Ovarian torsion (OT) or adnexal torsion is an abnormal condition where an ovary twists on its attachment to other structures, such that blood flow is decreased. Symptoms typically include

pelvic pain Pelvic pain is pain in the area of the pelvis. Acute pain is more common than chronic pain. If the pain lasts for more than six months, it is deemed to be chronic pelvic pain. It can affect both the male and female pelvis. Common causes in include ...

on one side. While classically the pain is sudden in onset, this is not always the case. Other symptoms may include

nausea Nausea is a diffuse sensation of unease and discomfort, sometimes perceived as an urge to vomit. While not painful, it can be a debilitating symptom if prolonged and has been described as placing discomfort on the chest, abdomen, or back of the ...

. Complications may include

infection An infection is the invasion of tissues by pathogens, their multiplication, and the reaction of host tissues to the infectious agent and the toxins they produce. An infectious disease, also known as a transmissible disease or communicable dis ...

, bleeding, or

infertility Infertility is the inability of a person, animal or plant to reproduce by natural means. It is usually not the natural state of a healthy adult, except notably among certain eusocial species (mostly haplodiploid insects). It is the normal state ...

. Risk factors include

ovarian cysts An ovarian cyst is a fluid-filled sac within the ovary. Often they cause no symptoms. Occasionally they may produce bloating, lower abdominal pain, or lower back pain. The majority of cysts are harmless. If the cyst either breaks open or causes ...

, ovarian enlargement,

ovarian tumors Ovarian tumors, or ovarian neoplasms, are tumors arising from the ovary. They can be benign or malignant (ovarian cancer). They consist of mainly solid tissue, while ovarian cysts contain fluid. Histopathologic classification Ovarian tumors ar ...

pregnancy Pregnancy is the time during which one or more offspring develops ( gestates) inside a woman's uterus (womb). A multiple pregnancy involves more than one offspring, such as with twins. Pregnancy usually occurs by sexual intercourse, but ca ...

fertility treatment Assisted reproductive technology (ART) includes medical procedures used primarily to address infertility. This subject involves procedures such as in vitro fertilization (IVF), intracytoplasmic sperm injection (ICSI), cryopreservation of gametes ...

, and prior

tubal ligation Tubal ligation (commonly known as having one's "tubes tied") is a surgical procedure for female sterilization in which the fallopian tubes are permanently blocked, clipped or removed. This prevents the fertilization of eggs by sperm and thus th ...

. The diagnosis may be supported by an

ultrasound done via the vagina Vaginal ultrasonography is a medical ultrasonography that applies an ultrasound transducer (or "probe") in the vagina to visualize organs within the pelvic cavity. It is also called transvaginal ultrasonography because the ultrasound waves go ''a ...

or CT scan, but these do not completely rule out the diagnosis. Surgery is the most accurate method of diagnosis. Treatment is by surgery to either untwist and fix the ovary in place or to remove it. The ovary will often recover, even if the condition has been present for some time. In those who have had a prior ovarian torsion, there is a 10% chance the other will also be affected. The diagnosis is relatively rare, affecting about 6 per 100,000 women per year. While it most commonly occurs in those of reproductive age, it can occur at any age.

Signs and symptoms

Patients with ovarian torsion often present with sudden onset of sharp and usually unilateral lower abdominal pain, in 70% of cases accompanied by

and

vomiting Vomiting (also known as emesis and throwing up) is the involuntary, forceful expulsion of the contents of one's stomach through the mouth and sometimes the nose. Vomiting can be the result of ailments like food poisoning, gastroenteri ...

Pathophysiology

The development of an ovarian mass is related to the development of torsion. In the reproductive years, regular growth of large corpus luteal cysts are a risk factor for rotation. The mass effect of ovarian tumors is also a common cause of torsion. Torsion of the ovary usually occurs with torsion of the fallopian tube as well on their shared vascular pedicle around the

broad ligament The broad ligament of the uterus is the wide fold of peritoneum that connects the sides of the uterus to the walls and floor of the pelvis. Structure Subdivisions Contents The contents of the broad ligament include the following: * Reprod ...

, although in rare cases the ovary rotates around the

mesovarium The mesovarium is the portion of the broad ligament of the uterus that suspends the ovaries. The ovary is not covered by the mesovarium; rather, it is covered by germinal epithelium. At first the mesonephros and genital ridge are suspended by a ...

or the fallopian tube rotates around the

mesosalpinx The mesosalpinx is part of the lining of the abdominal cavity in higher vertebrates, specifically the portion of the broad ligament that stretches from the ovary to the level of the fallopian tube. See also * Mesometrium * Mesovarium The m ...

