Diferencia entre revisiones de «Ovarian torsion»

(Major update: added Disposition section, whirlpool sign, Doppler limitations (50% sensitivity), salvage rates by time, do not assume nonviable, string of pearls sign, references with PMIDs)
(Strip excess bold)
 
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*'''5th most common gynecologic emergency'''
*'''5th most common gynecologic emergency'''
*Accounts for ~3% of all gynecologic emergencies
*Accounts for ~3% of all gynecologic emergencies
*Most common in '''reproductive-age women (20-40 years)'''
*Most common in reproductive-age women (20-40 years)
*Risk factors:
*Risk factors:
**'''Ovarian mass >5 cm''' (most common risk factor; dermoid cysts particularly prone)
**Ovarian mass >5 cm (most common risk factor; dermoid cysts particularly prone)
**Ovarian hyperstimulation syndrome (fertility treatment)
**Ovarian hyperstimulation syndrome (fertility treatment)
**'''Pregnancy''' (especially first trimester; corpus luteum cysts)
**Pregnancy (especially first trimester; corpus luteum cysts)
**Prior tubal ligation (increases ovarian mobility)
**Prior tubal ligation (increases ovarian mobility)
**Long utero-ovarian ligament
**Long utero-ovarian ligament
*'''Right side more common than left''' (sigmoid colon may limit left ovarian mobility)
*Right side more common than left (sigmoid colon may limit left ovarian mobility)
*Can occur in '''prepubertal girls''' (often without predisposing mass — normal ovary)
*Can occur in prepubertal girls (often without predisposing mass — normal ovary)


==Clinical Features==
==Clinical Features==
*'''Sudden onset, severe, unilateral lower abdominal/pelvic pain''' (most common presentation)
*Sudden onset, severe, unilateral lower abdominal/pelvic pain (most common presentation)
*Pain may be '''intermittent''' (intermittent torsion/detorsion)
*Pain may be intermittent (intermittent torsion/detorsion)
*'''Nausea and vomiting''' (present in 70% — may be prominent)
*Nausea and vomiting (present in 70% — may be prominent)
*Low-grade [[fever]] (late finding suggesting necrosis)
*Low-grade [[fever]] (late finding suggesting necrosis)
*Adnexal tenderness on bimanual exam; '''palpable adnexal mass''' in ~50%
*Adnexal tenderness on bimanual exam; palpable adnexal mass in ~50%
*May mimic [[appendicitis]], [[renal colic]], or [[ectopic pregnancy]]
*May mimic [[appendicitis]], [[renal colic]], or [[ectopic pregnancy]]
*'''Peritoneal signs are late''' and suggest necrosis
*Peritoneal signs are late and suggest necrosis
*In children: may present with non-specific abdominal pain
*In children: may present with non-specific abdominal pain


==Differential Diagnosis==
==Differential Diagnosis==
*[[Ectopic pregnancy]] ('''always obtain pregnancy test first''')
*[[Ectopic pregnancy]] (always obtain pregnancy test first)
*Ruptured [[ovarian cyst]]
*Ruptured [[ovarian cyst]]
*[[Appendicitis]]
*[[Appendicitis]]
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==Evaluation==
==Evaluation==
*'''Urine pregnancy test''' (rule out [[ectopic pregnancy]])
*Urine pregnancy test (rule out [[ectopic pregnancy]])
*'''CBC''': leukocytosis may be present (nonspecific)
*CBC: leukocytosis may be present (nonspecific)
*'''Urinalysis''': rule out [[UTI]], [[nephrolithiasis]]
*Urinalysis: rule out [[UTI]], [[nephrolithiasis]]
*'''Lactate''': may be elevated in late presentations
*Lactate: may be elevated in late presentations


===Transvaginal Ultrasound (Test of Choice)===
===Transvaginal Ultrasound (Test of Choice)===
*'''Enlarged ovary''' (>4 cm) compared to contralateral side
*Enlarged ovary (>4 cm) compared to contralateral side
*'''Ovarian edema''' (heterogeneous appearance)
*Ovarian edema (heterogeneous appearance)
*'''Peripherally displaced follicles''' ("string of pearls" sign)
*Peripherally displaced follicles ("string of pearls" sign)
*'''Whirlpool sign''' on Doppler: twisted vascular pedicle (most specific finding)
*Whirlpool sign on Doppler: twisted vascular pedicle (most specific finding)
*'''Free fluid''' in cul-de-sac
*Free fluid in cul-de-sac


