Ovarian Torsion

Definition | Aetiology | Risk Factors | Clinical Presentation | Investigations | Management | When to Refer | References

Definition

Ovarian torsion is a surgical emergency where the ovary twists around the ligaments that support it, potentially cutting off its blood supply. This condition can lead to ovarian infarction and loss of ovarian function if not promptly treated.

Aetiology

Ovarian torsion typically occurs when the ovary becomes twisted around its supporting structures, including the infundibulopelvic ligament and the utero-ovarian ligament. It is often associated with an adnexal mass or cyst, which increases the likelihood of the ovary twisting. In some cases, however, it can occur in normal ovaries, particularly in premenarchal girls.

Risk Factors

Several factors increase the risk of developing ovarian torsion:

• Ovarian Cysts or Masses: Large ovarian cysts, particularly those greater than 5 cm, can increase the risk of torsion.
• Polycystic Ovary Syndrome (PCOS): Women with PCOS may have enlarged ovaries, increasing the risk of torsion.
• Ovarian Hyperstimulation Syndrome: A complication of fertility treatments that can cause the ovaries to enlarge, making torsion more likely.
• Previous Ovarian Torsion: A history of ovarian torsion increases the risk of recurrence.
• Pregnancy: The ovaries are more mobile during pregnancy, which may contribute to an increased risk of torsion.
• Young Age: Torsion is more common in younger women and girls, particularly those with congenital abnormalities of the reproductive organs.

Clinical Presentation

Ovarian torsion presents with acute onset symptoms, making timely diagnosis and intervention crucial. Common symptoms include:

• Sudden, Severe Pelvic Pain: Typically unilateral, sharp, and may radiate to the back or thigh. The pain often starts suddenly and may be intermittent or constant.
• Nausea and Vomiting: These symptoms frequently accompany the pain and may be severe.
• Adnexal Tenderness: Tenderness over the affected ovary on physical examination.
• Palpable Adnexal Mass: In some cases, a mass may be palpable on pelvic examination.
• Fever: Although less common, fever may occur if there is associated infection or infarction.

Investigations

Ovarian torsion is primarily a clinical diagnosis, but imaging can aid in confirmation:

• Pelvic Ultrasound with Doppler: The first-line imaging modality. It can show an enlarged, edematous ovary with decreased or absent blood flow on Doppler studies. However, normal Doppler flow does not rule out torsion.
• Transvaginal Ultrasound: Provides a more detailed view of the adnexa and can help identify the presence of an adnexal mass or cyst.
• CT or MRI Scan: These are not typically first-line investigations for torsion but may be used if the diagnosis is unclear or if other pelvic pathology is suspected.
• Blood Tests: May show elevated white blood cell count (WBC) due to inflammation or infection, but these findings are non-specific.

Management

Ovarian torsion is a surgical emergency, and prompt treatment is essential to preserve ovarian function:

Initial Management

Once ovarian torsion is suspected, immediate referral to secondary care is required for surgical intervention. Analgesia should be provided to manage pain.

Surgical Management

• Laparoscopy: The preferred surgical approach, where the ovary is untwisted and the viability of the ovary is assessed. If the ovary appears viable, it can be preserved. In some cases, oophoropexy (fixation of the ovary) may be performed to prevent recurrence.
• Laparotomy: May be required if the patient is unstable or if laparoscopy is not feasible. It is also performed in cases where the ovary is necrotic and needs to be removed (oophorectomy).
• Oophorectomy: If the ovary is found to be non-viable due to prolonged torsion, it may need to be removed.

When to Refer

Ovarian torsion is a medical emergency, and any patient suspected of having this condition should be referred immediately to secondary care for surgical evaluation. Delays in treatment can result in the loss of ovarian function and fertility, as well as increased risk of complications.

References

1. NHS (2024) Ovarian Torsion. Available at: https://www.nhs.uk/conditions/ovarian-torsion/ (Accessed: 26 August 2024).
2. Royal College of Obstetricians and Gynaecologists (2024) Management of Ovarian Torsion. Available at: https://www.rcog.org.uk/guidance/management-of-ovarian-torsion/ (Accessed: 26 August 2024).
3. British Medical Journal (2024) Ovarian Torsion: Clinical Review. Available at: https://www.bmj.com/content/359/bmj.h2029 (Accessed: 26 August 2024).

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