. In 80%, torsion happens unilaterally, with slight predominance on the right. In ovarian torsion, the ovary rotates around both the infundibulopelvic ligament (ie, suspensory ligament) and the utero-ovarian ligament (i.e. ovarian ligament), disrupting blood flow to the ovary.

Diagnosis

Ovarian torsion is difficult to diagnose accurately, and operation is often performed before certain diagnosis is made. A study at an

obstetrics and gynaecology Obstetrics and Gynaecology (also spelled as Obstetrics and Gynecology; abbreviated as Obs and Gynae, O&G, OB-GYN and OB/GYN) is the medical specialty that encompasses the two subspecialties of obstetrics (covering pregnancy, childbirth, and t ...

department found that preoperative diagnosis of ovarian torsion was confirmed in only 46% of people.

Ultrasound

Gynecologic ultrasonography Gynecologic ultrasonography or gynecologic sonography refers to the application of medical ultrasonography to the female pelvic organs (specifically the uterus, the ovaries, and the fallopian tubes) as well as the bladder, the adnexa, and the rec ...

is the imaging modality of choice. Use of

doppler ultrasound Doppler ultrasonography is medical ultrasonography that employs the Doppler effect to perform imaging of the movement of tissues and body fluids (usually blood), and their relative velocity to the probe. By calculating the frequency shift of a ...

in the diagnosis has been suggested. However, doppler flow is not always absent in torsion – the definitive diagnosis is often made in the operating room. Lack of ovarian blood flow on

doppler sonography Doppler ultrasonography is medical ultrasonography that employs the Doppler effect to perform imaging of the movement of tissues and body fluids (usually blood), and their relative velocity to the probe. By calculating the frequency shift of ...

seems to be a good predictor of ovarian torsion. Women with pathologically low flow are more likely to have torsion. The

sensitivity and specificity ''Sensitivity'' and ''specificity'' mathematically describe the accuracy of a test which reports the presence or absence of a condition. Individuals for which the condition is satisfied are considered "positive" and those for which it is not are ...

of abnormal ovarian flow are 44% and 92%, respectively, with a

positive Positive is a property of positivity and may refer to: Mathematics and science * Positive formula, a logical formula not containing negation * Positive number, a number that is greater than 0 * Plus sign, the sign "+" used to indicate a posi ...

and negative predictive value of 78% and 71%, respectively. Specific flow features on Doppler sonography include: * Little or no intra-ovarian venous flow. This is commonly seen in ovarian torsion. * Absent arterial flow. This is a less common finding in ovarian torsion * Absent or reversed diastolic flow Normal vascularity does not exclude intermittent torsion. There may occasionally be normal Doppler flow because of the ovary's dual blood supply from both the ovarian arteries and uterine arteries. Other ultrasonographic features include: * Enlarged hypoechogenic or hyperechogenic ovary * Peripherally displaced

ovarian follicle An ovarian follicle is a roughly spheroid cellular aggregation set found in the ovaries. It secretes hormones that influence stages of the menstrual cycle. At the time of puberty, women have approximately 200,000 to 300,000 follicles, each with t ...

s * Free pelvic fluid. This may be seen in more than 80% of cases * ''Whirlpool sign'' of twisted vascular pedicle * Underlying ovarian lesion can often be found * Uterus may be slightly deviated towards the torted ovary.

Treatment

Surgical treatment of ovarian torsion includes

laparoscopy Laparoscopy () is an operation performed in the abdomen or pelvis using small incisions (usually 0.5–1.5 cm) with the aid of a camera. The laparoscope aids diagnosis or therapeutic interventions with a few small cuts in the abdomen.Medlin ...

to uncoil the torsed ovary and possibly oophoropexy to fixate the ovary which is likely to twist again. In severe cases, where blood flow is cut off to the ovary for an extended period of time,

necrosis Necrosis () is a form of cell injury which results in the premature death of cells in living tissue by autolysis. Necrosis is caused by factors external to the cell or tissue, such as infection, or trauma which result in the unregulated dige ...

of the ovary can occur. In these cases the ovary must be surgically removed.

Epidemiology

Ovarian torsion accounts for about 3% of gynecologic emergencies. The incidence of ovarian torsion among women of all ages is 5.9 per 100,000 women, and the incidence among women of reproductive age (15–45 years) is 9.9 per 100,000 women. In 70% of cases, it is diagnosed in women between 20 and 39 years of age. The risk is greater during pregnancy and in menopause. Risk factors include increased length of the ovarian ligaments, pathologically enlarged ovaries (more than 6 cm), ovarian masses or cysts, and enlarged corpus luteum in pregnancy.

References

External links

{{Female diseases of the pelvis and genitals Noninflammatory disorders of female genital tract Wikipedia medicine articles ready to translate