====Doppler Findings====
====Doppler Findings====
*'''Absent or decreased ovarian arterial/venous flow''' supports diagnosis
*Absent or decreased ovarian arterial/venous flow supports diagnosis
*'''HOWEVER: presence of Doppler flow does NOT exclude torsion'''<ref>Shadinger LL, et al. Surgically treated adnexal torsion: does the presence of doppler flow predict viability? ''J Ultrasound Med''. 2008;27(5):687-691. PMID 18424640</ref>
*HOWEVER: presence of Doppler flow does NOT exclude torsion<ref>Shadinger LL, et al. Surgically treated adnexal torsion: does the presence of doppler flow predict viability? ''J Ultrasound Med''. 2008;27(5):687-691. PMID 18424640</ref>
**'''Sensitivity of absent flow is only ~50%''' — dual blood supply (ovarian and uterine arteries)
**Sensitivity of absent flow is only ~50% — dual blood supply (ovarian and uterine arteries)
**Intermittent torsion may show normal flow between episodes
**Intermittent torsion may show normal flow between episodes
*If high clinical suspicion, proceed to OR despite normal Doppler
*If high clinical suspicion, proceed to OR despite normal Doppler
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*May show enlarged ovary, fat stranding, deviation of uterus toward affected side
*May show enlarged ovary, fat stranding, deviation of uterus toward affected side
*Less sensitive than US for torsion but may identify alternative diagnoses
*Less sensitive than US for torsion but may identify alternative diagnoses
*'''"Ovarian mass with surrounding fat stranding"''' on CT should raise concern
*"Ovarian mass with surrounding fat stranding" on CT should raise concern


==Management==
==Management==
*'''Emergent gynecology consultation for operative intervention'''
*Emergent gynecology consultation for operative intervention
*'''Time-sensitive''' — ovarian salvage rates decrease with prolonged ischemia
*Time-sensitive — ovarian salvage rates decrease with prolonged ischemia
**Detorsion within '''6 hours''': high salvage rate
**Detorsion within 6 hours: high salvage rate
**Detorsion at '''24-36 hours''': viable ovary still possible
**Detorsion at 24-36 hours: viable ovary still possible
**'''Do not assume a black/dusky ovary is nonviable''' — most recover after detorsion
**'''Do not assume a black/dusky ovary is nonviable''' — most recover after detorsion
*'''Laparoscopic detorsion''' is procedure of choice (preserves fertility)
*Laparoscopic detorsion is procedure of choice (preserves fertility)
*Oophoropexy (fixation) may be performed to prevent recurrence
*Oophoropexy (fixation) may be performed to prevent recurrence
*Oophorectomy reserved for clearly necrotic tissue or suspected malignancy
*Oophorectomy reserved for clearly necrotic tissue or suspected malignancy
*'''Supportive care''' in ED:
*Supportive care in ED:
**IV fluids, antiemetics (ondansetron 4 mg IV)
**IV fluids, antiemetics (ondansetron 4 mg IV)
**Pain control: '''ketorolac 15-30 mg IV''' and/or '''opioids'''
**Pain control: ketorolac 15-30 mg IV and/or opioids
**NPO for OR preparation
**NPO for OR preparation


==Disposition==
==Disposition==
*'''Admit for emergent surgical intervention'''
*Admit for emergent surgical intervention
*'''Do NOT delay surgery for additional imaging''' if clinical suspicion is high
*'''Do NOT delay surgery for additional imaging''' if clinical suspicion is high
*Consult gynecology early — even if US is equivocal, operative evaluation may be warranted
*Consult gynecology early — even if US is equivocal, operative evaluation may be warranted

Revisión actual - 09:35 22 mar 2026

Background

  • Rotation of the ovary around its vascular pedicle (infundibulopelvic and utero-ovarian ligaments)
  • Compromises venous/lymphatic drainage first → edema → eventual arterial compromise → ischemia and necrosis
  • 5th most common gynecologic emergency
  • Accounts for ~3% of all gynecologic emergencies
  • Most common in reproductive-age women (20-40 years)
  • Risk factors:
    • Ovarian mass >5 cm (most common risk factor; dermoid cysts particularly prone)
    • Ovarian hyperstimulation syndrome (fertility treatment)
    • Pregnancy (especially first trimester; corpus luteum cysts)
    • Prior tubal ligation (increases ovarian mobility)
    • Long utero-ovarian ligament
  • Right side more common than left (sigmoid colon may limit left ovarian mobility)
  • Can occur in prepubertal girls (often without predisposing mass — normal ovary)

