Ovarian torsion: to pex or not to pex? Pelvic ultrasound is the imaging modality of choice, but Doppler flow is not always absent in torsion. Earlier this month, Philipps posted an Instagram detailing a recent hospital visit. Ovarian torsion occurs most frequently in women during their reproductive years, but it does sometimes happen in prepubescent girls. Management of intermittent ovarian torsion by laparoscopic oophoropexy. Ovarian torsion is usually associated with a cyst or tumor, which is typically benign; the most common is mature cystic teratoma. Torsion of a normal ovary more commonly occurs in young children when developmental abnormalities predispose the ovary to torsion, such as excessively long Fallopian tubes or an absent mesosalpinx. While classically the pain is sudden in onset, this is not always the case. Torsion in the pediatric population is rare, but it presents more management challenges for gynecologists. Ovarian torsion. Ovarian torsion occurs in around 2%–15% of patients who have surgical treatment of adnexal masses. Ovarian torsion during pregnancy is a fairly uncommon complication with a high patient morbidity and fetal mortality if not immediately treated. Diagnosis can be difficult and is mainly based on clinical symptoms and imaging techniques such as ultrasound and MRI. At the time of the initial examination the patient appeared comfortable and in no acute distress. The authors disclosed none. No masses, distention or tenderness were detected. Sudden onset nausea and vomiting are also common symptoms. Introduction Ovarian torsion is a disorder with a very high patient morbidity. Sometimes, the fallopian tube may … Email: rjyoungmd@kaiser-ed.com. Healthline Media does not provide medical advice, diagnosis, or treatment. If recurrent, this can result in castration of young patients. Large right ovarian cysts were noted and there was arterial flow noted centrally in both the left and right ovaries. INTRODUCTION. Ovarian torsion is reported to be the fifth most common acute gynecologic disease, but overall it is quite rare 1, 2. A study did find that creatine supplementation is associated with an increase in a…. Intermittent testicular torsion Intermittent testicular torsion (ITT) is a less serious but chronic variant of torsion. The patient reported that the pain woke her up from sleep at 3 a.m. It may also involve the fallopian tube, in which case it is termed an adnexal torsion. A laparoscopic needle and syringe were used to drain two simple ovarian cysts. Torsion occurs most commonly with dermoid cysts and fibromas, but may occur with any mobile tumour of any size. However, experts say you shouldn’t wait to see if the ovary will twist back on its own. WestJEM Article by Stehman et al., from Indiana University, Featured in USA Today, April 10th, 2020 Ovarian torsion (adnexal torsion) occurs when an ovary becomes twisted around the tissues that support it. Pediatr Emerg Care. Ovarian torsion is the partial or complete rotation of the ovary on the ligamentous support (infundibulopelvic ligament and the utero-ovarian ligaments) within the abdomen, often critically limiting the blood supply to the ovary. It is a gynecological emergency and requires urgent surgical intervention to prevent ovarian necrosis. Ovarian enlargement with or without an underlying mass is the finding most frequently associated with torsion, but it is nonspecific. “It always is.”, Many women experience occasional ovary pain. “I felt like an idiot for going to the hospital but ultimately, going was the right move,” she wrote. Torsion always produces severe lower abdominal pain, often originating in the iliac fossa and radiating to the flank - so called "reverse renal colic." Learn…. WestJEM Articles by Richmond et al. Ovarian torsion is defined as partial or complete rotation of the ovarian vascular pedicle and causes obstruction to venous outflow and arterial inflow. WestJEM Would Like to Congratulate Our Top Board Members of 2019-2020! “It’s enough to stop you in your tracks [and] cause you to bend over,” said Dr. Angela Jones, a board-certified OB-GYN in New Jersey. It can affect females of all ages. Ovarian torsion is an under-recognized cause of chronic pelvic pain in women who have had their tubes tied. To date there is limited evidence that can help reliably identify cases of intermittent ovarian torsion. The diagnosis of ovarian torsion is a challenging feat in an emergency situation. 