Abstract

Seventeen year old unmarried girl presented in emergency with abdominal pain and distension. Clinical diagnosis of left ovarian torsion was made. Decision of laparoscopy followed by laparotomy was taken. Intra-operative findings revealed torsion of left sided ovarian cyst.

Exploratory laparotomy with evacuation of haematoma and ovarian reconstruction of right ovary was done.

Introduction

Ovarian torsion is an uncommon gynaecological emergency. It requires prompt recognition and treatment. It may present with nonspecific signs and symptoms. It should be considered in any female with acute abdominal pain. The diagnosis is based on an awareness of the relevant risk factors, the clinical presentation, and a high index of suspicion.

Timely investigation and management can make the difference between ovarian loss and salvage- an outcome of great importance in the population of reproductive age females.

Case Report

Seventeen year old unmarried girl presented in emergency with colicky pain in right lumbar region. No h/o vomiting, fever or anorexia No other urinary or bowel complaints.

Her last menstrual period was six days back. On abdominal examination, there was minimal tenderness, on deep palpation there was no guarding or rigidity. On local examination hymen was intact. On rectal examination uterus was retroverted, normal size, tender, firm mass was felt in left anterior fornix, groove felt between mass and uterus.

Patient was evaluated. Her Hb was 9.3 gm%. On Ultrasonography left ovary was 6.4 x 5.2 x 4.1 cm, there was 4.4 x 3.2 cm cyst in left ovary, no vascularity seen; there was free fluid in POD. Clinical diagnosis of left ovarian torsion was made. Patient received IV antibiotics Decision of laparoscopy followed by laparotomy was taken. Intra-operative findings were: Uterus normal, 4 x 4 cm cystic right ovary with 1 loop of torsion, capsule had a bluish discoloration. Rt and Lt fallopian tubes and right ovary were normal.

Exploratory laparotomy with evacuation of haematoma and pealing of the cyst wall, untwisting the ovarian ligament and ovarian reconstruction of right ovary was done.

Discussion

Ovarian torsion was first described by Kuestner in 1891.¹ If the rotation is partial or intermittent, the venous and lymphatic congestion may subside quickly, along with symptoms. If rotation is complete and prolonged, venous and arterial thrombosis occur, ultimately causing adnexal infarction.^1,2

Adnexal torsion is rarely bilateral and is more common on the right side,³ perhaps because the sigmoid colon leaves limited space for left adnexal mobility.⁴ Torsion occurs more commonly in young women, with the greatest incidence in the 20- to 30-year age group.⁵

Ovarian enlargement, adnexal masses, pregnancy, ovulation induction and previous pelvic surgery are the most common predisposing factors for ovarian torsion, and the exact mechanism of torsion varies according to its cause. Ovarian enlargement of any aetiology predisposes the adnexa to torsion; however, normal ovaries may undergo torsion, especially in prepubescent females.1 Because of the anatomy of the broad ligament, both the ovary (or adnexal mass) and the fallopian tube are usually involved in the torsion; it is uncommon for these structures to be involved in isolation.³

In the early stages of ovarian torsion, the ovary is enlarged with prominent peripheral follicles. Hyperechogenic and hypoechogenic areas may be seen which correspond to haemorrhage and oedema respectively. With prolonged and complete torsion, infarction may appear as cystic, clotted areas.⁶

Colour Doppler sonography (CDS) has been used increasingly in recent years to evaluate ovarian viability. Abnormal flow on CDS increases the likelihood of torsion.^3,7 but torsion may occur with incomplete vascular obstruction; therefore, evidence of vascular flow does not rule out torsion with certainty.5 In one recent case series, 14 of 15 patients with ovarian torsion had abnormal CDS flow patterns,³ but in another small retrospective series of 10 surgically confirmed cases, CDS often showed normal ovarian flow, and this test was associated with significant delays to diagnosis (5.3 v. 59 hours).⁸ Diagnostic laparoscopy is indicated when there is a high suspicion of ovarian torsion and the need for surgical intervention remains unclear. Early diagnosis will help to reduce the incidence of necrotic ovaries and hence increase their salvage rates. In the past, oophorectomy was considered the standard of care, because of concern that untwisting of the adnexa might precipitate pulmonary embolism from a thrombosed vein. Several studies have shown that in the absence of a grossly necrotic ovary, untwisting of the adnexa can be performed, and the ovary salvaged, without significant risk of thromboembolism.⁹ Conversely, an obvious haemorrhagic infarction or gangrenous adnexal structure requires surgical removal without attempt to untwist. All dedicated efforts should be attempted to salvage and conserve the ovary or part of the ovarian tissue as it is an endocrine organ and reservoir of primordial follicles. Presence of the other normal ovary should not be an indication for oophorectomy of the twisted ovary as the one remaining may undergo any disease process subsequently which may require its removal, leaving the woman without any functional gonads.

References

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7. Morrison L, Spence J. Vaginal bleeding and pelvic pain in the non-pregnant patient. In: Tintinalli J, Kelen GD, Stapczynski JS, editors. Emergency medicine: a comprehensive study guide. 5th ed. New York: McGraw-Hill; 2000 : 669-80.
   
8. Pena JE, Ulfberg D, Cooney N, et al. Usefulness of Doppler sopnography in the diagnosis of ovarian torsion. Fertil Steril 2000; 73 : 1047-50.
   
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*Associate Professor, **Resident, Department of Ophthalmology, T.N.M.C and B.Y.L. Nair Hospital, Mumbai - 400 008.