Ovarian Torsion with Dr. Jennifer Dietrich

Topic overview

Dr Jennifer E. Dietrich, discusses ovarian torsion with Dr Todd A. Ponsky
Edited by Nicholas E. Bruns, MD & Ian C. Glenn, MD

• Obtain sexual history and urine b-hCG
• Menstrual history (hemorrhagic cyst may occur)
• Pain
• Duration/onset
• Related activities
• Classic presentation is sudden onset, severe pelvic pain with nausea
• Ultrasound
• Asymmetry of the ovaries
• Characteristics of the ovary
• Normal size follicles
• Follicles at periphery may be due to congestion and edema of the central portion of the ovary from torsion
• Edema
• Presence or absence of blood flow
• Presence of blood flow is unreliable
• Absence of flow is indicative
• Lesion
• Solid vs cystic
• Simple vs complex cyst
• Size greater than 5-6 cm is concerning for torsion
• There is no size cutoff as prepubertal girls could have a torsion related to smaller cysts
• In prepubertal girls, torsion is a more common operative indication than an ovarian cyst
• Complex features, hypervascularity, and elevated tumor markers may be concerning for malignancy
• CT may be useful to assess for pelvic abscess or other intra-abominal cause of abdominal pain
• MRI may be useful to assess for Mullerian abnormalities
• Pelvic exam is unnecessary in an adolescent
• Labs
• CBC may help in evaluating for other causes
• If there is a complex cyst, the following tumor marks should be ordered
• AFP
• Serum b-hCG quantitative
• LDH
• CA-125

Diagnosis and treatment

• Ovarian torsion is a clinical diagnosis
• Patients with suspected torsion should be taken urgently to the operating room regardless of blood flow or other ultrasound findings
• Higher ovarian salvage rates in girls with 24-72 hours of pain with ovarian torsion
• A tube-ovarian abscess should be treated with antibiotics alone
• Rarely a surprise intra-operative findings
• Almost always diagnosed preoperatively on imaging
• In the case of pregnancy, if there is concern for ectopic pregnancy, laparoscopy should be performed. Early pregnancy may not be visualized in the uterus with trans-abdominal ultrasound

• Diagnostic laparoscopy
• If negative, assess for endometriosis in the cul-de-sac
• Lesions may be blue-black, clear or red
• Filling the pelvis with saline and submerging the laparoscope may improve visualization for endometriosis
• Excise lesions sharply or thermal energy
• Detorse ovary
• Remove any lesions to prevent retorsion
• Cystectomy for most cysts
• Fenestration may be okay for simple physiologic cyst
• Paratubal cysts will recur after fenestration
• Shell out cyst from the ovary and cauterize any bleeding from cyst wall
• Try to spare ovary
• Ovary should not be removed unless it is grossly necrotic and falling apart
• Tube as well should be spared unless devitalized
• Ovarian bivalving may improve peripheral blood flow to the ovary after detorsion by releasing pressure from edema. Ovarian biopsy may serve same purpose
• Oophoropexy is most useful for recurrent torsion or torsion associated without an associated lesion
• May be performed by shortening the utero-ovarian ligament or by pexying to the pelvic sidewall or posterior uterus
• May lead to infertility by alternating anatomy
• Clipping the utero-ovarian ligament or infundibulo-pelvic ligament may serve the same purpose by stabilizing the adnexa
• If an ectopic pregnancy is visualized in the tube, a salpingotomy should be performed and the ectopic pregnancy removed. No closure is required.

• Most patients are sent home in a few hours with limited activity
• Oral contraceptives may be used to prevent recurrence of a simple cyst in the menstruating female
• Surveillance ultrasound typically performed at 3 months post-operatively and then annually

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