Paula C. Brady1
(1)
Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women’s Hospital, Boston, MA, USA
Paula C. Brady
Email: Pbrady2@partners.org
Keywords
Ovarian torsionTubal torsionOvarian cystLaparoscopyOophoropexy
Definitions
Adnexal Torsion
Twisting of the adnexa—the ovary and/or fallopian tube—leading to occlusion of vascular outflow, resulting in pain and eventual necrosis. Ovarian torsion constitutes 3 % of gynecologic emergencies [1]. Risk factors for ovarian torsion include ovarian cysts greater than 5 cm, prior ovarian torsion (particularly torsion of a normal-appearing ovary), polycystic ovarian syndrome, treatment with gonadotropins for ovarian stimulation, ovarian hyperstimulation syndrome (OHSS), and pregnancy [2, 3]. Isolated tubal t orsion is very rare and almost always associated with tubal enlargement, either with fluid or a mass; the clinical presentation is indistinguishable from ovarian torsion [4].
Differential Diagnosis
Conditions that may present similarly to adnexal torsion include:
· Ruptured ovarian cyst
· Pelvic inflammatory disease or tubo-ovarian abscess
· Ectopic pregnancy
· Degenerating fibroid
· Appendicitis
· Nephrolithiasis
· Pyelonephritis
· Postoperative complications of gynecologic surgery
Please see Chap. 1, Acute Pelvic Pain, for a full differential diagnosis of acute-onset pelvic pain.
When You Get the Call
Ask for a full set of vital signs, and request a pelvic ultrasound if one has not already been performed. Request that the patient not receive further pain medications prior to a physical examination by gynecology, to allow for an accurate assessment.
When You Arrive
Review the full vital signs flow sheet and whether the patient has received any pain medications, which may affect the patient’s physical exam findings. Assess the patient’s discomfort and distress.
History
Review the acuity of the patient’s onset of symptoms—whether the pain began abruptly or developed over several days—and any associated symptoms, including nausea, vomiting, and diarrhea. Review the location and quality of her pain, including aching, sharp, continuous, or episodic. Pain from adnexal torsion is usually acute in onset and unilateral, often associated with nausea and emesis [5, 6]. Review whether she has ever had this pain before or suffers from chronic pain.
Review her full medical, surgical, obstetrical, and gynecologic history, including whether she is currently pregnant or recently had surgery. Review the patient’s last menstrual period and whether she is undergoing ovulation induction or controlled ovarian hyperstimulation for in vitro fertilization. Review whether she has a history of polycystic ovarian syndrome, ovarian cysts, or ovarian torsion.
Physical Examination
Before examining a patient, review when she last received narcotics, which may mask clinically significant findings. Adnexal torsion is primarily a clinical diagnosis. Observe the patient’s degree of discomfort with her pain, as evidenced by posture or inability to settle into a comfortable position. Patients with adnexal torsion often have significant abdominal pain and may have peritoneal signs, including rebound (pain on the abrupt release of abdominal palpation), involuntary abdominal guarding, or shake tenderness (pain with shaking the patient’s abdomen or bed). On bimanual exam, the patient usually has unilateral adnexal tenderness and may have an enlarged adnexa [6].
Diagnosis
A complete blood count, serum human chorionic gonadotropin (hCG), and pelvic ultrasound should be obtained. Up to 50 % of patients with adnexal torsion may have a leukocytosis, though this finding is nonspecific [5].
A transvaginal ultrasound can support the diagnosis of adnexal torsion. Adnexal torsion is commonly associated with adnexal masses; in the absence of a mass, a torsed ovary may appear larger than the normal contralateral ovary [7]. Patients with ovarian torsion will often have ovarian edema (85 %), and the ovarian follicles may appear peripheralized (Fig. 5.1). Abnormal ovarian displacement may also be noted, such as into the anterior cul-de-sac. Of patients with adnexal torsion, 70 % may have free fluid around the torsed adnexa and/or in the posterior cul-de-sac (Fig. 5.2) [7]. Transvaginal ultrasound in patients with adnexal torsion may also reveal the whirlpool sign, which refers to the whirled appearance of the torsed vascular pedicle (Fig. 5.3) [8]. Tubal torsion may appear as a hydrosalpinx by ultrasound—a thick-walled tortuous cystic structure, sometimes with intraluminal debris [9].
