*In children: may present with non-specific abdominal pain
*[[Fever]] (<2%)
*Up to 20% of cases seen in pregnant women, with most in the 1st trimester and/or received fertility treatments<ref>Albayram, F. and Hamper, U.M. Ovarian and adnexal torsion: spectrum of sonographic findings with pathologic correlation. J Ultrasound Med. 2001; 20: 1083–1089.</ref>


==Differential Diagnosis==
==Differential Diagnosis==
{{Abd DDX RLQ}}
*[[Ectopic pregnancy]] (always obtain pregnancy test first)
*Ruptured [[ovarian cyst]]
*[[Appendicitis]]
*[[Renal colic]] / [[nephrolithiasis]]
*[[Pelvic inflammatory disease]] / [[tubo-ovarian abscess]]
*[[Endometriosis]]
*[[Testicular torsion]] (analogous condition)
*Hemorrhagic corpus luteum


{{LLQ DDX}}
{{Pelvic pain DDX}}


==Evaluation==
==Evaluation==
===Pelvic exam===
*Urine pregnancy test (rule out [[ectopic pregnancy]])
*May not have adnexal TTP or adnexal mass
*CBC: leukocytosis may be present (nonspecific)
*Urinalysis: rule out [[UTI]], [[nephrolithiasis]]
*Lactate: may be elevated in late presentations
 
===Transvaginal Ultrasound (Test of Choice)===
*Enlarged ovary (>4 cm) compared to contralateral side
*Ovarian edema (heterogeneous appearance)
*Peripherally displaced follicles ("string of pearls" sign)
*Whirlpool sign on Doppler: twisted vascular pedicle (most specific finding)
*Free fluid in cul-de-sac


===Doppler [[Ultrasound]]===
====Doppler Findings====
Findings suggestive of torsion may include:
*Absent or decreased ovarian arterial/venous flow supports diagnosis
*Diminished or absent blood flow in the ovarian vessels<ref name="Lee">Lee EJ et-al. Diagnosis of ovarian torsion with color Doppler sonography: depiction of twisted vascular pedicle. J Ultrasound Med. 1998;17 (2): 83-9.</ref>
*HOWEVER: presence of Doppler flow does NOT exclude torsion<ref>Shadinger LL, et al. Surgically treated adnexal torsion: does the presence of doppler flow predict viability? ''J Ultrasound Med''. 2008;27(5):687-691. PMID 18424640</ref>
**2/3 of patients with ovarian torsion have had normal blood flow
**Sensitivity of absent flow is only ~50% — dual blood supply (ovarian and uterine arteries)
**Venous and lymphatic obstruction occurs before arterial disruption, especially early in disease process<ref>Cicchiello, L.A., Hamper, U.M., and Scoutt, L.M. Ultrasound evaluation of gynecologic causes of pelvic pain. Ultrasound Clin. 2010; 38: 85–114.</ref>
**Intermittent torsion may show normal flow between episodes
**Abnormal blood flow, whether venous or arterial, is ~85% sensitive, ~37% specific when not combined with below findings<ref>Cicchiello, L.A., Hamper, U.M., and Scoutt, L.M. Ultrasound evaluation of gynecologic causes of pelvic pain. Ultrasound Clin. 2010; 38: 85–114.</ref>
*If high clinical suspicion, proceed to OR despite normal Doppler
*Enlarged ovarian volume
**'''MC finding'''
**A maximum ovarian diameter (MOD) under 3cm in a postmenarchal patient is unlikely to represent ovarian torsion<ref>Budhram G, Elia T, Dan J, et al. A Case-Control Study of Sonographic Maximum Ovarian Diameter as a Predictor of Ovarian Torsion in Emergency Department Females With Pelvic Pain. Acad Emerg Med. 2019;26(2):152-159.</ref>
*Loss of echogenicity
*Peripherally displaced follicles with hyperechoic central stroma
*Midline ovary
*Pelvic free fluid
*An infarcted ovary may have a more complex appearance with cystic or hemorrhagic degeneration
*Whirlpool sign of twisted vascular pedicle may be seen but rare<ref name="Lee"></ref>


