Ovarian Torsion
Introduction
Ovarian torsion is a rare cause of lower abdominal pain in females and refers to the complete or partial rotation of the ovary around it’s ligamentous support. This results in reduced or absent blood supply to the ovary, which becomes oedematous due to reduced outflow. The resultant ischaemia can result in ovarian necrosis and localised haemorrhage. Timely diagnosis is necessary to preserve ovarian function and other morbidity, however given that the symptoms can be very non-specific this can be challenging.
Risk factors for the development of ovarian torsion include the presence of an ovarian mass (e.g ovarian cyst) or a prior history of ovarian torsion. It is most likely to occur with masses >5cm.
Clinical Features
Symptoms
Pain
Sudden onset and moderate to severe
Collicky or sometimes sharp
Can be unilateral or diffuse
May radiate to buttock / groin / back
Nausea +/- vomiting
May experience syncope / pre-syncope
Signs
Abdominal tenderness (tenderness absent in up to 1/3)
Peritonism should prompt suspicion for ovarian necrosis
Low grade fever may be present
Rarely - palpable pelvic mass - oedematous ovary / large cyst
Complications
Hemorrhage
Sepsis
Ovarian necrosis
Pelvic adhesions - leading to tubal infertility
Recurrence
Differential Diagnosis
Gynaecologic
Ruptured ovarian cyst
Ectopic pregnancy
Tubo-ovarian abscess
Gastrointestinal
Appendicitis
Pancreatitis when pain is diffuse
Urologic
Ureteric colic
Clinical Investigations
Bedside
Urinary HCG - rule in alternative diagnosis - ectopic pregnancy
Urinalysis - exclude urinary tract infection
Lactate - may be elevated but usually is not
Laboratory
FBC - leucocytosis may be present
CRP - may be elevated
U&E, LFT, Amylase - aid in excluding alternative diagnosis
Radiology
Ultrasound pelvis
May demonstrate large cyst or mass
Ovary may appear abnormal in appearance, position or demonstrate reduced flow
Doppler flow on ultrasound does not exclude the diagnosis as torsion can be intermittent or there may be incomplete occlusion of the blood supply
Other
CT & MRI are not indicated in the work up of ovarian torsion. If performed they would show similar findings
Management & Disposition
Initial Resuscitation
Iv access
Iv fluid if dehydrated from vomiting
Specific Treatment
Laparoscopic
Ovarian salvage if still viable
Cystectomy if cyst present
Oophrectomy if necrotic or malignant mass present
Symptomatic Treatment
Analgesia as per analgesic ladder
Anti-emetic if required
Disposition
Patients with suspected torsion should be referred to gynaecology on call service immediately
References
Laufer, Marc R. Ovarian and Fallopian Tube Torsion. UpToDate. [Online] July 2021.
https://www.uptodate.com/contents/ovarian-and-fallopian-tube-torsion?search=Ovarian%20torsion%20complications&source=search_result&selectedTitle=1~75&usage_type=default&display_rank=1.
This blog was written by Dr. Jessica Abrahams and was last updated in August 2021