Charles S. Dietrich III
Bradford P. Whitcomb
Presentation
A 35-year-old female with no significant prior history presents to the emergency department with acute-onset severe right lower-quadrant pain that started earlier that day and has been progressively worsening. Her vital signs are significant for a low-grade temperature, mild tachycardia, and a normal blood pressure. On abdominal examination, tenderness to deep palpation is noted in the right pelvic region, and rebound tenderness is elicited. Her pelvic examination is remarkable for exquisite right-adnexal tenderness that further precludes adequate examination.
Differential Diagnosis
Acute pelvic pain can be caused by a number of possible diagnoses that include not only gynecologic causes but also gastrointestinal, urologic, and musculoskeletal etiologies. The most common gynecologic causes for lower-abdominal pain include complications of pregnancy (ectopic pregnancy or spontaneous abortion), hemorrhagic or ruptured ovarian cysts, pelvic inflammatory disease (PID), ovarian torsion, dysmenorrhea, degenerating uterine leiomyomas, endometriosis, and pelvic adhesive disease. Nongynecologic causes that should be considered include appendicitis, diverticulitis, acute cystitis, and urinary calculi (Table 1).
TABLE 1. Common Causes for Acute Pelvic Pain
Workup
The patient undergoes ultrasound evaluation of the pelvis revealing an 8-cm solid/cystic right ovarian mass resting anterior to the uterus (Figure 1). Doppler studies reveal no internal ovarian flow. A small amount of pelvic fluid surrounds the ovary and fills the pelvic cul-de-sac. The endometrial lining is approximately 8 mm in maximal diameter. The uterus and left adnexa are normal in shape and size. Serum laboratory assessment is notable for a white blood count of 12.2 × 103/µL, a hemoglobin of 12 g/dL, and a normal platelet count. Quantitative β-hCG is <5 mlU/mL. Serum chemistries, liver function tests, and urinalysis are unremarkable. Tumor markers including a CA125, AFP, LDH, and inhibin levels are collected but are pending. CT imaging is ordered for further evaluation confirming the right complex ovarian mass (Figure 2). Further findings include a normal caliber appendix, no suspicious pelvic or paraaortic lymphadenopathy, and no evidence of metastatic disease.
FIGURE 1 • Ultrasound image showing an 8-cm complex solid/cystic right ovarian mass.
FIGURE 2 • CT image of the complex right ovarian mass. The calcific density within the mass is suggestive of a teratoma.
Discussion
Female patients presenting with acute pelvic pain should be initially evaluated with a thorough history and physical exam. An accurate menstrual history should be collected including age of menarche, start date of the last menstrual period, duration of menstrual flow, quantification of flow, and time interval between menses. Any intermenstrual bleeding should also be documented. Other important aspects of the history include a sexual history, contraceptive techniques, and a history of prior pregnancies, sexually transmitted diseases, abnormal cervical cytology, or other gynecologic problems. Abdominal examination should be performed to assess for signs of a surgical abdomen. Pelvic examination should include direct visualization of the cervix, assessment for cervical motion tenderness, and bimanual examination to determine uterine size and the presence of pelvic masses as well as regions of tenderness. Rectovaginal examination is also useful to help localize any masses that may be found.
All women of reproductive age presenting with acute pain should have pregnancy testing. If qualitative testing is positive, further clarification with a quantitative β-hCG is warranted. Other important laboratory assessments include a complete blood count, basic chemistries, liver function tests, and urinalysis.
The best initial imaging modality for assessing pelvic pain is ultrasound. Ultrasound can accurately identify ovarian pathology, and morphology indexing to stratify the risk for malignancy can be performed if an ovarian mass is noted. Ultrasound is invaluable in assessing early pregnancy complications as well. Doppler studies are often used to establish the presence of ovarian blood flow and to further assess the risk for a malignant process. CT imaging may also be useful to exclude other diagnoses such as appendicitis.
Diagnosis and Treatment
The findings in this case are most consistent with acute ovarian torsion. Ovarian torsion is the fifth most common emergency room presentation for acute pain in females (following ectopic pregnancy, hemorrhagic ovarian cyst, PID, and appendicitis). While it can occur in all age groups, the majority of females affected are under 50 years. In most cases involving adnexal torsion, an ovarian or tubal tumor is present. The risk for torsion increases linearly with ovarian size. In one series, 83% of affected patients had an ovarian tumor ≥5 cm. Conversely, very large tumors become less likely to undergo torsion, as mobility decreases. Normal-sized ovaries can also undergo torsion, but this presentation is more prevalent in children and early adolescents. Histologically, any ovarian tumor can twist; however, dermoid tumors are more commonly seen secondary to their prevalence and greater tissue density when compared to other diagnoses. Fortunately, malignancy is rarely encountered in cases of ovarian torsion, occurring in <2% of adult patients.
