Ovarian Torsion

Question 1

Aetiological factors to consider

Answer 1

• Ovarian enlargement, especially ovarian cysts
• In premenopausal women pregnancy and OHSS increase the risk
• Consider ovarian malignancy in postmenopausal women
• Masses >5cm more likely to tort, however once very large they become fixed and are less likely to tort
• Fixed masses (ie endometrioma, TOA, malignant masses) less likely to tort
• Right ovary more likely to tort than left (?longer ligament)
• Previous torsion is a risk factor

Question 2

Differential Diagnoses to consider

Answer 2

• Gynaecological
• Ectopic pregnancy
• Tubo-ovarian abscess
• Ruptured ovarian cyst/Cyst Haemorrhage
• Degenerating fibroid
• Endometrioma
• Non-gynaecological
• Appendicitis

Question 3

History suggestive of Ovarian torsion

Answer 3

• Sudden onset of moderate-to-severe pain (90%)
• Nausea and vomiting (70%)
• Known ovarian mass
• Genital tract bleeding
• Timing of onset (ie vigorous activity)

Remember history of Endometriosis/endometrioma REDUCE likelihodd
History of TOC with adhesions REDUCE likelihood

Question 4

Exam findings suggestive of Ovarian torsion

Answer 4

• Low grade fever (20%)
• Abdominal examination – mass, peritonism
• Bimanual examination – mass, tenderness

Question 5

Investigations

Answer 5

o Bloods
- FBE (leucocytosis)
- UEC
- bhCG – pregnancy increases risk, also to exclude ectopic
- Consider ovarian tumour markers
o Transvaginal USS (Not essential if clinically peritonitic/acute abdomen and not readily available)
- Enlarged, oedematous ovary or ovarian mass
- Lateral placement of ovarian follicles as displaced by oedema
- Decreased or absent ovarian Doppler flow
- ‘Whirlpool sign’ of twisting ovarian vessels in vascular pedicle

Question 6

Management of Ovarian torsion

Answer 6

• Initial resuscitation
• IV insertion with blood draw and IV Fluid
• Call for help/ Gynae consultant if needed
• If suspicious mass: Consider Gynae oncology input
• Discuss with Anaesthetic team
• Informed consent re LSC
• Surgery (via laparoscopic approach) is mainstay of treatment
• Timing
  o Ideally within 36/24 of symptom onset, however evidence of viable oocyctes up to 70 hours after symptom onset
• Premenopausal patient
  o Confirm torsion by direct visualisation of rotated ovary
  o Instrument uterus
  o Detorsion should be performed even if ovary appears non-viable
  o Consider cystectomy if cyst present, however if very friable ovary may be better to do in second procedure (Risk of recurrent torsion without cystectomy 5%)
  o Consider oophorectomy if:
  § Necrotic gelatinous mass with no improvement after detorsion
  § Suspicion of malignancy
• Postmenopausal patient
  o Consent for USO if a mass present due to higher chance of malignancy
• Postoperative
  o Observe for signs of sepsis or peritonitis (especially if ovary may not have been viable)
• Debrief and follow up planning
• Prevent recurrence
  o Suppression of ovarian cysts with OCP
  o Oophoropexy
  § Usually in children who have ovarian torsion without ovarian mass
  § Consider in adults with recurrent torsion (and therefore may have abnormally long ligaments)