Ovarian Torsion

Ovarian torsion is rotation of the ovary on its ligamentous supports, which blocks its blood supply. It may involve the tube as well.

• It affects women of all ages, including girls and postmenopausal women, and may occur with or without a cyst.
• An ovary with a cyst or enlarged by ovarian hyperstimulation or polycystic ovaries is most at risk.
• Early detorsion saves the ovary in most women.

Acute, severe pelvic pain with nausea and vomiting, sometimes colicky, with a history of similar episodes.

• Adnexal tenderness and a mass, fever and peritonism later.
• Differential diagnosis: ectopic pregnancy, appendicitis, ruptured cyst, tubo-ovarian abscess, renal colic, mesenteric adenitis, pelvic inflammatory disease.
• Complications: ovarian infarction, peritonitis, infertility, loss of ovary and sepsis.

Diagnosis is clinical, supported by ultrasound, and normal Doppler flow does not exclude torsion.

• Pregnancy test; full blood count; C-reactive protein; urinalysis.
• Transvaginal or pelvic ultrasound: enlarged oedematous ovary of more than 4 cm or volume above 20 mL, peripheral follicles, free fluid, whirlpool sign; Doppler flow does not exclude torsion.
• MRI or CT scan in unclear cases in a stable woman.
• Laparoscopy is both diagnostic and therapeutic.

Operate urgently to untwist the ovary and preserve it, even when it looks black.

• Supportive: nil by mouth; IV crystalloid; analgesia; early theatre; reassure and explain that the ovary is usually saved.
• Pharmacological: morphine 2.5 to 5 mg IV titrated every 5 minutes (child 0.05 to 0.1 mg/kg IV); paracetamol 1 g IV 6-hourly (maximum 4 g in 24 hours; child 15 mg/kg); ondansetron 4 mg IV 8-hourly (child 0.15 mg/kg, maximum 4 mg per dose). Ceftriaxone 1 g IV single dose for prophylaxis if infection is suspected.
• Procedures: laparoscopic detorsion without removing the ovary, even when it is black; cystectomy for any cyst at the same time or after 6 to 8 weeks; oophoropexy for recurrent torsion or in girls with a long ligament; oophorectomy only for necrotic tissue or suspected cancer.
• Special groups: in children and adolescents operate early because the ovary is usually normal; in pregnancy use laparoscopy in the first or second trimester; in ovarian hyperstimulation drain tense ascites and detort.
• Red flags: pain lasting more than 24 hours, fever, peritonism, shock, suspicion of malignancy.
• Follow-up: review at 1 and 6 weeks; ultrasound at 6 to 8 weeks to confirm ovarian size and follicles; counsel on recurrence.