Ovarian Torsion

Accounts for 2-3% of acute surgical emergencies (fifth most common gynecologic emergency)
More common in young women (peaks at ages 20 to 30 years)
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

Partial or complete rotation of ovarian pedicle
1. Results in lymphatic and venous engorgement in partial rotation, or in early torsion
2. Results in ischemia or infarction in complete rotation, or in late torsion
Typically unilateral and more commonly right sided
Typically both the ovary and the fallopian tube are involved in the torsion
Enlarged ovary or mass is most common predisposing factor (present in a majority of cases)
1. However, girls prior to Puberty with Ovarian Torsion typically have normal ovaries

No risk factors in 25% of patients
Prior torsion
Enlarged Ovary
1. Torsion is uncommon in Polycystic Ovary Syndrome (despite the bilateral enlarged ovaries)
2. Murakami (2013) Clin Exp Obstet Gynecol 40(4):609-11+PMID: 24597271 [PubMed]
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
Pregnancy
1. Related to Adnexal displacement (especially between weeks 6 to 14)
Ovulation induction (Infertility management)
Prior pelvic surgery (including Tubal Ligation)
1. Adhesions may act at pivot points for torsion

Symptoms are initially non-specific
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, low back or flank
5. Pain may be intermittent if partial torsion occurs with spontaneous resolution
  1. Up to 40% of patients have had episodes of prior similar pain
Other associated symptoms
1. Nausea or Vomiting
2. Low grade fever may be present in up to 20% of patients

Abdominal exam
1. Frequently benign Abdomen in early cases
2. Peritoneal signs suggest a longer standing Ovarian Torsion
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

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

High level of suspicion for Ovarian Torsion
1. Consult Gynecology early
2. Pelvic Ultrasound (normal result does not exclude high suspicion Ovarian Torsion)
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
Intermittent Torsion
1. Pelvic Ultrasound may show normal Blood Flow
2. However, intermittent torsion is typically accompanied by Adnexal Mass seen on Ultrasound

Gynecologic emergency
1. Requires prompt diagnosis and treatment for optimal surgical management and ovarian salvage
2. However, delayed presentation does not exclude a salvageable ovary
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