Torsion of Ovary

Mehdi Parva and Charles J. Dunton

Causes of acute abdominal pain unique to women include pelvic inflammatory disease, ectopic pregnancy, endometrioma, rupture or hemorrhage of a cor­pus luteum cyst, and torsion of adnexal structures (1).

ETIOLOGY

Torsion of the adnexa is caused by rotation of the ovary or the adnexa about the ovarian pedicle, resulting in arterial, venous, or lymphatic obstruction (Fig. 23.1). Initially, the venous and lymphatic obstruction without arterial obstruction produces edema and enlargement of the ovary. If arterial obstruction occurs, the organs may become necrotic and gangrenous. This in turn may lead to peritonitis and intestinal obstruction. In some cases, the twisted adnexa may be absorbed, leading to unilat­eral absence of the adnexa. Torsion of the fallopian tube alone is rare and has been associated with hydrosalpinx, neoplasms of the tube, and previous tubal ligation (2-5) (Fig. 23.2). Torsion of the adnexa is increased in ovarian hyperstimulation syn­drome (OHSS) caused by menotropin therapy for infertility (6-8).

Pregnancy has been associated with an increased risk of adnexal torsion (9,10). If an adnexal mass is associated with a pregnancy, a recent review found that the most frequent complication was torsion (11). This may be due to the repositioning of the ovaries by the enlarging uterus. Torsion is most likely in the first trimester (10,12).

Torsion of the adnexa may involve the ovary, the fallopian tube, or both structures together. In most cases, an ovarian neoplasm is involved (9). Nonethe­less, in up to 18% of cases, the torsion may involve normal tubes and ovaries.

It is unusual for malignant neoplasm to present with symptoms of torsion. A review of 10 years’ experience at the Women’s Hospital, Los Angeles County, showed only two cases of malignant neoplasms undergoing torsion. In comparison, the relative risk for a benign neoplasm to undergo torsion was 12.9% (95% CI, 10.2 to 15.9) (14,15). However, if a postmenopausal woman presents with torsion, clinicians should con­sider the possibility of malignancy. In series with a high percentage of malignancy reported with torsion, most patients were postmenopausal (13,16). Postmenopausal patients also had a delayed diagnosis compared to younger patients (13).

Torsion of a normal ovary may present as a massive ovarian edema. This tumor-like condition presents with significant ovarian enlargement and patho­logically shows only edema of a normal ovary (17).

CLINICAL FEATURES

The clinical diagnosis of adnexal torsion is often difficult. It occurs mainly in young women and less frequently in children and postmenopausal females. Pain,

FIGURE 23.1 Torsion of infundibulopelvic ligament.

FIGURE 23.2 Torsion of the adnexa.

Source. With permission from Lomano JM, Trelford JD, Ullery JC. Torsion of the uterine adnexa causing an acute abdomen. Obstet Gynecol. 1970;Vol.no. 35, issue.no. 2.

low-grade temperature, moderate leukocytosis, and nausea and vomiting (70%) are present in most cases. The pain associated with torsion may be unilateral or bilateral (25%) and either intermittent or constant.

Abdominal examination may show initial rigidity, spasm, tenderness, and unilateral pain on deep palpation. On pelvic examination, unilateral adnexal ten­derness and a palpable mass are usually present. The torsion is more likely to involve the right adnexal (3:2), perhaps because of the proximity of the sigmoid colon to the left adnexa, resulting in less space in which the torsion can occur (21). Half of the patients may have radiation to the back, flank, or groin. One third of patients may exhibit only mild abdominal tenderness and some have no pelvic tenderness (18).

In Bouguizane et al. (22), a review of 135 cases of adnexal torsion, only 57.8% of patients were diagnosed accurately at the first clinical examination. Incorrect preoperative diagnoses in patients subsequently having torsion include adnexal mass, appendicitis, myoma, ectopic pregnancy, abscess, and ruptured viscus (23). Torsion must be considered in the differential diagnosis of abdominal pain, especially when a palpable pelvic mass is present.

