Ovarian torsion is an acute surgical condition caused by a complete or partial inversion of the ovary, disrupting its blood flow and nutrition. Ovarian torsion is characterized by sudden severe abdominal pain with unilateral localization, bloody whites, nausea and vomiting, stool disorders, dysuria, fever, tachycardia. Ovarian torsion is established according to bimanual examination, ultrasound of the abdominal cavity and pelvis, laparoscopy. Ovarian torsion requires emergency surgical procedures – laparoscopic detorsion, cystectomy, ovarian resection, ovariectomy, adnexectomy.
Ovarian torsion is a severe pathology of appendages that develops with the reversal of ligaments that fix the ovary, compression of its vessels and ischemia of the organ. It refers to emergency gynecological conditions, ranking fifth among them. Ovarian torsion occurs in 3% of women of all age groups, but with the greatest frequency – in young patients aged 17-30 years. Pathology is quite common in the adolescent population; ovarian torsion can often be observed during pregnancy or after childbirth. Ovarian torsion has a serious impact on a woman’s childbearing function.
Late diagnosis due to the lack of a specific clinical picture (especially in girls) can lead to the loss of one or both ovaries and infertility. The danger is the involvement in the pathological process of adjacent organs (uterus, peritoneum, bladder, ureters, small intestine, caecum and sigmoid colon) with the development of pelvioperitonitis, peritonitis and threats to life.
As a rule, torsion of one ovary develops in various variants. This can be a twist of a healthy ovary around its axis, a twist of ovarian formation, a twist of appendages, a twist of appendages and intestinal loops. According to available observations, torsion of the left ovary occurs 1.5 times less often than the right one, due to the left-sided location of the sigmoid colon, which limits its mobility in this zone. Sometimes there is a simultaneous or sequential (with an interval of several weeks to several years) twisting of both ovaries.
Ovarian torsion can be complete – 360 ° and incomplete; it can occur suddenly or gradually, in isolation or together with other anatomical structures (fallopian tube or intestines). Complete torsion with compression of the ovarian arteries leads to severe trophic disorders with the development of ischemia and necrosis of ovarian tissue. With incomplete torsion, there is a predominant violation of the outflow of blood and lymph with venous stagnation and hemorrhages inside the organ, the risk of ovarian apoplexy and bleeding into the abdominal cavity.
Ovarian torsion usually occurs against the background of previously diagnosed congenital and acquired abnormalities of the ovaries, fallopian tubes and utero-ovarian ligaments, gynecological operations and other interventions on the pelvic organs. In the children’s population, a healthy ovary is twisted, in adult women – usually an ovary affected by pathological changes.
In most (up to 60%) cases, ovarian torsion develops with an increase in its volume and mass due to various formations – large, up to 5-6 cm in diameter, cysts (paraovarial, dermoid) and tumors, more often benign – fibrom, teratoma, cystadene. The entire affected ovary or only the leg of the overall formation may twist. Endometrioid cysts and malignant ovarian tumors are less likely to undergo torsion due to the widespread adhesive process in the pelvis.
A twist of an unchanged ovary occurs when its fixation is violated due to weakness, stretching or surgical damage to the utero-ovarian ligaments, elongation of the fallopian tubes (spiral twist of the tube and ovarian ligaments between each other), and sometimes – abnormal mobility of the intestinal loops or its long mesentery. The torsion of the ovary with other anatomical structures disrupts the blood supply to both organs and is considered the most severe pathology. Ovarian hypermobility can lead to bilateral recurrent twists.
Ovarian torsion is often associated with sudden movements or changes in body position (rotation), physical exertion, increased sports; especially, with a sudden stop of trunk rotation. The development of this condition can be facilitated by acute or blunt abdominal trauma, prolonged severe coughing attacks, increased intestinal motility, stretching of the bladder. Among the conditions provoking ovarian torsion, tortuosity and elongation of the vessels of the mesosalpinx, the presence of hydro- or pyosalpinx are also distinguished. During pregnancy, ovarian torsion is mediated by the displacement of the organ by the uterus growing in volume.
The clinical picture of ovarian torsion is similar in many ways to the manifestations of diseases related to the “acute abdomen”. Typical cases begin unexpectedly, against the background of rest or physical exertion, with sudden strong stabbing or cramping pains in the abdomen or pelvis on the one hand, radiating into the side, back or groin area, The increasing pain syndrome is usually accompanied by weakness, nausea and vomiting of a wave-like nature, bringing temporary relief, flatulence, constipation, dysuria, bloody whites. Fever, tachycardia, pallor of the skin, cold sweat are noted.
With incomplete ovarian torsion, manifestations develop gradually, patients may complain of dull pain with exacerbations for some time. The consequences of ovarian torsion can be bleeding, ovarian necrosis, the development of pelvioperitonitis and a life-threatening condition, in the future – the adhesive process in the pelvic cavity, chronic pelvic pain.
Due to the acute surgical condition, the diagnosis of ovarian torsion should be established as soon as possible by collecting anamnesis (the fact of operations on the abdominal and pelvic organs, the presence of appendage formations), examination, ultrasound of the abdominal and pelvic organs, general blood analysis, diagnostic laparoscopy.
Palpation of the abdomen allows you to determine the infiltrate only in half of the cases of ovarian torsion. Signs of irritation of the peritoneum usually appear in the late stages of pathology. Bimanual examination reveals moderate or severe pain in the appendage area, an increase in volume and compaction of the ovary. High leukocytosis is determined by the development of inflammatory and necrotic processes.
Ultrasound in color Doppler mode helps to visualize the asymmetry of the position, an increase in the size and density of the twisted ovary, a change in its structure due to a large formation, the presence of free fluid in the pelvis, a violation / absence of blood flow in the affected organ. Only diagnostic laparoscopy or laparotomy directly reveal hyper-mobility and torsion of the ovary, the presence of bloody effusion. Histological examination proves hemorrhagic infiltration of ovarian tissue, manifestations of necrosis.
In gynecology, the differential diagnosis of torsion is carried out with ovarian apoplexy, inflammation of the uterine appendages, ectopic pregnancy, acute appendicitis, acute intestinal obstruction.
Due to the urgency of the condition in case of ovarian torsion, urgent hospitalization and emergency surgery are performed. Depending on the severity of the process, different approaches can be applied. In unburdened cases, in childhood, in women of childbearing age and pregnant women, it is advisable to perform the most sparing laparoscopic detorsion (unwinding) of appendages; in the presence of an ovarian cyst, its simultaneous surgical removal – cystectomy, when the tumor leg is twisted – ovarian resection. To prevent recurrence of ovarian torsion, fixation of the ovary to the pelvic walls (ovariopexy) is recommended.
Laparotomy access is used in the development of complications. Ovariectomy, adnexectomy are used in advanced cases of ovarian torsion with irreversible circulatory disorders of the affected organs, the presence of borderline ovarian formation or during postmenopause. With obvious signs of non-viability of the ovary, the organ is removed without unwinding. The patient is necessarily prescribed antibacterial therapy (infusion or intramuscular). The terms of hospitalization are determined by the presence of complications. In case of a malignant ovarian tumor, additional removal of the nearest lymph nodes is performed and the patient is referred to an oncologist for further treatment.
The prognosis for early accurate diagnosis and treatment of ovarian torsion is considered favorable, in the absence of necrosis, it is usually possible to preserve the organ and reproductive function. With a delayed diagnosis due to rapidly developing complications, the prognosis worsens, adverse consequences are possible. For the prevention of ovarian torsion, annual professional examinations by a gynecologist with ultrasound of the pelvic organs, timely detection and treatment of cystic formations and tumors of the appendages are important.