eMedicine Specialties > Emergency Medicine > Obstetrics & Gynecology

Ovarian Torsion

Erik D Schraga, MD, Consulting Staff, Department of Emergency Medicine, Mills-Peninsula Emergency Medical Associates; Consulting Staff, Permanente Medical Group, Kaiser Permanente, Santa Clara Medical Center
Michelle Blanda, MD, Chair, Department of Emergency Medicine, Summa Health System; Professor of Emergency Medicine, Northeastern Ohio Universities College of Medicine

Updated: Aug 4, 2008

Introduction

Background

Ovarian torsion (adnexal torsion) is an infrequent but significant cause of acute lower abdominal pain in women. The clinical presentation is often nonspecific with few distinctive physical findings, commonly resulting in delay in diagnosis and surgical management.

Pathophysiology

Ovarian torsion classically occurs unilaterally in a pathologically enlarged ovary. The irregularity of the ovary likely creates a fulcrum around which the oviduct revolves. The process can involve the ovary alone but more commonly affects both the ovary and the oviduct (adnexal torsion). Approximately 60% of torsion occurs on the right side.

Multiple factors have been found to be responsible for the development of ovarian torsion. Although torsion may rarely occur in normal adnexa, it more frequently arises from one of many anatomic changes. Torsion of a normal ovary is most common among young children, in whom developmental abnormalities such as excessively long fallopian tubes or absent mesosalpinx may be responsible. In fact, less than half of torsed ovaries in pediatric patients involve cysts, teratomas, or other masses. During early pregnancy, the presence of an enlarged corpus luteum cyst likely predisposes the ovary to torsion. Women undergoing induction of ovulation for infertility carry an even greater risk, as numerous theca lutein cysts significantly expand the ovarian volume.

Ovarian tumors, both benign and malignant, are implicated in 50-60% of cases of torsion. Involved masses are nearly all greater than 4-6 cm, although torsion is possible with smaller masses.

Frequency

United States

Studies reveal that ovarian torsion is the fifth most common gynecologic surgical emergency accounting for 2.7% of cases of acute gynecologic complaints in one series.

International

Ovarian torsion is encountered more often in women who have had ovarian stimulation, which likely accounts for a small increased incidence in developed countries.

Mortality/Morbidity

Most patients with ovarian torsion have a delayed diagnosis, often resulting in infarction and necrosis of the ovary. The ovarian salvage rate has been reported below 10% in adults but as high as 27% in a study among pediatric patients¹ . Although it is unlikely that the loss of a single ovary results in significantly reduced fertility and no cases of death have been reported due to ovarian torsion, early diagnosis allows for conservative laparoscopic treatment and reduction in complications.

Sex

Ovarian torsion applies strictly to the female sex.

Age

Ovarian torsion can occur at any age, but most cases occur in the early reproductive years. Approximately 17% of cases have been found to occur in premenarchal or postmenopausal women.

• The median age reported by one large review was 28 years.
• The percentage of patients younger than 30 years is approximately 70-75%.

Clinical

History

• Classically, patients present with sudden onset, severe, unilateral lower abdominal pain that worsens intermittently over many hours. A minority of patients, however, complain of mild pain that follows a more prolonged time course. The pain usually is localized over the involved side, often radiating to the back, pelvis, or thigh. Approximately 25% of patients experience bilateral lower quadrant pain. It may be described as sharp and stabbing or less frequently crampy.
• Nausea and vomiting occur in approximately 70% of patients, mimicking a gastrointestinal source of pain and further obscuring the diagnosis.
• History of prior episodes may be elicited possibly due to partial, spontaneously resolving torsion.
• Fever may occur as a late finding as the ovary becomes necrotic.
• Onset during exercise or other agitating movement is common.

Physical

The physical examination, like the history, is typically nonspecific and is highly variable.

• A unilateral, tender adnexal mass has been reported in between 50 and 90% of patients. However, absence of such a finding does not exclude the diagnosis.
• Tenderness to palpation is common; however, it is mild in approximately 30% and absent in another 30% of patients. Therefore, the absence of tenderness cannot be used to rule out torsion.
• Peritoneal findings are infrequent and indicate advanced disease if present.