Fig. 5.1
Peripheralized follicles. In a 26-year-old patient with laparoscopy-confirmed ovarian torsion, the ovarian follicles (indicated with arrows) appeared peripheralized by transvaginal ultrasound. No ovarian blood flow was documented by color Doppler. An ovarian cyst is denoted with an asterisk (*)
Fig. 5.2
Free fluid in the posterior cul-de-sac. In a 26-year-old patient with laparoscopy-confirmed ovarian torsion, free fluid was noted in the posterior cul-de-sac by transvaginal ultrasound, indicated with an asterisk (*)
Fig. 5.3
Whirlpool sign with color Doppler. Ut uterus, WS whirlpool sign (Reprinted from Valsky et al. [8], with permission of John Wiley & Sons, Inc.)
By ultrasound, abnormal blood flow within the torsed ovary or the ovarian pedicle may be observed by Doppler evaluation. In small series, the absence of arterial and venous blood flow has been reported to have a positive predictive value of 80 % or more [7, 10]. Studies, however, conflict on the reliability of abnormal blood flow in diagnosing ovarian torsion, particularly as this ultrasound finding is operator dependent [7]. Overall, while absence of normal ovarian blood flow may increase suspicion of adnexal torsion, management decisions should not be made based on the presence or absence of Doppler flow.
In patients with suspected adnexal torsion, CT and MRI are not required, but may be obtained to rule out other diagnoses such as nephrolithiasis and appendicitis. In a patient with adnexal torsion, a CT scan with IV contrast may show an enlarged ovary with decreased enhancement, free fluid, and uterine deviation to the side of the torsion [11]. In a patient with ovarian torsion, MRI may show an enlarged ovary (relative to the normal contralateral ovary) with edema, a twisted ovarian pedicle, and ovarian hemorrhage [12].
Management
Management of ovarian torsion is surgical. Intraoperatively, a torsed ovary and/or tube will often appear dusky and sometimes necrotic or hemorrhagic. The ovary and/or fallopian tube should be untwisted. Adnexal detorsion does not confer a significant risk of thromboembolism (0.2 %) [12]. Following adnexal detorsion, the ovary and tube should be observed intraoperatively for return of normal color; significant necrosis is more common after 48 h of torsion [13]. The majority of ovaries can be left in situ, as over 94 % of discolored or hemorrhagic ovaries will regain normal ovarian function and normal appearance by ultrasound [14, 15].
At the time of surgery, any adnexal cysts potentially responsible for the torsion should be drained or removed, as deemed appropriate by the surgeon. Of note, an ovarian cystectomy in a pregnant patient may result in the removal of the corpus luteum, which secretes progesterone crucial for pregnancy maintenance for up to 9 weeks of gestation [16]. Pregnant patients who undergo ovarian cystectomies before 9 weeks of gestation should receive progesterone supplementation, such as intramuscular progesterone in oil (50 mg per day) or micronized vaginal progesterone (200 mg three times per day).
Oophoropexy, or surgical fixation of the ovary, can be considered to prevent recurrent torsion, but clear guidelines have not been established, and the practice is controversial [17]. Oophoropex y may be considered if ovarian torsion occurred in the absence of risk factors (such as an ovarian mass), in a patient with only one ovary, or if torsion is recurrent. Techniques include truncation of the utero-ovarian ligament and fixation of the ovary to the ipsilateral round ligament, pelvic sidewall, uterosacral ligament, or posterior uterus, using absorbable or permanent suture [18, 19]. There are no randomized studies comparing recurrence rates or long-term effects on fertility of these techniques.
References
1.
Hibbard LT. Adnexal torsion. Am J Obstet Gynecol. 1985;152:456–61.CrossRefPubMed
2.
