Ovarian torsion

Diriba Ragassa –Ambo university

Ovarian cyst • An ovarian cyst is any collection of fluid,

surrounded by a very thin wall, within an ovary.

• Any ovarian follicle that is larger than about 2cm is termed as ovarian cyst.

• Most ovarian cysts are functional in nature, and harmless (benign)

Ovarian torsion

Ovarian torsion • Ovarian torsion refers to the complete or

partial rotation of the ovary on its ligamentous supports

• often resulting in impedance of its blood supply

• Is one of gynecologic emergencies and may affect females of all ages

• The fallopian tube often twists along with the ovary; when this occurs, it is referred to as adnexal torsion

• Complete occlusion of the ovarian blood supply

will ultimately result in loss of ovarian function

and necrosis of the torsed tissues

• w/c may result in hemorrhage (rupture) or

peritonitis , pelvic pain or infertility

• The primary risk factor for ovarian torsion is an

ovarian mass, particularly a mass that is 5 cm in

diameter or larger

Risk factors

• Ovarian mass – benign or malignant (86 to 95%)• Age 20-50• size >/= 5cm in ø• ovulation induction• Prev. Hx of torsion• Pregnancy• PCOS

Clinical features Frequently presenting symptoms :-• Pelvic pain (90 %)• Adnexal mass (86 to 95 %)• Nausea and vomiting (47 to 70 %)• Fever (2 to 20 %)• Abnormal genital tract bleeding (4 %)

Laboratory evaluation • A serum HCG to R/O ectopic pregnancy• Hct, WBC count, and electrolyte panel should

be drawn.• Pelvic ultrasound (Doppler) - first line imaging

study• Definitive diagnosis of ovarian torsion is made

by direct visualization of a rotated ovary at the time of surgical evaluation

Management • The mainstay of treatment of ovarian torsion

is swift operative evaluation to preserve ovarian function to prevent hemorrhage, peritonitis, adhesion formation

• For premenopausal patientsdetorsion and ovarian conservation rather than salpingo-oophorectomy

• Salpingo-oophorectomy is also reasonable for postmenopausal women

• Ovarian cystectomy for benign mass• necrotic ovary or an ovarian mass that is

suspicious for malignancy require salpingo-oophorectomy

• Pregnant women — Management of torsion in pregnancy is similar to that in nonpregnant patients, but may be technically more difficult given the size of the gravid uterus

Prevention of recurrence

• Suppression of ovarian cysts – Use of high dose oral contraceptives (≥50 mcg estrogen)

• Oophoropexy – Unilateral or bilateral oophoropexy following ovarian detorsion

Ruptured Ovarian cyst• Rupture of an ovarian cyst is a common

occurrence in women of reproductive age• Rupture of an ovarian cyst may be asymptomatic

or • Associated with the sudden onset of unilateral

lower abdominal pain• The pain often begins during strenuous physical

activity, or sexual intercourse.• It may be accompanied by light vaginal bleeding

due to a drop in secretion of ovarian hormones and subsequent endometrial sloughing

Clinical features• Blood from the rupture site may seep into the

ovary, which can cause pain from stretching of the ovarian cortex, or

• it may flow into the abdomen, which has an irritant effect on the peritoneum

• Vital signs are usually in the normal range, although a low-grade fever may be present.

• Significant hemorrhage leading to shock is rare

• lower abdomen is often tender to palpation• The right lower quadrant is most commonly

affected• adnexal mass may be palpable• Cervical motion tenderness may also be

present

Diagnosis • First R/O ruptured ectopic pregnancy• medical and surgical Hx should be reviewed for

potential gynecologic causes of lower abdominal pain:

• history of and risk factors for ovarian cysts, endometriosis, pelvic inflammatory disease, endometritis, or leiomyomas and medication use (anticoagulant)

• the possibility of pregnancy (ectopic, intrauterine, or heterotopic) and nongynecological causes of pain

Laboratory tests

• Β-hCG, CBC,coagulation profile, Blood type and crossmatch

• Serum CA-125 assay (ovarian cancer)• Severe thrombocytopenia can worsen bleeding

associated with cyst rupture• Urinalysisrenal stone /infection• Blood and urine cultures and cervical studies for STI• U/S –cornerstone (adnexal mass, ectopic preg, TOA,

hemorrhage

Management Uncomplicated cyst rupture • In the absence of hypotension, tachycardia, fever, signs of

an acute abdomen, leukocytosis, or• Absence of sonographic evidence of an enlarging

hemoperitoneum or findings suggestive of malignancy.

• Mgt would be as OP– analgesics (nonhemmorhagic cyst fluid resorb within 24 hours)

• Surgery only indicated for for diagnosis and treatment of ovarian cysts that are large (>5cm in Ø) or persistent, and those with findings suspicious for malignancy

Complicated cyst rupture • Admission • Manage with fluid replacement,• frequent vital signs, serial hematocrit levels,

and repeated imaging to monitor bleeding• After bleeding has stopped, hemoperitoneum

may take several weeks to resolve• Surgery is performed to control hemorrhage

if the patient's clinical condition is unstable or deteriorating or drainage

Prevention

• There are no known methods to prevent rupture of an existing ovarian cyst, with the exception of surgical drainage or removal or the cyst.

• Hormonal suppression of ovulation may prevent cyst formation