Ovarian torsion, also termed as adnexal torsion, is the total or partial twisting of the ovary and almost always involves part of the fallopian tube. The incidence of adnexal tumors increases with age and one of the complications is adnexal or ovarian torsion. While ovarian torsion is seldom seen in the emergency department, it is the fifth leading gynecological emergency. Early diagnosis is key in preserving ovarian and tubal function and preventing adnexal necrosis or death of the ovary. Recognizing risk factors and signs and symptoms is of the upmost importance for you and your health care provider in making a prompt diagnosis; however, the nonspecific, vague signs and symptoms make diagnosing ovarian torsion a challenge.

If you’re experiencing symptoms of ovarian torsion, seek immediate medical attention at the emergency room. The longer the condition goes untreated, the more likely you are to experience complications. Typically symptoms present as sharp pelvic and/or abdominal pain that can either be local or widespread. Pain severity ranges from moderate to severe; however, up to a third of patients have no complaint of pain or tenderness, even on exam.

Abdominal and pelvic examinations should be performed, but findings can vary. The absence of pain and tenderness does not rule ovarian torsion out. The abdominal exam and pelvic exam your healthcare provider performs may or may not confirm a pelvic mass. Again, nonspecific exam findings further demonstrate the challenge of diagnosing this condition, and the need for further diagnostic testing.

 Your healthcare provider  will also use blood, urine and imaging tests to rule out other potential diagnoses, such as:

• appendicitis,
• cystitis,
• diverticulitis,
• ectopic pregnancy,
• endometriosis,
• bowel obstruction,
• nephrolithiasis,
• ovarian cysts,
• kidney stones,
• pelvic inflammatory

Once ovarian torsion is highly suspected or confirmed, a swift surgical consult should be obtained. The less time between onset of symptoms and surgery, the more likely the ovary and/or fertility can be spared.

An appropriately focused history and a complete physical exam can provide findings suspicious of adnexal torsion. Pelvic CT and abdominal and transvaginal ultrasound, will be ordered. This is to view the ovaries, fallopian tubes and blood flow promptly so as to not delay emergent surgical consultation where laparoscopic evaluation can provide definitive diagnosis and treatment. Rapid recognition and treatment of ovarian torsion is key to sparing the ovary and fertility.

When ovarian torsion occurs, blood flow to your ovary and possibly to your fallopian tube is reduced. A prolonged reduction in blood flow can lead to necrosis, death of ovary. If this happens, your surgeon will remove the ovary and any other affected tissue.

Treatment

• Laparoscopy: An instrument with a light will be used by your surgeon after a small incision is made in your lower abdomen. The surgeon is then able to view your internal pelvic organs. Another incision is made to allow access to the ovary. Once the ovary is accessible, your surgeon will use a blunt probe or other tool to untwist is or remove it if the ovary is necrotic or dead.
• Oophorectomy: If your ovary is no longer functional, your surgeon will use this laparoscopic procedure to remove the ovary.
• Salpingo-Oophorectomy: If both the ovary and fallopian tube is are no longer functional, your surgeon will use this laparoscopic procedure to remove them both. Your surgeon may also perform this procedure to prevent recurrence in women who are postmenopausal.

•  This procedure requires general anesthesia and is usually done on an outpatient basis.

After surgery your surgeon will recommend over-the-counter pain medications to ease the discomfort such as:

• acetaminophen (Tylenol)
• ibuprofen (Advil)
• naproxen (Aleve)

For pain more severe, your surgeon may prescribe a short 3-4 day prescription of opioids such as:

• oxycodone (OxyContin)
• oxycodone with acetaminophen (Percocet)

Beyond Surgery

Ovarian torsion is considered a medical emergency, and surgery is required to correct it. Delayed diagnosis and treatment can increase your risk of complications such as infection or loss of the ovary.

If you are not perimenopausal or postmenopausal once the ovary has been untwisted or removed, you may be advised to take high hormonal birth control to reduce your risk of recurrence. Torsion doesn’t have an impact on your ability to conceive or carry a pregnancy to term.

Melanie A. Kroger-Jarvis, Tamara Pavlik-Maus, Kimberly Mullins
University of Cincinnati College of Nursing, USA

Publication

Ovarian Torsion: ED Recognition and Management.
Kroger-Jarvis MA, Pavlik-Maus T, Mullins K
J Emerg Nurs. 2018 Nov

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