Ovarian torsion management

🌪️ Pathophysiology - The Ovarian Twist

• The ovary and fallopian tube twist around the infundibulopelvic (suspensory) ligament and the utero-ovarian ligament.
• This rotation initially obstructs the low-pressure venous and lymphatic outflow, leading to congestion, edema, and ovarian enlargement.
• Continued swelling and twisting eventually compromise the high-pressure arterial inflow, causing ischemia and hemorrhagic infarction.

⭐ The presence of arterial flow on Doppler ultrasound does NOT rule out ovarian torsion, as venous occlusion occurs first.

😱 Clinical Manifestations - Sudden, Sharp & Scary

• Pain:
  • Sudden-onset, severe, unilateral lower abdominal/pelvic pain.
  • Character: Sharp, stabbing, or colicky.
  • Radiation: May radiate to flank, back, or groin.
  • Intermittent pain suggests episodes of torsion and detorsion.
• Associated Symptoms:
  • Nausea & vomiting are very common (~70%).
  • Low-grade fever may be present.
• Physical Exam:
  • Unilateral adnexal tenderness.
  • Palpable adnexal mass.
  • ⚠️ Peritoneal signs (guarding, rebound) suggest ischemia or necrosis.

⭐ While the classic presentation is acute, ~50% of patients report subacute, intermittent pain for days or weeks before the acute event.

🩺 Diagnosis - Spotting the Spin

• Initial Workup:

  • Based on high clinical suspicion (acute severe pain, nausea/vomiting, adnexal mass).
  • Labs: Stat β-hCG to rule out ectopic pregnancy, CBC.

• Imaging Gold Standard: Pelvic Ultrasound with Doppler.

  • Key Findings:
    • Unilateral enlarged, edematous ovary (>4 cm).
    • Peripherally displaced follicles.
    • 💡 "Whirlpool sign": pathognomonic finding of a twisted pedicle.
    • ↓ or absent blood flow on Doppler (venous flow lost before arterial).

⭐ High-Yield: Normal Doppler flow is seen in up to 60% of surgically confirmed cases and does NOT rule out torsion. Clinical suspicion dictates management.

• Definitive Diagnosis: Direct visualization via laparoscopy.

✂️ Management - Untwist and Untack

• Approach: Urgent surgical exploration, typically via laparoscopy.
• Primary Goal: Ovarian salvage.
• Procedure Steps:
  • Detorsion (Untwist): The twisted adnexa is untwisted to restore blood flow.
  • Cystectomy: If a benign cyst is the lead point, it is removed while preserving ovarian tissue.
  • Oophoropexy (Tack): Consider suturing the ovary to the pelvic sidewall to prevent recurrence, especially in pediatric patients.
  • Salpingo-oophorectomy: Reserved for necrotic, non-viable tissue or suspected malignancy.

⭐ Even a dusky or "black" appearing ovary should be untwisted and conserved. Ovarian color is a poor predictor of viability; most regain function after reperfusion.

🌪️ Complications - The Twisted Aftermath

• Ovarian Necrosis/Infarction: Most severe outcome from prolonged ischemia, leading to irreversible tissue death and loss of function.
• Infertility: Risk ↑ with oophorectomy (if ovary is non-viable) or significant damage.
• Peritonitis/Sepsis: From ruptured necrotic tissue or secondary infection.
• Hemorrhage & Adhesions: Post-operative risks.

⭐ Pearl: A dusky, cyanotic ovary upon detorsion does not mandate oophorectomy. Many regain viability and function.

⚡ High-Yield Points - Biggest Takeaways

• Sudden, severe unilateral pelvic pain with nausea/vomiting is the classic presentation.
• Ultrasound with Doppler is the initial imaging of choice, showing an enlarged ovary with absent/decreased blood flow.
• Definitive diagnosis is made via direct surgical visualization.
• Management is urgent diagnostic laparoscopy with detorsion to attempt ovarian conservation.
• A necrotic-appearing ovary should still be detorsed and conserved in premenopausal women.
• Salpingo-oophorectomy is considered for postmenopausal patients or suspected malignancy.