Ovarian Torsion

Background:

- Twisting of ovary and infundibulopelvic (suspensory) ligament, which holds ovarian vessels, impeding lymphatic and venous outflow and arterial inflow

- Increased in first year of life, menarche, pregnancy, ovulation, induction during infertility treatment

- 50% initially misdiagnosed

Risk Factors

- large ovarian cyst or tumor especially if >5cm tubal ligation

Presentation:

- 70% R sided (longer utero-ovarian lig, sigmoid colon on L)

- Acute onset severe unilateral pain, often after exertion (although half with gradual onset)

- Nausea and vomiting in 70%

- +/- low grade fever

Exam:

- Unilateral lower abdominal tenderness with guarding, adnexal tenderness on bimanual exam, palpable adnexal mass

DDx:

- Appendicitis, PID, TOA, ectopic pregnancy, ruptured ovarian cyst

Work up:

- Obtain beta-Hcg

- Pelvic Ultrasound w/ doppler

- not 100% sensitive or specific

- most common - ovary >4cm due to cyst, tumor, or edema

- heterogenous appearance of stroma

- multiple peripheral follicles ("string of pearls")

- decrease/absent flow within the ovary

- Confirmation of diagnosis is direct visualization

Management:

- Surgical emergency - consult OB/Gyn

Complications:

- loss of ovarian function

- necrosis

- hemorrhage

- peritonitis

Key Point: Maintain a high index of suspicion as this is easy to miss and has significant consequences if not caught early!

Reference:

Heniff, M, Fleming, H. “Abdominal and Pelvic Pain in the Nonpregnant Female.” Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 8eEds. Judith E. Tintinalli, et al. New York, NY: McGraw-Hill, 2016.