When an ovarian torsion occurs, the ovary’s vascular pedicle becomes compromised. Initially, venous flow is more affected than arterial flow, causing ovarian engorgement. As the torsion becomes more complete, ischemia results, which eventually leads to necrosis and peritonitis. Pain is the most common presenting complaint and is often associated with nausea. The pain can come in waves, especially with activity, if an intermittent torsion is present. Fevers occasionally are noted and are usually low grade. Mild leukocytosis is often the only laboratory abnormality, although mild anemia can also occur from secondary hemorrhage. Unfortunately, the clinical presentation is often nonspecific, making diagnosis challenging in many cases. Ultrasound is highly sensitive for identifying ovarian masses, and the presence of an adnexal mass should raise the suspicion for torsion if acute pain is present. Doppler studies are usually reported when a tumor is identified; however, diminished or absent flow can be found in normal adnexa. Conversely, the presence of flow does not exclude an intermittent torsion. Maintaining a high index of suspicion with early operative intervention confirms the diagnosis and maximizes the chance for ovarian conservation.
Further Discussion
Other diagnoses to consider for acute gynecologic pain that can mimic ovarian torsion include ectopic pregnancy, PID, and hemorrhagic ovarian cysts. Pain associated with an ectopic pregnancy can be similar to a torsion presentation. The key difference, however, is an elevated hCG level. Ultrasound, again, is critical to the diagnosis. When no intrauterine gestational sac is noted with an hCG level over 1,500 to 2,000 mIU/mL, then an ectopic pregnancy should be strongly considered. If the hCG level rests below this discriminatory zone, then serial hCG levels can be helpful to differentiate between a normal and abnormal early gestation as the levels usually rise at least 66% over 48 hours. While an adnexal mass can be found with an ectopic pregnancy, it is usually smaller than those associated with torsion and often is paraovarian in location. Historically, surgical removal was the standard approach to treatment. With accurate hCG assays and improving ultrasound technology, earlier diagnosis has made medical management with methotrexate more prevalent.
Acute PID can also have a similar presentation to torsion, although the onset of pain tends to be more insidious. Severe cases of PID are often associated with a tubo-ovarian abscess, which on ultrasound can be quite sizable and associated with diminished Doppler flow. Fevers and leukocytosis tend to be more prominent in PID. A mucopurulent cervical discharge and cervical motion tenderness are also typically seen. Most acute cases are associated with gonorrhea or chlamydia, although many presentations are polymicrobial. Antibiotics, in most cases, quickly lead to resolution. Occasionally, surgical or percutaneous drainage of a tubo-ovarian abscess is required.
Hemorrhagic or ruptured ovarian cysts also present similarly to ovarian torsion. Pain often has an acute onset, and an adnexal mass is obviously noted on ultrasound. Fevers and leukocytosis are typically absent, while anemia may be more pronounced if active bleeding is ongoing. On ultrasound, pelvic fluid may also be more prominent. Management is usually conservative with ultrasound abnormalities often resolving within 6 weeks, although cases involving hemodynamic instability require urgent surgical intervention.
Surgical Approach
Surgical management of ovarian pathology in the acute setting can be accomplished by several routes including laparoscopy, minilaparotomy, and laparotomy. The decision on the approach should be based on operator experience, available resources, ovarian size and mobility, the risk for a malignant process, and patient comorbidities. Relatively large ovarian masses can be removed laparoscopically if they are predominantly cystic and can be decompressed once placed inside an endobag. If there is concern for a malignant process, care should be taken not to rupture the tumor, as this upstages the malignancy and usually necessitates postoperative chemotherapy. Predominantly solid tumors cannot be adequately decompressed, and are more amenable to removal via open laparotomy. When performing a laparotomy, most benign pelvic pathology can be addressed via a Pfannenstiel incision. If further lateral exposure is needed, conversion to a Cherney incision can be accomplished by detaching the rectus muscles from their tendonous insertions on the pubic symphysis. If malignancy is suspected, or if distorted fixed anatomy is anticipated, then a midline vertical approach is indicated. Maximal pelvic exposure is achieved by developing the space of Retzius and ensuring the fascial incision extends completely to the pubic symphysis.