Mashiach S, Bider D, Moran O, Goldenberg M, Ben-Rafael Z. Adnexal torsion of hyperstimulated ovaries in pregnancies after gonadotropin therapy. Fertil Steril. 1990;53:76–80.CrossRefPubMed
3.
Huchon C, Staraci S, Fauconnier A. Adnexal torsion: a predictive score for pre-operative diagnosis. Hum Reprod. 2010;25:2276–80.CrossRefPubMed
4.
Richard 3rd HM, Parsons RB, Broadman KF, Shapiro RS, Yeh HC. Torsion of the fallopian tube: progression of sonographic features. J Clin Ultrasound. 1998;26:374–6.CrossRefPubMed
5.
Shadinger LL, Andreotti RF, Kurian RL. Preoperative sonographic and clinical characteristics as predictors of ovarian torsion. J Ultrasound Med. 2008;27:7–13.PubMed
6.
Sasaki KJ, Miller CE. Adnexal torsion: review of the literature. J Minim Invasive Gynecol. 2014;21:196–202.CrossRefPubMed
7.
Mashiach R, Melamed N, Gilad N, Ben-Shitrit G, Meizner I. Sonographic diagnosis of ovarian torsion: accuracy and predictive factors. J Ultrasound Med. 2011;30:1205–10.PubMed
8.
Valsky DV, Esh-Broder E, Cohen SM, Lipschuetz M, Yagel S. Added value of the gray-scale whirlpool sign in the diagnosis of adnexal torsion. Ultrasound Obstet Gynecol. 2010;36:630–4.CrossRefPubMed
9.
van der Zanden M, Nap A, van Kints M. Isolated torsion of the fallopian tube: a case report and review of the literature. Eur J Pediatr. 2011;170:1329–32.CrossRefPubMed
10.
Nizar K, Deutsch M, Filmer S, Weizman B, Beloosesky R, Weiner Z. Doppler studies of the ovarian venous blood flow in the diagnosis of adnexal torsion. J Clin Ultrasound. 2009;37:436–9.CrossRefPubMed
11.
Rha SE, Byun JY, Jung SE, Jung JI, Choi BG, Kim BS, et al. CT and MR imaging features of adnexal torsion. Radiographics. 2002;22:283–94.CrossRefPubMed
12.
McGovern PG, Noah R, Koenigsberg R, Little AB. Adnexal torsion and pulmonary embolism: case report and review of the literature. Obstet Gynecol Surv. 1999;54:601–8.CrossRefPubMed
13.
Chen M, Chen CD, Yang YS. Torsion of the previously normal uterine adnexa. Evaluation of the correlation between the pathological changes and the clinical characteristics. Acta Obstet Gynecol Scand. 2001;80:58–61.PubMed
14.
Shalev E, Bustan M, Yarom I, Peleg D. Recovery of ovarian function after laparoscopic detorsion. Hum Reprod. 1995;10:2965–6.PubMed
15.
Santos XM, Cass DL, Dietrich JE. Outcome following detorsion of torsed adnexa in children. J Pediatr Adolesc Gynecol. 2015;28:136–8.CrossRefPubMed
16.
Practice Committee of the American Society for Reproductive Medicine. Progesterone supplementation during the luteal phase and in early pregnancy in the treatment of infertility: an educational bulletin. Fertil Steril. 2008;89:789–92.CrossRef
17.
Abeş M, Sarihan H. Oophoropexy in children with ovarian torsion. Eur J Pediatr Surg. 2004;14:168–71.CrossRefPubMed
18.
Pansky M, Smorgick N, Herman A, Schneider D, Halperin R. Torsion of normal adnexa in postmenarchal women and risk of recurrence. Obstet Gynecol. 2007;109:355–9.CrossRefPubMed
19.
Fuchs N, Smorgick N, Tovbin Y, Ben Ami I, Maymon R, Halperin R, et al. Oophoropexy to prevent adnexal torsion: how, when, and for whom? J Minim Invasive Gynecol. 2010;17:205–8.CrossRefPubMed