Ovarian Torsion Flashcards
Aetiological factors to consider
- 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
Differential Diagnoses to consider
- Gynaecological
- Ectopic pregnancy
- Tubo-ovarian abscess
- Ruptured ovarian cyst/Cyst Haemorrhage
- Degenerating fibroid
- Endometrioma
- Non-gynaecological
- Appendicitis
History suggestive of Ovarian torsion
- 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
Exam findings suggestive of Ovarian torsion
- Low grade fever (20%)
- Abdominal examination – mass, peritonism
- Bimanual examination – mass, tenderness
Investigations
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
Management of Ovarian torsion
- 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)