Clinical Features

  • Sudden onset, severe, unilateral lower abdominal/pelvic pain (most common presentation)
  • Pain may be intermittent (intermittent torsion/detorsion)
  • Nausea and vomiting (present in 70% — may be prominent)
  • Low-grade fever (late finding suggesting necrosis)
  • Adnexal tenderness on bimanual exam; palpable adnexal mass in ~50%
  • May mimic appendicitis, renal colic, or ectopic pregnancy
  • Peritoneal signs are late and suggest necrosis
  • In children: may present with non-specific abdominal pain

Differential Diagnosis

Acute Pelvic Pain

Differential diagnosis of acute pelvic pain

Gynecologic/Obstetric

Genitourinary

Gastrointestinal

Musculoskeletal

Vascular

Evaluation

  • Urine pregnancy test (rule out ectopic pregnancy)
  • CBC: leukocytosis may be present (nonspecific)
  • Urinalysis: rule out UTI, nephrolithiasis
  • Lactate: may be elevated in late presentations

Transvaginal Ultrasound (Test of Choice)

  • Enlarged ovary (>4 cm) compared to contralateral side
  • Ovarian edema (heterogeneous appearance)
  • Peripherally displaced follicles ("string of pearls" sign)
  • Whirlpool sign on Doppler: twisted vascular pedicle (most specific finding)
  • Free fluid in cul-de-sac

Doppler Findings

  • Absent or decreased ovarian arterial/venous flow supports diagnosis
  • HOWEVER: presence of Doppler flow does NOT exclude torsion[2]
    • Sensitivity of absent flow is only ~50% — dual blood supply (ovarian and uterine arteries)
    • Intermittent torsion may show normal flow between episodes
  • If high clinical suspicion, proceed to OR despite normal Doppler

CT Abdomen/Pelvis

  • May show enlarged ovary, fat stranding, deviation of uterus toward affected side
  • Less sensitive than US for torsion but may identify alternative diagnoses
  • "Ovarian mass with surrounding fat stranding" on CT should raise concern

Management

  • Emergent gynecology consultation for operative intervention
  • Time-sensitive — ovarian salvage rates decrease with prolonged ischemia
    • Detorsion within 6 hours: high salvage rate
    • Detorsion at 24-36 hours: viable ovary still possible
    • Do not assume a black/dusky ovary is nonviable — most recover after detorsion
  • Laparoscopic detorsion is procedure of choice (preserves fertility)
  • Oophoropexy (fixation) may be performed to prevent recurrence
  • Oophorectomy reserved for clearly necrotic tissue or suspected malignancy
  • Supportive care in ED:
    • IV fluids, antiemetics (ondansetron 4 mg IV)
    • Pain control: ketorolac 15-30 mg IV and/or opioids
    • NPO for OR preparation

Disposition

  • Admit for emergent surgical intervention
  • Do NOT delay surgery for additional imaging if clinical suspicion is high
  • Consult gynecology early — even if US is equivocal, operative evaluation may be warranted

See Also

References

  1. ↑ Norris DL, Young JD. UTI. EM Clin N Am. 2008; 26:413-30.
  2. ↑ Shadinger LL, et al. Surgically treated adnexal torsion: does the presence of doppler flow predict viability? J Ultrasound Med. 2008;27(5):687-691. PMID 18424640
  • Huchon C, Fauconnier A. Adnexal torsion: a literature review. Eur J Obstet Gynecol Reprod Biol. 2010;150(1):8-12. PMID 20189289
  • Chang HC, et al. Pearls and pitfalls in diagnosis of ovarian torsion. Radiographics. 2008;28(5):1355-1368. PMID 18794312
  • Houry D, Abbott JT. Ovarian torsion: a fifteen-year review. Ann Emerg Med. 2001;38(2):156-159. PMID 11468611
  • Oelsner G, Shashar D. Adnexal torsion. Clin Obstet Gynecol. 2006;49(3):459-463. PMID 16885652
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