Causes

• Anatomic changes affecting the weight and the size of the ovary may alter the position of the fallopian tube and allow twisting to occur.
• Pregnancy is occasionally responsible for torsion, likely secondary to ovarian enlargement that occurs during ovulation in combination with laxity of the supporting tissues of the ovary.
• Congenitally malformed and elongated fallopian tubes may be seen particularly in young, prepubertal patients.
• Ovarian tumors result in over half of cases of adnexal torsion.
  • Dermoid tumors are most common.
  • Malignant tumors are much less likely to result in torsion than benign tumors. This is due to the presence of cancerous adhesions that fix the ovary to surrounding tissues.
• Conversely, patients with a history of pelvic surgery (principally tubal ligation) have an increased risk of torsion, likely owing to adhesions providing a site around which the ovarian pedicle may twist.

Differential Diagnoses

Other Problems to Be Considered

Ovarian tumor
Tubal ovarian abscess
Ureteral calculi
Perforated colonic carcinoma

Workup

Laboratory Studies

• A pregnancy test is the most critical laboratory test that can be performed in the ED.
• General laboratory studies are not helpful in verifying a diagnosis of ovarian torsion; however, they may be indicated in ruling out alternative or coexisting diagnoses of lower abdominal or pelvic pain. These may include GC/chlamydia cultures, wet mount, and urinalysis.
• The use of a complete blood count to evaluate for leukocytosis and anemia is nonspecific and unlikely to support or exclude the diagnosis.

Imaging Studies

• Ultrasonography is the primary modality of imaging for patients with suspected ovarian torsion.
  • Ovarian enlargement secondary to impaired venous and lymphatic drainage is the most common sonographic finding in ovarian torsion.
  • The finding of an ovarian mass may suggest a focus for torsion but may also be misleading as to being the source of pain itself. Because implicated masses are most frequently non-neoplastic or hemorrhagic cysts, which can themselves produce pain of similar quality and location, diagnosis even with appropriate imaging can be challenging. Nevertheless, given a history reminiscent of torsion the discovery of an ovarian cyst should greatly increase one's suspicion of the diagnosis.
  • Combination of Doppler flow imaging with the morphologic assessment of the ovary may improve diagnostic accuracy. However, the interpretation of Doppler sonography is inconsistent due to dual ovarian blood supply from the uterine artery and the ovarian artery. Additionally, if the scan is performed during a transient period of detorsing of the ovary a normal Doppler flow may falsely suggest a normal ovary.
  • Although absence of arterial blood flow may be diagnostic, early in the progression of disease arterial perfusion may be preserved with only obstruction of venous and lymphatic flow.
  • Color Doppler sonography may be helpful in predicting viability of adnexal structures by depicting blood flow within the twisted vascular pedicle and presence of central venous flow.
• Computed tomography may demonstrate an enlarged ovary and adnexal masses but is unable to evaluate the presence or absence of blood flow to the involved ovary. However, CT may be useful in ruling out other possible causes of lower abdominal pain in cases of diagnostic uncertainty. Additionally, CT can exclude the presence of a pelvic mass, which greatly adds in the ability to rule out torsion.

Procedures

• Laparoscopy can be used for both confirmation of the diagnosis and treatment.
• Culdocentesis is a nonspecific test that is unlikely to confirm or exclude torsion and is not recommended in the diagnostic workup.

Treatment

Prehospital Care

Prehospital care of a patient presenting with ovarian torsion includes assessing vital signs and establishing an intravenous line if the patient appears hypotensive or tachycardic, as alternative emergent diagnoses must be considered.

