Ovarian torsion
From Medical-Wiki
While ovarian torsion can occur in normal ovaries, at least half of the cases involve ovarian masses. These masses are usually in the range of 4cm to 6 cm or larger. 60% of torsions occur on the right side. The most common population to experience torsion are young children. In these patients, there is a high incidence of developmental abnormalities, e.g., long fallopian tubes or absent mesosalpinx. Another risk factor is pregnancy where early on, an enlarged corpus luteum cyst places the ovary at risk for torsion. [1]
A new class of at-risk patients are those suffering from ovarian hyperstimulation syndrome (OHSS). This is a side effect of infertility treatment and has a significantly increased incidence of ovarian torsion because of enlarged ovaries. [2]
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Clinical presentation
Ovarian torsion often presents with a sudden onset of abdominal pain that worsens over a period of hours. It is usually unilateral. A smaller number of patients experience a milder, more prolonged course. The pain may radiate posteriorly and even to the thigh. Nausea and vomiting may accompany the pain. If the torsion is intermettant, symptoms may also be intermettant. As the ovary necroses, patients may become feverish.
Diagnosis
Because of the wide range of symptoms and findings, diagnosis of torsion may often be delayed. This is one of the reasons that ovarian salvage rate has been reported as less than 10%. [3]
Physical findings
Physical exam is as variable as the clinical course. In half the cases, a unilateral, tender adnexal mass is present. But the absence of this finding does not rule out torsion. In later stages of the disease, peritoneal findings may appear.
Radiological findings
Ultrasound is the most widely used imaging technique in the diagnosis of ovarian torsion. One study concluded that if ultrasound shows an enlarged ovary in a setting compatible with ovarian torsion, the diagnosis must be considered very likely—even if Doppler does not reveal diagnostic flow patterns. [4] This approach increases the sensitivity of ultrasound—though specificity remains low. [5]
The occurrence of torsion in the setting of pregnancy makes diagnosis not only more difficult but more imperative because it can threaten the viability of the fetus. If ultrasound visualizes an enlarged ovary or cannot visualize the ovaries adequately, MRI should be used to avoid the risks of radiation.
Treatment
Because surgery during pregnancy is complicated by the necessity to protect the fetus, it is a complex proposition. The gestational age of the fetus will determine the best form of anesthesia. Surgical expedience is still a priority. [6]
In the pediatric population recent studies have demonstrated greater ovarian viability than once thought. "Pediatric care professionals should obtain urgent ultrasound in girls with a possible diagnosis of ovarian torsion and advocate for emergent surgical evaluation and operative detorsion in those with an abnormal ultrasound finding." [7]