===CT Abd/Pelvis===
===CT Abdomen/Pelvis===
*CT has a low sensitivity for torsion
*May show enlarged ovary, fat stranding, deviation of uterus toward affected side
**Examine for asymmetric ovarian enlargement, which warrants a pelvic US if concerning symptoms exist<ref>Lourenco, A.P., Swenson, D., Tubbs, R.J. et al. Ovarian and tubal torsion: imaging findings on US, CT and MRI. Emerg Radiol. 2014; 21: 179–187.</ref>
*Less sensitive than US for torsion but may identify alternative diagnoses
*CT may be used to rule out other possible causes of lower abdominal pain; also exclude presence of pelvic mass
*"Ovarian mass with surrounding fat stranding" on CT should raise concern


==Management==
==Management==
*Emergent OB/GYN consult in ED
*Emergent gynecology consultation for operative intervention
**Consider if high suspicion exists even after equivocal US
*Time-sensitive — ovarian salvage rates decrease with prolonged ischemia
*Surgical detorsion is required to prevent ovarian necrosis
**Detorsion within 6 hours: high salvage rate
**If the ovary becomes necrotic, there is a high risk of infection
**Detorsion at 24-36 hours: viable ovary still possible
**Salvage rate may be high even if time is prolonged beyond several hours of symptoms<ref>Anders JF, Powell EC. Urgency of evaluation and outcome of acute ovarian torsion in pediatric patients. Arch Pediatr Adolesc Med. 2005;159:532–535</ref>
**'''Do not assume a black/dusky ovary is nonviable''' — most recover after detorsion
*Laparoscopic detorsion is procedure of choice (preserves fertility)
*Oophoropexy (fixation) may be performed to prevent recurrence
*Oophorectomy reserved for clearly necrotic tissue or suspected malignancy
*Supportive care in ED:
**IV fluids, antiemetics (ondansetron 4 mg IV)
**Pain control: ketorolac 15-30 mg IV and/or opioids
**NPO for OR preparation
 
==Disposition==
*Admit for emergent surgical intervention
*'''Do NOT delay surgery for additional imaging''' if clinical suspicion is high
*Consult gynecology early — even if US is equivocal, operative evaluation may be warranted


==See Also==
==See Also==
*[[Abdominal pain]]
*[[Ovarian cyst]]
*[[Ectopic pregnancy]]
*[[Testicular torsion]]
*[[Pelvic pain]]
*[[Appendicitis]]


==References==
==References==
<references/>
<references/>
*Huchon C, Fauconnier A. Adnexal torsion: a literature review. ''Eur J Obstet Gynecol Reprod Biol''. 2010;150(1):8-12. PMID 20189289
*Chang HC, et al. Pearls and pitfalls in diagnosis of ovarian torsion. ''Radiographics''. 2008;28(5):1355-1368. PMID 18794312
*Houry D, Abbott JT. Ovarian torsion: a fifteen-year review. ''Ann Emerg Med''. 2001;38(2):156-159. PMID 11468611
*Oelsner G, Shashar D. Adnexal torsion. ''Clin Obstet Gynecol''. 2006;49(3):459-463. PMID 16885652
[[Category:OBGYN]]
[[Category:OBGYN]]

Latest revision as of 09:35, 22 March 2026

Background

  • Rotation of the ovary around its vascular pedicle (infundibulopelvic and utero-ovarian ligaments)
  • Compromises venous/lymphatic drainage first → edema → eventual arterial compromise → ischemia and necrosis
  • 5th most common gynecologic emergency
  • Accounts for ~3% of all gynecologic emergencies
  • Most common in reproductive-age women (20-40 years)
  • Risk factors:
    • Ovarian mass >5 cm (most common risk factor; dermoid cysts particularly prone)
    • Ovarian hyperstimulation syndrome (fertility treatment)
    • Pregnancy (especially first trimester; corpus luteum cysts)
    • Prior tubal ligation (increases ovarian mobility)
    • Long utero-ovarian ligament
  • Right side more common than left (sigmoid colon may limit left ovarian mobility)
  • Can occur in prepubertal girls (often without predisposing mass — normal ovary)