2007;37:446-51. As in this case, the abdominal examination often does not correspond with the level of distress that the patient would present with. The patient’s abdominal examination did not match her level of distress. MANAGEMENT OF INTERMITTENT OVARIAN TORSION BY LAPAROSCOPIC OOPHOROPEXY Michelle Gemain, MD, Thomas Rarick, MD, and Edwin Robins, MD Backgrowd Ovarian torsion is a serious gynecologic condi- tion that often results in adnexal removal. Debra Rose Wilson, PhD, MSN, RN, IBCLC, AHN-BC, CHT, Debra Sullivan, Ph.D., MSN, R.N., CNE, COI, Does Creatine Cause Hair Loss? “Torsion… can essentially block the blood supply to the ovary, and it can lead to the death of the ovary, which is called necrosis,” said Gupta. There are other reasons women can feel pain in their pelvic area, such as menstrual cramps, endometriosis, or irritable bowel syndrome. “It should be done long enough so you can actually watch the blood flow come and go, and if you see an obstruction to the blood flow, then definitely that person should be taken up for surgery.”. Ovarian cysts are common in women and not necessarily a cause for alarm. The development of better systems to provide emergency care, including technology solutions, is critical to enhancing population health. When torsion is considered, early consultation with OB/GYN should be obtained as both current and future fertility are at stake. Torsion must be considered in any female with sudden onset, severe lower abdominal pain. Copyright © 2018 WestJEM / eScholarship University of California.. All rights reserved. Ovarian torsion is when an ovary twists back and forth, causing intense pain in the pelvic area that comes and goes, explained Dr. Adeeti Gupta, a board-certified OB-GYN in New York. Ovarian torsion rarely presents with classic symptoms. In adulthood, causes include both benign and malignant ovarian tumors, polycystic ovaries and adhesions. The ovary is a ductless reproductive gland in which the female reproductive cells are produced. The goal of the ED physician is to diagnose torsion in a timely fashion in an attempt to preserve ovarian function and viabili… WestJEM is very happy to welcome Dr. Taylor Burkholder to our team of Section Editors! Germain M(1), Rarick T, Robins E. Author information: (1)Department of Obstetrics and Gynecology, National Naval Medical Center, Bethesda, Maryland, USA. Sometimes ovarian torsion resolves itself on its own, as it did with Philipps. When diagnosed, this condition is considered a surgical emergency. Ovarian torsion is not an easy diagnosis to make and it is commonly missed. As a result of the twisting of the ovary around its ligamentous support, the blood supply to and from the ovary may be compromised. “I would just like all clinicians to be aware that [teenagers] could be having a torsion, which could be missed,” Gupta said. The diagnosis becomes more challenging in that torsion can occur in female patients of all ages, including infants and the elderly. Crouch NS, Gyampoh B, Cutner AS, et al. Here's what to know about this organic latex option. Comprehensive Gynecology. Case report and review of the literature. Adnexal torsion: review of the literature. We present an unusual case of intermittent ovarian torsion discussing both the presentation and the operative and post-operative management. Ovarian torsion should be considered a clinical diagnosis, and a high level of clinical suspicion is needed by the practitioner to ensure that this diagnosis is not missed. Lentz GM, Lobo RA, Gershenson D, et al. This article looks at the nutrition, benefits, downsides, and…. The main risk in ovarian torsion is an ovarian mass. Pediatric Ovarian Torsion Clinical Update and Case Discussion. This twisting can cut off blood flow to the ovary and fallopian tube. She had a similar presentation occuring 1 month ago. “You don’t have another option.”. The emergency department specifically deals with social injustice, health and economic disparities, violence, substance abuse, and disaster preparedness and response. Ovarian torsion is one of the most common gynecologic emergencies encountered by Emergency Medicine physicians and remains a must not miss diagnosis. She was also very nauseated and actively vomiting. June 12, 2020 Other symptoms may include nausea. This article provides an overview of the symptomatology, ultrasound diagnosis and classification, as well as treatment options for ovarian torsion. Epub 2007 Mar 15. 9 This may be in part due to the dual blood supply to the ovary, or cases in which torsion was intermittent or partial. Clinically, patients may experience dynamic torsing and detorsing of the ovary leading to intermittent symptoms and variable radiographic findings. Regarding Doppler flow, one study found that 61% of ovarian torsion on the right had normal doppler flow while 27% on the left had normal flow. Emergency Medicine is a specialty which closely reflects societal challenges and consequences of public policy decisions. With an incidence of 3%, ovarian torsion is the fifth most common gynecologic emergency in women. The right ovary was manually detorsed and healthy viable ovarian tissue returned. When the physical examination is not congruent with the level of patient distress, ischemic pain from an ovarian torsion must be considered. Servaes