Emergency Department Care

• Early and judicious use of analgesics may be required. Withholding analgesia has not been shown to delay or impede diagnosis.
• Initial evaluation must include exclusion of emergent causes of abdominal pain including ectopic pregnancy and appendicitis. Treat nausea and vomiting with antiemetics. Intravenous fluids may be required to treat volume depletion secondary to prolonged vomiting.
• For the patient with a concerning history, physical examination, or ultrasonographic findings suspicious for torsion, prompt gynecologic consultation should be sought for evaluation and definitive treatment.
• Conservative management is favored early in the course of disease and consists of laparoscopy with uncoiling of the torsed ovary and possible oophoropexy. Since recurrence of torsion is rare except in profoundly enlarged ovaries (ie, polycystic ovaries), some suggest that fixation of the ovary to the pelvic wall is unwarranted.
• Salpingo-oophorectomy may be indicated if severe vascular compromise, peritonitis, or tissue necrosis is clearly evident. However, since the size, color, and edema of the ovary may not accurately reflect the amount of tissue injury, multiple studies now support early conservative management with a success rate of 88% or greater.
• Recently, laparoscopic triplication of the utero-ovarian ligament has been performed to prevent recurrent torsion in young patients in attempt to shorten the excessively long ligament.

Consultations

• Obstetrician/gynecologist

Medication

Pain medication may be given to a patient who presents with abdominal pain that is suspected to be from ovarian torsion. The use of nonsteroidal anti-inflammatory drugs (NSAIDs) and opioids is acceptable.

Analgesics

Pain control is essential to quality patient care and should not be delayed pending surgical or gynecologic evaluation.

Ketorolac (Toradol)

Inhibits prostaglandin synthesis by decreasing the activity of the enzyme, cyclooxygenase, which results in decreased formation of prostaglandin precursors.

Dosing

Adult

30-60 mg IM initially followed by 15-30 mg q6h prn; not to exceed 5 d of treatment

Pediatric

Not established; recommended dose is 0.4-1 mg/kg IM once

Interactions

Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; closely monitor PT (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently

Contraindications

Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency; high risk of bleeding; do not administer into CNS

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Acute renal insufficiency, hyperkalemia, hyponatremia, interstitial nephritis, and renal papillary necrosis may occur; increases risk of acute renal failure in patients with preexisting renal disease or compromised renal perfusion; low WBC counts (rare) usually return to normal during ongoing therapy; discontinue therapy if persistent leukopenia, granulocytopenia, or thrombocytopenia occur; perform ophthalmologic studies in patients who develop eye complaints during therapy (effects include blurred or diminished vision, scotomata, changes in color vision, corneal deposits, and retinal disturbances, including macula degeneration); discontinue therapy if ocular changes are noted

Morphine (Astramorph, Duramorph, MS Contin)

DOC for narcotic analgesia because of reliable and predictable effects, safety profile, and ease of reversibility with naloxone.
Morphine sulfate administered IV may be dosed in a number of ways and is commonly titrated until the desired effect is obtained.

Dosing

Adult

2-10 mg IV/IM; titrate to pain relief

Pediatric

0.1 mg/kg IV/IM

Interactions

Phenothiazines may antagonize the analgesic effects of opiate agonists; coadministration of tricyclic antidepressants, MAOIs, and other CNS depressants may potentiate the adverse effects

Contraindications

Documented hypersensitivity; hypotension; potentially compromised airway with uncertain rapid airway control

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Avoid in hypotension, respiratory depression, nausea, emesis, constipation, and urinary retention; caution in atrial flutter and other supraventricular tachycardias; has vagolytic action and may increase ventricular response rate

Antiemetics/sedatives

These agents are useful in the treatment of nausea associated with the clinical symptoms of ovarian torsion. Some antiemetics also have sedative effects.

Prochlorperazine (Compazine)

May relieve nausea and vomiting by blocking postsynaptic mesolimbic dopamine receptors through anticholinergic effects and depressing reticular activating system. In addition to antiemetic effects, has the advantage of augmenting hypoxic ventilatory response, acting as a respiratory stimulant at high altitude.

Dosing

Adult

10 mg PO/IM tid/qid; not to exceed 40 mg/d
2.5-10 mg IV q3-4h prn; not to exceed 10 mg/dose or 40 mg/d
25 mg PR bid

Pediatric

2.5 mg PO/PR q8h or 5 mg q12h prn; not to exceed 15 mg/d
0.1-0.15 mg/kg/dose IM; change to PO as soon as possible
IV dosing is not recommended for children

Interactions

Coadministration with other CNS depressants or anticonvulsants may cause additive effects; with epinephrine may cause hypotension

Contraindications

Documented hypersensitivity; bone marrow suppression; narrow-angle glaucoma; severe liver or cardiac disease

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Drug-induced Parkinson syndrome or pseudoparkinsonism occurs frequently; akathisia is most common extrapyramidal reaction in elderly persons; lowers seizure threshold; caution with history of seizures

Metoclopramide (Reglan)

Blocks dopamine receptors in the chemoreceptor trigger zone of CNS.