If no palpable mass is present, ultrasonography may prove helpful in the diag­nosis (17,24). Ultrasonography has been shown to demonstrate a mass in all patients

Source. With permission from Lomano JM, Trelford JD, Ullery JC. Torsion of the uterine adnexa causing an acute abdomen. Obstet Gynecol. 1970;Vol.no. 35, issue.no.

with torsion. However, the ultrasonic appearance of the masses was nonspecific (17). The use of Doppler flow examination has recently been shown to be helpful in the diagnosis and management of ovarian torsion. Doppler ultrasound is able to identify the twisted vascular pedicle in the majority of cases (24,25). If normal arte­rial and venous flow can be demonstrated, untwisting of the pedicle is possible. If no blood flow is seen, this is generally associated with necrotic adnexa (17). How­ever, more recent studies of Doppler ultrasound have shown that normal flow does not exclude the diagnosis of ovarian torsion (17,26). In fact, in one case report, up to 60% of confirmed ovarian torsions had normal flow (27). Approximately 20% of patients with an adnexal torsion will have a concomitant intrauterine pregnancy. Ultrasound can demonstrate the location of the pregnancy and aid in differentia­tion of torsion with intrauterine pregnancy from an ectopic gestation.

Magnetic resonance imaging (MRI) and computed tomography (CT) scan­ning have been described in a small number of patients. CT and MRI findings are generally nonspecific unless edema or hemorrhagic findings are present. MRI findings of large areas of high signal intensity on both T₁- and T₂-weighted images are associated with passive congestion of the torsed mass. The common CT and MRI features of adnexal torsion include thickening of the twisted fallopian tube, smooth thickening of the wall of the cystic ovarian mass, ascites, and uterine deviation to the side of torsion (28-30).

DIFFERENTIAL DIAGNOSIS

The diagnosis of torsion of the adnexa must be considered in women with abdom­inal pain. The differential diagnoses include ectopic pregnancy, appendicitis, pelvic inflammatory disease, adnexal mass without torsion, endometrioma, degeneration of a myoma, renal calculi, urinary tract infection, and ruptured functional cyst (1,19).

Ectopic pregnancy without an acute abdomen is diagnosed by serial β-human chorionic gonadotropin (β-hCG) testing along with appropriate use of ultrasound when the quantitative β-hCG level reaches the discriminatory zone.

In appendicitis, the symptoms of midline abdominal pain with migration to the right lower quadrant and negative pelvic findings other than tenderness on rectal examination differentiate this entity from torsion. In addition, the nau­sea and vomiting seen in torsion generally occur rapidly after the onset of pain, rather than gradually, as in acute appendicitis.

Pelvic inflammatory disease is usually characterized by bilateral pain and tenderness. Temperature elevation and leukocytosis may be more marked. Perti­nent history—such as episodes of pelvic infl ammatory disease, intrauterine device use, and multiple or new sexual partners—points to pelvic inflammatory disease.

Patients who have an adnexal mass without torsion generally present with­out pain. Those who have a ruptured functional cyst may present at the midpoint of the menstrual cycle (Mittelschmerz) or just prior to the next expected period. Symptoms of nausea and vomiting are less frequent. In cases where there is no hemorrhage, symptoms are less severe than those seen with adnexal torsion and resolve over 48 hours.

Renal calculi usually present with flank pain and hematuria. There is also lack of a palpable pelvic mass. Degeneration of a myoma, especially if peduncu­lated, may require laparoscopy to confirm the diagnosis. A history of chronic pelvic pain will usually accompany endometriosis. Fever, acute pain, and increased leukocyte count are not seen with endometriomas unless there is a rupture. In cases of rupture, an acute abdomen may be seen necessitating opera­tive intervention.

In all cases of acute pain, an empty bladder is necessary to ensure that uri­nary retention is not the cause of the pain.