S, Zurakowski D, Laufer MR, Feins N, Chow JS. Postoperatively the patient was started on intravaginal progesterone 200mg for the following four weeks. July 13, 2020 Ovarian torsion is not too common and accounts only for a small number of gynecological emergencies. The most common finding is an ovary > 4cm. When the patient is pregnant this can also lead to fetal mortality and potential loss of fertility for the patient. It is a gynecological emergency and requires urgent surgical intervention to prevent ovarian necrosis. WestJEM Article by Takeuchi et al., Featured in The News Tribune: Man who died during Tacoma arrest was heading for snack after church, friends say, May 3rd, 2020 However, it was noted that body habitus limited the exam. The patient arrived to the ED approximately three hours after the onset of pain. Concomitant ovarian and tubal torsion has been shown to occur in up to 67% of cases of adnexal torsio… Most women will develop at least one cyst on their ovaries during their lives. If treated quickly, the testicle can usually be saved. When a person comes in with a suspected ovarian torsion, medical professionals will check for a high pulse rate and examine the belly area for pain or tenderness. Adnexal torsion is a term that is inclusive of either the ovary, fallopian tube, or both. WestJEM Article by Eckhardt et al., from Linköping University, Featured in Health Affairs, April 6th, 2020 The presentation of acute onset unilateral abdominal pain on the background of a similar previous presentation should alert the clinician of this diagnosis. WestJEM Article by Langabeer et al., from University of Texas Health Center, Featured in Tech Crunch, March 16th, 2020 We present an unusual case of intermittent ovarian torsion discussing both the presentation and the operative and post-operative management Intraoperative laparoscopic view of two large ovarian cysts with ischemic discoloration of the tissue. Ovarian torsion is a disorder with a very high patient morbidity. 9 This may be in part due to the dual blood supply to the ovary, or cases in which torsion was intermittent or partial. WestJEM to Fast Track Publication of Selected COVID-19 Related Manuscripts. As Philipps described, ovarian torsion makes itself known through sudden, intense pain. 1:108 – 110, Submission history: Revision received October 20, 2016; Submitted December 12, 2016; Accepted December 19, 2016. Radiol. BACKGROUND: Ovarian torsion is a serious gynecologic condition that often results in adnexal removal. A definitive diagnosis of ovarian torsion is made upon direct visualization of a rotated ovary during surgical evaluation. An OB-GYN will keep an eye on an ovarian cyst during routine gynecological exams to watch whether it grows in size. American College of Osteopathic Emergency Physicians, Intermittent Ovarian Torsion in Pregnancy, Bilateral Chylothorax Due to Blunt Trauma Without Radiographic Evidence of Traumatic Injury, Phelgmasia Cerulea Dolens Diagnosed by Point-of-Care Ultrasound, The Psychopharmacology of Agitation: Consensus Statement of the American Association for Emergency Psychiatry Project BETA Psychopharmacology Workgroup, Validation of the Social Security Death Index (SSDI): An Important Readily-Available Outcomes Database for Researchers, Combining Ketamine and Propofol (“Ketofol”) for Emergency Department Procedural Sedation and Analgesia: A Review, High School Students’ Perceptions of Motivations for Cyberbullying: An Exploratory Study, Crowding and Delivery of Healthcare in Emergency Departments: The European Perspective, Ultrasound-Assisted Peripheral Venous Access in Young Children: A Randomized Controlled Trial and Pilot Feasibility Study, Nonreciprocal and Reciprocal Dating Violence and Injury Occurrence Among Urban Youth, Factors Associated with Complications in Older Adults with Isolated Blunt Chest Trauma, Verbal De-escalation of the Agitated Patient: Consensus Statement of the American Association for Emergency Psychiatry Project BETA De-escalation Workgroup, A Case of Complicated Urinary Tract Infection: Klebsiella pneumoniae Emphysematous Cystitis Presenting as Abdominal Pain in the Emergency Department, The Clinical Differentiation of Cerebellar Infarction from Common Vertigo Syndromes, Fatal Metformin Overdose Presenting with Progressive Hyperglycemia, The Standard of Care: Legal History and Definitions: the Bad and Good News, Paget-Schroetter Syndrome: Review of Pathogenesis and Treatment of Effort Thrombosis, Wide Complex Tachycardias: Understanding this Complex Condition Part 2 - Management, Miscellaneous Causes, and Pitfalls, Kaiser Permanente San Diego Medical Center, Department of Emergency Medicine, San Diego, California, Kaiser Permanente San Diego Medical Center, Department of Obstetrics and Gynecology, San Diego, California. 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