When faced with twisted adnexa, the primary intraoperative decision to make revolves around ovarian salvage. Historically, salpingo-oophorectomy was the procedure of choice as it was thought that reduction of the torsion would release clots or inflammatory cells into the ovarian vein. Recent reports, however, have confirmed the efficacy of conservative, ovarian-sparing approaches. Conservation is significantly more common in children, adolescents, and women early in their reproductive years. Timing is critical, as the risk for ovarian necrosis significantly increases after 24 hours of torsion. Following conservation, the ovary will often remain dark or dusky, but subsequent ovarian function is usually noted. Adjuncts to assess ovarian perfusion intraoperatively include intravenous fluorescein injection and ovarian bivalving. The primary risk associated with ovarian conservation is necrosis in cases where irreversible ischemic injury has occurred, leading to peritonitis and systemic infection. Fortunately this risk is low, but necessitates close surveillance immediately following surgery. Oophoropexy is sometimes performed following ovarian conservation, especially in cases of recurrent torsion, and in children or adolescents.
Ovarian cystectomy is a relatively simple surgical procedure allowing for ovarian conservation in reproductive-aged individuals. It should be reserved for benign pathology or for an interval procedure where the diagnosis is uncertain. Initially, either a linear or elliptical incision over the top antimesenteric portion of the ovarian mass is created in the serosa with either a scalpel or Bovie cautery. Blunt and sharp dissection with Metzenbaum scissors or endoshears is then used to identify the underlying tumor and to separate it from the surrounding stroma. The ease of dissection is highly variable, depending on tumor histology and other cofactors such as infection or prior surgeries. Bleeding is usually minimal until the base of the tumor is reached where the ovarian vessels enter the ovarian hilum. Care should be taken to avoid tumor rupture; however, this is not an uncommon event, especially with thin-walled tumors. Once the tumor is removed, bleeding is controlled with suture ligation and cautery. The ovarian serosa can either be left open, or reapproximated with fine suture (Table 2).
TABLE 2. Key Technical Steps for Ovarian Cystectomy
Salpingo-oophorectomy is also a relatively straightforward procedure. It is indicated for malignant pathology, nonviable ovarian tissue following torsion, definitive management of recurrent benign pathology, and in postmenopausal patients. The first step is to develop the pararectal space to allow for identification of important retroperitoneal structures (Figure 3). The infundibulopelvic ligament is located on the pelvic sidewall and the peritoneum 1 cm lateral to this structure is incised in a parallel fashion from the round ligament toward the line of Toldt. The external iliac artery and vein can then be identified. Careful blunt dissection of the loose areolar tissue medial to these vessels will open up the pararectal space, which can be further developed inferiorly until the sacrum is reached. The ureter should then be directly visualized as it courses along the medial peritoneal reflection. By following the iliac vessels cephalad and gently lifting anteriorly on the infundibulopelvic ligament, it is usually easy to locate the ureter as it crosses over the external iliac artery and vein near the bifurcation of the common iliac vessels. Once the ureter has been positively identified, a window is then made between the ureter and ovarian vessels. The ovarian vessels can then be safely transected with suture ligation or laparoscopic vessel sealant devices. Once the ovarian vessels are ligated and divided, the ovary and fallopian tube should be placed on anterior traction and the remainder of the sidewall peritoneum skeletonized toward the utero-ovarian ligament. Finally, the fallopian tube and utero-ovarian ligament are transected close to the uterus, freeing the remaining ovarian attachments in the process (Table 3).
FIGURE 3 • Retroperitoneal pelvic anatomy. IVC, inferior vena cava; CIA, common iliac artery; U, Ureter; EIA, external iliac artery; EIV, external iliac vein.
TABLE 3. Key Technical Steps for Salpingo-Oopherectomy
Special Intraoperative Considerations
While ovarian cystectomy and salpingo-oophorectomy are relatively straightforward procedures, several dilemmas may arise intraoperatively regarding management of adnexal masses. The first issue that is commonly encountered is management of an incidental adnexal mass found during surgical evaluation for a separate indication. Key issues surrounding this problem include consent parameters, the impact intervention might have on reproductive potential, the risk for malignant pathology, and the potential morbidity associated with nonintervention (future tumor rupture, hemorrhage, or torsion). While there is no definitive answer, several guiding principles can be used to help make decisions. Simple ovarian cysts in reproductive-aged females <5 cm in diameter are usually functional in nature and will resolve on their own. Solid tumors, masses ≥10 cm, or those associated with excrescences are more likely to be malignant, and removal should be considered. Finally, any mass found intraoperatively in a postmenopausal patient should be considered for removal. Intraoperative consultation with a gynecologist is recommended if possible. If the indications are unclear or resources unavailable for management, it is always appropriate to refer the patient postoperatively for treatment counseling. While this approach may result in a second operation, it allows for better planning and gives the patient time to deal with potential impacts on fertility, hormonal status, or a malignant diagnosis.
