Pocket ObGyn – Adnexal Torsion
See Abbreviations
Definition and Epidemiology (Am J Obstet Gynecol 1985;152:456)
- Twisting of adnexal components (most commonly ovary ± fallopian tube) on their ligamentous supports ® venous, arterial, & lymphatic obst
- 5th most common gyn emergency; 7% of female surgical emergencies
- Females of all ages (fetal/neonat to elderly); however, 70% are of ages 20–39
- Increased risk w/ Preg (20–25% of all cases) & ovarian hyperstimulation
Etiology (Clin Exp Obstet Gynecol 2004;31:34; Am J Obstet Gynecol 1991;164:577)
- 94% a/w adnexal mass (48% cysts, 46% neoplasms). w/ masses 6–10 cm
- Congenitally long ovarian ligaments
- w/ strenuous exercise, intercourse or sudden in abdominal pressure
- Right ovarian torsion more common than left (protection from sigmoid colon)
Pathophysiology
- Compromise of vascular pedicles impedes arterial inflow & lymphatic & venous outflow ® Venous drainage interrupted before arterial due to less compressibility of arterial walls ® Marked ovarian enlargement can develop w/ continued perfusion & blocked outflow
Clinical Manifestations and Physical Exam (Ann Emerg Med 2001;38:1506)
- Acute pelvic pain (83%): Sudden/sharp pain (59%) radiating to back/flank/groin (51%) w/ peritoneal signs (3%)
- Nausea &/or vomiting (70%): Colicky or sporadic sx from intermittent torsion
- Neonates: Usually in 1st 3 mo of life w/ feeding intolerance, vomiting, abdominal distension, & fussiness/irritability – usually ovarian cysts have already been identified w/ prenatal US (Arch Pediatr Adolesc Med 1998;152:1245).
- Resolution of sx seen after ~24 h due to ischemic death of involved Functionality can be preserved w/ immediate intervention.
- Bimanual exam: Adnexal mass (72%), tenderness in RLQ or LLQ
- Fever (<2%): May be a marker of necrosis, particularly in the setting of increased WBC
Diagnostic Workup/Studies
- Dx confirmed at ~40% correct preop dx (J Reprod Med 2000;45:831)
- Clinical dx: (1) Lower abdominal pain, (2) ovarian cyst/mass, & (3) diminished or absent bld flow in the ovarian vessels on color Doppler flow Rule out ectopic Preg, PID, appendicitis, diverticulitis, nephrolithiasis, & leiomyoma- related sx.
- Lab studies: hCG to rule out Preg; labs: CBC, BMP, may see anemia, leukocytosis, or electrolyte abnormalities from
- US: Cystic or solid mass (70%), free fluid in post cul-de-sac (>50%), enlarged heterogenous appearing ovary (J Ultrasound Med 2001;20:1083). Nml ovary on US does not rule out
Doppler: Controversial; some studies w/ sens & spec of 100% & 97%, others w/ 43% & 92% (Eur J Obstet Gynecol Reprod Biol 2002;104:64); color Doppler flow dx of tor- sion when absent but not reliable when flow is present.
Whirlpool sign: Doppler finding in vascular pedicle (J Ultrasound Med 2009;28:657)
MRI/CT: Limited value, can ID ovarian edema; diagnostic criteria not been well defined or validated. CT potentially useful in excluding other diagnoses on diff.
Treatment (NEJM 1989;321:546; Obstet Gynecol Surv 1999;54:601)
- Swift operative eval: Preserve ovarian fxn & prevent infxn from necrosis
Laparoscopic detorsion w/ cystectomy vs. salpingo-oophorectomy: Consider detorsion in premenopausal pts, majority regain prev form & fxn, even if ischemic appearing intraoperatively. No risk of clot dislodgement/PE in either detorsion or salpingo-oophorectomy. Consider oophoropexy for prevention esp w/ recurrent ovarian torsion.