Ovarian Torsion

Pediatric Surgery
Dr Jennifer E. Dietrich, discusses ovarian torsion with Dr Todd A. Ponsky
Edited by Nicholas E. Bruns, MD & Ian C. Glenn, MD

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Evaluation of the adolescent female with pelvic pain
  • Obtain sexual history and urine b-hCG
  • Menstrual history (hemorrhagic cyst may occur)
  • Pain
    • Duration/onset
    • Related activities
    • Classic presentation is sudden onset, severe pelvic pain with nausea
  • Ultrasound
    • Asymmetry of the ovaries
    • Characteristics of the ovary
      • Normal size follicles
      • Follicles at periphery may be due to congestion and edema of the central portion of the ovary from torsion
      • Edema
      • Presence or absence of blood flow
        • Presence of blood flow is unreliable
        • Absence of flow is indicative
      • Lesion
        • Solid vs cystic
        • Simple vs complex cyst
        • Size greater than 5-6 cm is concerning for torsion
        • There is no size cutoff as prepubertal girls could have a torsion related to smaller cysts
      • In prepubertal girls, torsion is a more common operative indication than an ovarian cyst
      • Complex features, hypervascularity, and elevated tumor markers may be concerning for malignancy
    • CT may be useful to assess for pelvic abscess or other intra-abominal cause of abdominal pain
    • MRI may be useful to assess for Mullerian abnormalities
    • Pelvic exam is unnecessary in an adolescent
  • Labs
    • CBC may help in evaluating for other causes
    • If there is a complex cyst, the following tumor marks should be ordered
      • AFP
      • Serum b-hCG quantitative
      • LDH
      • CA-125

Diagnosis and treatment

  • Ovarian torsion is a clinical diagnosis
  • Patients with suspected torsion should be taken urgently to the operating room regardless of blood flow or other ultrasound findings
  • Higher ovarian salvage rates in girls with 24-72 hours of pain with ovarian torsion
  • tube-ovarian abscess should be treated with antibiotics alone
    • Rarely a surprise intra-operative findings
    • Almost always diagnosed preoperatively on imaging
  • In the case of pregnancy, if there is concern for ectopic pregnancy, laparoscopy should be performed. Early pregnancy may not be visualized in the uterus with trans-abdominal ultrasound
Operative technique

 

  • Diagnostic laparoscopy
    • If negative, assess for endometriosis in the cul-de-sac
    • Lesions may be blue-black, clear or red
    • Filling the pelvis with saline and submerging the laparoscope may improve visualization for endometriosis
    • Excise lesions sharply or thermal energy
  • Detorse ovary
  • Remove any lesions to prevent retorsion
    • Cystectomy for most cysts
    • Fenestration may be okay for simple physiologic cyst
    • Paratubal cysts will recur after fenestration
    • Shell out cyst from the ovary and cauterize any bleeding from cyst wall
  • Try to spare ovary
    • Ovary should not be removed unless it is grossly necrotic and falling apart
    • Tube as well should be spared unless devitalized
  • Ovarian bivalving may improve peripheral blood flow to the ovary after detorsion by releasing pressure from edema. Ovarian biopsy may serve same purpose
  • Oophoropexy is most useful for recurrent torsion or torsion associated without an associated lesion
    • May be performed by shortening the utero-ovarian ligament or by pexying to the pelvic sidewall or posterior uterus
    • May lead to infertility by alternating anatomy
    • Clipping the utero-ovarian ligament or infundibulo-pelvic ligament may serve the same purpose by stabilizing the adnexa
  • If an ectopic pregnancy is visualized in the tube, a salpingotomy should be performed and the ectopic pregnancy removed. No closure is required.
Post-operative management

 

  • Most patients are sent home in a few hours with limited activity
  • Oral contraceptives may be used to prevent recurrence of a simple cyst in the menstruating female
  • Surveillance ultrasound typically performed at 3 months post-operatively and then annually

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