Ovarian torsion

Question 1

Definition

Answer 1

Ovarian torsion is a condition where the ovary twists in relation to the surrounding connective tissue, fallopian tube and blood supply (the adnexa).

Question 2

Aetiology

Answer 2

• Ovarian torsion is usually due to an ovarian mass larger than 5cm, such as a cyst or a tumour. It is more likely to occur with benign tumours. It is also more likely to occur during pregnancy.
• Can also happen with normal ovaries in younger girls before menarche when girls have longer infundibulopelvic ligaments that can twist more easily.

Question 3

Pathophysiology

Answer 3

Twisting of the adnexa and blood supply to the ovary leads to ischaemia. If the torsion persists, necrosis will occur, and the function of that ovary will be lost. Therefore, ovarian torsion is an emergency, where a delay in treatment can have significant consequences. Prompt diagnosis and management is essential.

Question 4

Signs and symptoms

Answer 4

• Sudden onset of severe unilateral pelvic pain
  = Constant
  = Gets progressively worse
  = Associated with nausea and vomiting
• Pain can be a milder and more prolonged course
  Occasionally the ovary can twist and untwist intermittently causing pain to come and go.
• On examination there will be localised tenderness. There may be a palpable mass in the pelvis, (absence does not exclude the diagnosis).

Question 5

Diagnosis

Answer 5

FIRST LINE = Pelvic ultrasound
- Transvaginal ideal
- Shows “whirlpool sign” = free fluid in pelivs and oedema of the ovary
- Doppler USS may show lack of blood flow
GOLD STANDARD = Laparoscopic surgery

Question 6

Treatment

Answer 6

• Emergency admission under gynaecology
• Laparoscopic surgery to either:
  = Un-twist the ovary and fix it in place (detorsion)
  = Remove the affected ovary (oophorectomy)
  = The decision whether to save the ovary made during the surgery, based on a visual inspection of the ovary. Laparotomy may be required where there is a large ovarian mass or malignancy is suspected.

Question 7

Complications

Answer 7

Delay in treating ovarian torsion can result in loss of function of that ovary.
- The other ovary can usually compensate, so fertility is not typically affected.
- Where this is the only functioning ovary, loss of function leads to infertility and menopause.
- Where a necrotic ovary is not removed, it may:
= become infected,
= develop an abscess
= and lead to sepsis
= Additionally it may rupture, resulting in peritonitis and adhesions.