Partial or complete rotation of the ovary around the infundibulopelvic ligament, leading to ovarian vessel occlusion and ovarian ischemia.
utero-ovarian ligament may be involved as pic below
| Risk factors | • Ovarian mass • Women of reproductive age • Infertility treatment with ovulation induction | | --- | --- | | Clinical presentation | • Sudden-onset unilateral pelvic pain • Nausea & vomiting • ± Palpable adnexal mass | | Diagnosis | • Clinical (read below) | | Ultrasound | • Adnexal mass with absent Doppler flow to ovary supports the diagnosis but not required • Normal findings don’t exclude torsion | | **Treatment (**Emergency) | • Laparoscopy with detorsion • Ovarian cystectomy • Oophorectomy if necrosis or malignancy |
<aside> 💡 Any large ovarian mass (≥5 cm) can induce torsion
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Precipitated by physical activity, and the initial pain can be colicky in cases of partial torsion (ie, intermittent adnexal twisting and untwisting)
Torsion initially impedes venous outflow with continued arterial inflow, leading to vascular congestion and edema.
<aside> 💡 Is a clinical diagnosis but Doppler ultrasound revealing decreased or absent ovarian blood flow can support the diagnosis, normal findings do not exclude torsion.
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Ovarian torsion can cause elevated CA-125 levels due to release from the ischemic ovary.
Partial ovarian torsion causes temporary ovarian vessel occlusion and pelvic pain (from ovarian ischemia). Patients classically have nausea, vomiting, and intermittent pain that self-resolves (ie, no symptoms between episodes) as spontaneous adnexal untwisting allows blood flow to return. Therefore, Doppler ultrasound may show normal ovarian arterial and venous blood flow.
Partial torsion can progress to complete ovarian torsion. patients typically triggered by physical activity (eg, walking) and present with severe sudden onset, unilateral lower abdominal pain with nausea/vomiting due to ovarian ischemia and necrosis from complete ovarian vessel obstruction (eg, decreased ovarian Doppler flow).
As ovarian ischemia progresses, patients may develop radiating pain, ovarian edema (eg, adnexal tenderness or fullness, with or without a palpable mass), and peritonitis (eg, rebound/guarding, fever) and an acute abdomen (eg, rebound, guarding).
May have vaginal bleeding (ie, from adnexal edema and necrosis).
The ovary can become enlarged, edematous, and tender and have associated inflammatory pelvic free fluid.
Although torsion can cause low-grade fever and mild leukocytosis (due to ovarian necrosis), the absence of these findings makes appendicitis and tuboovarian abscess less likely, the question had normal leukocyte count and no fever
<aside> 💡 Although torsion is less common in the pediatric population, an ovarian mass (as in this patient) increases the risk for complete torsion because the increased adnexal size and density make spontaneous untwisting less likely
Although ovarian torsion can occur in all reproductive-aged women, those with a history of ovarian cysts (eg, hemorrhagic cyst) or masses (eg, mature cystic teratoma) are at increased risk.
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Because of the risk of tissue necrosis and loss of ovarian function (eg, infertility, menopause), ovarian torsion requires urgent diagnostic laparoscopy to manually untwist the adnexa and restore blood flow and removal of any contributory cysts or masses; oophorectomy may be required if the ovary is necrotic.
Due to the emergent nature of ovarian torsion, additional imaging (eg, CT scan of the abdomen and pelvis) is inappropriate because it delays evaluation and treatment.
CT scan of the abdomen and pelvis is indicated if another diagnosis (eg, appendicitis) is suspected. And is usally is negative in setting of ovarian torison (few Qs presented with negative CTs and asked for what is the best next step? the answer was U/S)
(Choice E) Scheduling surgical explorationmay be appropriate because the viability of the ovary in ovarian torsion depends on its urgent detorsion. However, the diagnosis should first be confirmed with ultrasonography.