eMedicine Specialties > Emergency Medicine > Obstetrics & Gynecology
Ovarian Torsion: Treatment & Medication
Updated: Aug 4, 2008
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
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.
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
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
Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency; high risk of bleeding; do not administer into CNS
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.
Adult
2-10 mg IV/IM; titrate to pain relief
Pediatric
0.1 mg/kg IV/IM
Phenothiazines may antagonize the analgesic effects of opiate agonists; coadministration of tricyclic antidepressants, MAOIs, and other CNS depressants may potentiate the adverse effects
Documented hypersensitivity; hypotension; potentially compromised airway with uncertain rapid airway control
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.
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
Coadministration with other CNS depressants or anticonvulsants may cause additive effects; with epinephrine may cause hypotension
Documented hypersensitivity; bone marrow suppression; narrow-angle glaucoma; severe liver or cardiac disease
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.
Adult
10-20 mg PO tid/qid for 7 d
Pediatric
1-2 mg/kg PO tid/qid for 7 d
Opiate analgesics may increase metoclopramide toxicity in CNS
Documented hypersensitivity; pheochromocytoma; GI hemorrhage; obstruction or perforation of bowels; seizure disorders
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
More on Ovarian Torsion |
| Overview: Ovarian Torsion |
| Differential Diagnoses & Workup: Ovarian Torsion |
 Treatment & Medication: Ovarian Torsion |
| Follow-up: Ovarian Torsion |
| References |
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References
Anders JF, Powell EC. Urgency of evaluation and outcome of acute ovarian torsion in pediatric patients. Arch Pediatr Adolesc Med. Jun 2005;159(6):532-5. [Medline].
Bellah RD, Griscom NT. Torsion of normal uterine adnexa before menarche: CT appearance. AJR Am J Roentgenol. Jan 1989;152(1):123-4. [Medline].
Bider D, Ben-Rafael Z, Goldenberg M. Pregnancy outcome after unwinding of twisted ischaemic-haemorrhagic adnexa. Br J Obstet Gynaecol. Apr 1989;96(4):428-30. [Medline].
Bider D, Mashiach S, Dulitzky M, et al. Clinical, surgical and pathologic findings of adnexal torsion in pregnant and nonpregnant women. Surg Gynecol Obstet. Nov 1991;173(5):363-6. [Medline].
Canning DA. Ovarian torsion: to pex or not to pex? Case report and review of the literature. J Urol. Apr 2005;173(4):1364. [Medline].
Cappell MS, Friedel D. Abdominal pain during pregnancy. Gastroenterol Clin North Am. Mar 2003;32(1):1-58. [Medline].
Germain M, Rarick T, Robins E. Management of intermittent ovarian torsion by laparoscopic oophoropexy. Obstet Gynecol. Oct 1996;88(4 Pt 2):715-7. [Medline].
Graif M, Itzchak Y. Sonographic evaluation of ovarian torsion in childhood and adolescence. AJR Am J Roentgenol. Mar 1988;150(3):647-9. [Medline].
Hibbard LT. Adnexal torsion. Am J Obstet Gynecol. Jun 15 1985;152(4):456-61. [Medline].
Houry D, Abbott JT. Ovarian torsion: a fifteen-year review. Ann Emerg Med. Aug 2001;38(2):156-9. [Medline].
Kamin RA, Nowicki TA, Courtney DS, Powers RD. Pearls and pitfalls in the emergency department evaluation of abdominal pain. Emerg Med Clin North Am. Feb 2003;21(1):61-72, vi. [Medline].
Koonings PP, Grimes DA. Adnexal torsion in postmenopausal women. Obstet Gynecol. Jan 1989;73(1):11-2. [Medline].
Lambert MJ, Villa M. Gynecologic ultrasound in emergency medicine. Emerg Med Clin North Am. Aug 2004;22(3):683-96. [Medline].
Lawrence LL. Unusual presentations in obstetrics and gynecology. Emerg Med Clin North Am. Aug 2003;21(3):649-65. [Medline].
Lee EJ, Kwon HC, Joo HJ. Diagnosis of ovarian torsion with color Doppler sonography: depiction of twisted vascular pedicle. J Ultrasound Med. Feb 1998;17(2):83-9. [Medline].
Mazouni C, Bretelle F, Menard JP, et al. [Diagnosis of adnexal torsion and predictive factors of adnexal necrosis]. Gynecol Obstet Fertil. Mar 2005;33(3):102-6. [Medline].
Oelsner G, Shashar D. Adnexal torsion. Clin Obstet Gynecol. Sep 2006;49(3):459-63. [Medline].
Schlaff WD, Lund KJ, McAleese KA, Hurst BS. Diagnosing ovarian torsion with computed tomography. A case report. J Reprod Med. Sep 1998;43(9):827-30. [Medline].
Shih S, Vetto JT, Berek JS, et al. Adnexal torsion. An unusual cause of abdominal pain in postmenopausal women. Am Surg. May 1991;57(5):327-9. [Medline].
Sommerville M, Grimes DA, Koonings PP, Campbell K. Ovarian neoplasms and the risk of adnexal torsion. Am J Obstet Gynecol. Feb 1991;164(2):577-8. [Medline].
Stenchever. Comprehensive Gynecology. 2001:507-520.
Warner MA, Fleischer AC, Edell SL, et al. Uterine adnexal torsion: sonographic findings. Radiology. Mar 1985;154(3):773-5. [Medline].
Webb EM, Green GE, Scoutt LM. Adnexal mass with pelvic pain. Radiol Clin North Am. Mar 2004;42(2):329-48. [Medline].
Further Reading
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
