Ovarian Torsion

Ovarian torsion refers to the partial or complete rotation of the ovary often together with its fallopian tube on its ligamentous support resulting in a compromise to the venous or arterial blood supply to it. This is a gynecological emergency as any delay will result in necrosis of the ovary which will result in subfertility. 

Ovarian Torsion accounts for about 2.7% of gynecological emergencies. The median age it occurred is 28 years. About 70-75% of Ovarian Torsion occurs in females under 30 years old. The risk is also increased during pregnancy and in post-menopausal women who have ovarian cysts.

Causes of Ovarian Torsion

Ovarian torsion usually occurs unilaterally, 60% on the right ovary. It usually involves an enlarged ovary that around which the fallopian tube twists around it. Pregnancy results in the enlargement of ovary in combination with laxity of the supporting tissues of the ovary. Hence 20% of ovarian torsions happen during pregnancy. Other causes of enlarged ovary like ovarian cysts, ovarian cancer and other non-cancerous ovarian mass will also predispose the woman to ovarian torsion.

Congenital developmental abnormalities like malformed and elongated fallopian tubes also increase the risk of ovarian torsion in the pre-pubertal patients.

Patients who have undergone previous pelvic surgery especially tubal ligation tend to have adhesions to surrounding tissue predisposing the ovary to twist around it resulting in torsion.

Clinical presentation and clinical signs of Ovarian Torsion

Typically patients with ovarian torsion will present with a sudden onset severe unilateral lower abdomen pain. It commonly occurs during exercise or during other agitating movements. The intensity of pain usually increases with time. The pain may then radiate to the back, thigh and pelvis area. In a minority group of patients may complain vague pain over a prolonged time. This pain may be associated with nausea and vomiting. Fever is uncommon.

Your attending doctor will do an abdomen and pelvic examination on you. Palpation of your abdomen will reveal unilateral localized tender ovarian mass. Peritonitis will result in rebound tenderness and guarding of the abdomen. Pelvic examination will reveal tenderness at the affected ovary.

Complications of Ovarian Torsion

1.    Sepsis- spread of infection from the ovary to the entire body
2.    Peritonitis- Rupture of the ovary resulting in the spread of infection to the peritoneum, a membrane that lines the inside of abdomen and all organs.
3.    Adhesions- fibrous bands of scarred tissue that binds organs and tissues together abnormally.
4.    Chronic pain- prolonged persistent pain in the lower abdomen
5.    Infertility (rare) - when not diagnosed early and the ovary cells die off, fertility is reduced.

Diagnostic Tests of Ovarian Torsion

1.    Doppler ultrasound: It is the method of choice to diagnose ovarian torsion. Not only it can help the physician know the morphology and physiology state of the ovary, it can also detect if blood flow to the ovary is impeded. Normal Doppler does not exclude ovarian torsion. Typical ultrasound findings of an ovarian torsion include abnormal ovarian blood flow, an enlarged ovary with immature peripheral follicles, edema around ovary, an ovarian mass, ovarian cyst and also free pelvic fluid indicating hemorrhage (bleeding).

2.    CT/ MRI scan: These scans are rarely indicated for diagnosis. Ct scan can demonstrate enlarged ovary and masses and associated free fluid or hemorrhage however it cannot provide the physician information on whether the ovarian blood flow is impeded. It is used basically to exclude other causes of lower abdomen pain.

Treatment of ovarian torsion

Any patient with a typical history, positive physical findings and ultrasound images suggestive of ovarian torsion should be prepared for operation. Surgical treatment is the only treatment for ovarian torsion.

The ovary must be untwisted as soon as possible to ensure its viability. The best outcomes are when the operation is within 8 hours from the onset of the torsion. Laparoscopy (key-hole surgery) is diagnostic and only treatment of choice.

If the ovary has already become necrotic (tissues have died), it will be removed resulting in subsequent sub-fertility. Any ovarian mass or cysts that are found intra-operative may be removed too.

Differential Diagnosis

After having discussed ovarian torsion extensively, there are certain medical conditions that may present similarly like ovarian torsion. The conditions includeovarian cancer, ovarian abscesses, ureter stones, perforated colorectal tumor, appendicitis, diverticulitis, ectopic pregnancy, endometriosis, bowel obstruction, urinary tract infection, pelvic inflammatory disease and bowel ischemia.

Your attending doctor will take a clinical history; conduct a thorough examination and appropriate tests to come to the correct diagnosis and treatment.

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