A high index of suspicion for torsion in cases of abdominal pain with a palpable or ultrasonically detected pelvic mass is necessary. Combined with l aparoscopy in equivocal cases, early diagnosis and prompt treatment of this condition are possible.

Serum concentrations of interleukin-6 have been reported to be elevated in ovarian torsion in 75% of cases (six of eight) (31). Ovarian torsion has also been reported along with cases of inguinal hernia (32).

TREATMENT

Treatment for adnexal torsion is surgical and depends on the condition of the ovary at the time of surgery. In most series, treatment has consisted of removal of the affected adnexa because of fear of embolism from thrombosed ovarian veins or necrosis of the ovary and the tube. In these cases, it is wise to expose the ureter to determine its location prior to ligating the ovarian blood supply, as the tenting of the peritoneum by the torsion may cause the ureter to be in or adjacent to the twisted pedicle.

Laparoscopic management of ovarian torsion has become the standard of care. If the ovary is not necrotic and fertility is important, it may be untwisted and stabilized by suturing it to the posterior wall of the uterus or by shortening the ovarian ligament. Observation is important to determine viability. Long-term follow-up has demonstrated that normal ovarian function is present in the great majority of cases. Follow-up ultrasounds have demonstrated normal follicu­lar function in 95% of cases. Two important facto rs that may influence a success­ful conservative management of adnexal torsion are the surgeon’s experience and the time interval from the beginning of abdominal pain (36 hours) to definitive treatment (33-38). Since torsion is usually associated with neoplasms of the ovary, the ovary should be carefully inspected and cystectomy carried out if necessary. If there is suspicion of a malignancy, unilateral adnexectomy should be performed. Appropriate surgical staging should be carried out if a frozen section shows malignancy (2).

Laparoscopic oophoropexy has been described to prevent recurrent ovar­ian torsion. This may be performed if the surgeon feels that the risk of recurrent torsion is high based on physical findings or if it represents the remaining ovary in premenopausal women (36).

Ovarian torsion has been described in postmenopausal women on tamox­ifen therapy (39).

SPECIAL CONSIDERATIONS

Torsion of the ovary is associated with OHSS caused by the hMG (Pergonal) use for ovulation induction. This syndrome is characterized by high estrogen secretion, enlargement of the ovaries, abdominal discomfort, and nausea and vomiting. In severe cases, clinical manifestations may include ascites, pleural effusions, electrolyte imbalance, oliguria, and shock. Torsion of the ovary was present in 7.4% of cases of OHSS in one series. It was more common (16%) in patients who were pregnant and had OHSS (40). A review of assisted reproductive technologies demonstrated nine cases of ovarian torsion in 10,583 cycles. However, 3 of 104 patients with OHSS demonstrated torsion. All cases were treated conservatively (41). Recent reports of treatment of these patients by the untwisting of the ovarian pedicle even when the ovary appears necrotic have demonstrated no complications. Normal subsequent ovarian function has been demonstrated by ultrasound in these patients. Continuation of pregnancy without problems was also demonstrated. Although the number of patients treated in this manner is still small, this option should be considered for these patients, in whom fertility is such an important issue. This method of treatment may not be applicable to patients who do not have OHSS (38,40).

The diagnosis of ovarian torsion must be considered in children pre­senting with abdominal pain. In children, the adnexal torsion may present as an abdominal mass. The diagnosis in children is especially important. Kokoska et al. (42) reported on 51 children with ovarian torsion. At their institution, all 51 underwent salpingo-oophorectomy. Earlier diagnosis may allow for conservative treatment (36). This entity has been reported in the infant as well (43).

CONCLUSIONS

Torsion of the adnexal structures must be considered in women of all ages pre­senting with abdominal pain. The incidence is highest in the reproductive-age group. A palpable or an ultrasonically detected pelvic mass along with pain should alert the clinician to consider this diagnosis. Because of the difficulty of clinical diagnosis, the more frequent use of laparoscopy may lead to early treat­ment and preservation of fertility.

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