Dosing

Adult

10-20 mg PO tid/qid for 7 d

Pediatric

1-2 mg/kg PO tid/qid for 7 d

Interactions

Opiate analgesics may increase metoclopramide toxicity in CNS

Contraindications

Documented hypersensitivity; pheochromocytoma; GI hemorrhage; obstruction or perforation of bowels; seizure disorders

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Caution in history of mental illness and Parkinson disease or other movement disorder

Follow-up

Complications

• Infection
• Peritonitis
• Sepsis
• Adhesions
• Chronic pain
• Infertility (rare)

Prognosis

• The prognosis is excellent with early diagnosis and appropriate treatment.

Miscellaneous

Medicolegal Pitfalls

• Failure to consider adnexal torsion in the differential diagnosis is not uncommon given its relative infrequency. Consideration is particularly imperative in a patient with a known ovarian mass or pregnancy.
• Normal Doppler imaging must not be used as basis for exclusion of the diagnosis.
• In a patient with a history and physical suggestive of ovarian torsion, gynecologic consultation and subsequent laparoscopy is critical regardless of normal laboratory and radiologic studies.

Special Concerns

• Pregnancy
  • Approximately 1 in 1800 pregnancies is complicated by adnexal torsion, typically between the sixth and fourteenth weeks of gestation. This increased frequency is likely due to greater laxity of the tissues adjoining the ovaries and oviducts during pregnancy as well as enlargement of the ovary in early pregnancy secondary to the corpus luteum cyst.
  • Detorsion of the adnexa during pregnancy has not been found to compromise to fetal well-being. However, if the corpus luteum cyst is removed during salpingo-oophorectomy, supplemental progesterone is indicated.
• Postmenopausal women
  • As with other causes of abdominal pain, patients of advanced age are increasingly prone to unusual presentations of ovarian torsion.
  • Adnexal torsion is not limited to women of reproductive age. Ovarian tumors of both benign and malignant nature are common in postmenopausal women and may result in torsion.
• Children and adolescents: Greater than 50% of patients with torsion in this age group have normal-sized ovaries. In those with indicative histories and absence of alternative diagnoses further investigation must be sought.

References

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Keywords

adnexal torsion, abdominal pain, ovaries, fallopian tubes, mesosalpinx, ovarian torsion, lower abdominal pain in women, enlarged ovary, ovarian tumor, dermoid tumor, elongated fallopian tube, ovarian enlargement, ovarian cyst

Contributor Information and Disclosures

Author

Erik D Schraga, MD, Consulting Staff, Department of Emergency Medicine, Mills-Peninsula Emergency Medical Associates; Consulting Staff, Permanente Medical Group, Kaiser Permanente, Santa Clara Medical Center
Disclosure: Nothing to disclose.

Coauthor(s)

Michelle Blanda, MD, Chair, Department of Emergency Medicine, Summa Health System; Professor of Emergency Medicine, Northeastern Ohio Universities College of Medicine
Michelle Blanda, MD is a member of the following medical societies: American College of Emergency Physicians and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Medical Editor

Jerome FX Naradzay, MD, FACEP, Medical Director, Consulting Staff, Department of Emergency Medicine, Maria Parham Hospital; Medical Examiner, Vance County, North Carolina
Jerome FX Naradzay, MD, FACEP is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Mark Zwanger, MD, MBA, Assistant Professor, Department of Emergency Medicine, Thomas Jefferson University
Mark Zwanger, MD, MBA is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and American Medical Association
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Pamela L Dyne, MD, Associate Professor, Program Director, Department of Medicine, Division of Emergency Medicine, University of California at Los Angeles School of Medicine
Pamela L Dyne, MD is a member of the following medical societies: American College of Emergency Physicians and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

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