Clinical Features

  • Sudden onset, severe, unilateral lower abdominal/pelvic pain (most common presentation)
  • Pain may be intermittent (intermittent torsion/detorsion)
  • Nausea and vomiting (present in 70% — may be prominent)
  • Low-grade fever (late finding suggesting necrosis)
  • Adnexal tenderness on bimanual exam; palpable adnexal mass in ~50%
  • May mimic appendicitis, renal colic, or ectopic pregnancy
  • Peritoneal signs are late and suggest necrosis
  • In children: may present with non-specific abdominal pain

Differential Diagnosis

Acute Pelvic Pain

Differential diagnosis of acute pelvic pain

Gynecologic/Obstetric

Genitourinary

Gastrointestinal

Musculoskeletal

Vascular

Evaluation

  • Urine pregnancy test (rule out ectopic pregnancy)
  • CBC: leukocytosis may be present (nonspecific)
  • Urinalysis: rule out UTI, nephrolithiasis
  • Lactate: may be elevated in late presentations

Transvaginal Ultrasound (Test of Choice)

  • Enlarged ovary (>4 cm) compared to contralateral side
  • Ovarian edema (heterogeneous appearance)
  • Peripherally displaced follicles ("string of pearls" sign)
  • Whirlpool sign on Doppler: twisted vascular pedicle (most specific finding)
  • Free fluid in cul-de-sac

Doppler Findings

  • Absent or decreased ovarian arterial/venous flow supports diagnosis
  • HOWEVER: presence of Doppler flow does NOT exclude torsion[2]
    • Sensitivity of absent flow is only ~50% — dual blood supply (ovarian and uterine arteries)
    • Intermittent torsion may show normal flow between episodes
  • If high clinical suspicion, proceed to OR despite normal Doppler

CT Abdomen/Pelvis

  • May show enlarged ovary, fat stranding, deviation of uterus toward affected side
  • Less sensitive than US for torsion but may identify alternative diagnoses
  • "Ovarian mass with surrounding fat stranding" on CT should raise concern

Management

  • Emergent gynecology consultation for operative intervention
  • Time-sensitive — ovarian salvage rates decrease with prolonged ischemia
    • Detorsion within 6 hours: high salvage rate
    • Detorsion at 24-36 hours: viable ovary still possible
    • Do not assume a black/dusky ovary is nonviable — most recover after detorsion
  • Laparoscopic detorsion is procedure of choice (preserves fertility)
  • Oophoropexy (fixation) may be performed to prevent recurrence
  • Oophorectomy reserved for clearly necrotic tissue or suspected malignancy
  • Supportive care in ED:
    • IV fluids, antiemetics (ondansetron 4 mg IV)
    • Pain control: ketorolac 15-30 mg IV and/or opioids
    • NPO for OR preparation

Disposition

  • Admit for emergent surgical intervention
  • Do NOT delay surgery for additional imaging if clinical suspicion is high
  • Consult gynecology early — even if US is equivocal, operative evaluation may be warranted

See Also

References

  1. ↑ Norris DL, Young JD. UTI. EM Clin N Am. 2008; 26:413-30.
  2. ↑ Shadinger LL, et al. Surgically treated adnexal torsion: does the presence of doppler flow predict viability? J Ultrasound Med. 2008;27(5):687-691. PMID 18424640
  • Huchon C, Fauconnier A. Adnexal torsion: a literature review. Eur J Obstet Gynecol Reprod Biol. 2010;150(1):8-12. PMID 20189289
  • Chang HC, et al. Pearls and pitfalls in diagnosis of ovarian torsion. Radiographics. 2008;28(5):1355-1368. PMID 18794312
  • Houry D, Abbott JT. Ovarian torsion: a fifteen-year review. Ann Emerg Med. 2001;38(2):156-159. PMID 11468611
  • Oelsner G, Shashar D. Adnexal torsion. Clin Obstet Gynecol. 2006;49(3):459-463. PMID 16885652
Retrieved from "https://www.wikem.org/w/index.php?title=Ovarian_torsion&oldid=389367"