Another potential challenge that may arise when dealing with pelvic pathology is distorted or fixed masses. In this case, rushing into the surgery without a well-thought-out approach can lead to unintended injuries and hemorrhage. In this event, the operative team should be alerted of the situation, and blood products should be readily available. Experienced assistance should be called. The first step should be to optimize exposure. If a large tumor is present that limits pelvic sidewall exposure, controlled tumor decompression or partial debulking may be necessary to improve visualization. Development of avascular pelvic spaces will improve visualization of important retroperitoneal structures. Vascular control should be obtained as early in the surgical process as is feasible. Ureteral stenting can help with identification of the ureters; however, the risk for injury is not decreased, and ureterolysis is often required to ensure ureteral integrity. During this process, care should be taken as the tunnel of Wertheim is entered since the uterine artery crosses over the ureter near this point. Bowel adhesions usually can be freed from the pelvis; however, on occasion, en bloc resection with dense intestinal adhesions is necessary.
Postoperative Management
Postoperative care for a patient who has recently undergone laparoscopic or open ovarian cystectomy or oophorectomy is relatively straightforward and is similar to any patient having abdominal surgery. Postoperative complications such as bleeding, venous thromboembolism, or infection occur at rates comparable to other similarly classed procedures. Pelvic rest is often recommended during the convalescent period. In general, most patients recover quickly and are able to resume normal activities in 4 to 6 weeks after open procedures or sooner after laparoscopic procedures.
Questions that often arise in the postoperative setting in patients who have had a unilateral salpingo-oophorectomy include the impact on future fertility in reproductive-aged women as well as the possibility for earlier menopause. In most cases, fertility is minimally impacted as long as the contralateral ovary and fallopian tube are normal. However, fertility rates are challenging to generalize as the disease process requiring surgery in the first place can impact reproductive potential. There are a number of studies that suggest patients who have had unilateral oophorectomy reach menopause slightly earlier than those who did not; however, in many of these studies, the patients also had concurrent hysterectomy.
Case Conclusion
The patient was taken to the operating room for a diagnostic laparoscopy, where a right-ovarian torsion was noted. Following reduction, no vascular flow was identified and necrotic tissue was evident. Conversion to an open laparotomy was necessary as the tumor was predominantly solid. A right salpingo-oophorectomy was performed without complications (Figure 4). The patient’s final pathology was consistent with a mature cystic teratoma with significant regions of necrosis. Her postoperative course was uneventful and she was released from the hospital 2 days later.
FIGURE 4 • A necrotic right ovarian mass following salpingo-oophorectomy. Final pathology was consistent with a mature teratoma.
TAKE HOME POINTS
· Leading diagnoses for acute pelvic pain in females include ectopic pregnancy, hemorrhagic ovarian cyst, pelvic inflammatory disease, appendicitis, and adnexal torsion.
· All women of reproductive potential with pelvic pain should have hCG testing as part of their initial evaluation.
· Ultrasound is the best initial modality for imaging pelvic pathology.
· Adnexal torsion can be difficult to diagnose. Therefore, any patient presenting with acute pain in the presence of an ovarian mass should raise suspicion. Early surgical intervention confirms the diagnosis and increases the chance for ovarian conservation.
· Reducing adnexal torsion does not increase the risk for clot embolization and will help determine if ovarian salvage is possible.
· Optimal pelvic exposure and development of the avascular pelvic spaces minimize the risk for adjacent structural injury during salpingo-oophorectomy.
SUGGESTED READINGS
Baggish MS, Karram MM, eds. Atlas of Pelvic Anatomy and Gynecologic Surgery. 3rd ed. Philadelphia, PA: Saunders Elsevier, 2010.
Cass DL. Ovarian torsion. Semin Pediatr Surg. 2005;14:86–92.
Dietrich CS, Martin RF. Obstetrics and gynecology for the general surgeon. Surg Clin North Am. 2008;88(2).
Dolgin SE, Lublin M, Shlasko E. Maximizing ovarian salvage when treating idiopathic adnexal torsion. J Pediatr Surg. 2000;35:624.
The views expressed in this manuscript are those of the authors and do not reflect the official policy or position of the Department of the Army, Department of Defense, or the United States Government.