Ovarian Torsion
Ann M. Polcari
The ovary is a female reproductive organ suspended within the pelvis.
It is in close proximity to the uterus and fallopian tubes by several ligaments (Figure 45.1A):
Directly connected to the uterus via the ovarian ligament
Directly connected to the pelvic wall via the suspensory, or infundibulopelvic, ligament
Covered by the broad ligament. As the name describes, the broad ligament consists of a wide, fibrous tissue connecting and covering the uterus, fallopian tubes, and ovaries. It is divided into 3 continuous parts: the mesometrium, mesosalpinx, and mesovarium
The ovary has dual blood supply: from the uterine arteries, found within the broad ligament, and from the ovarian artery, found in the suspensory ligament (Figure 45.1B).
The uterine artery branches off of the internal iliac, whereas the ovarian artery branches directly off the descending aorta
Venous drainage parallels the arterial supply.
The ureters pass just posterior to the uterine artery to reach the bladder. This is a potential site of ureteral damage during pelvic surgery.
EPIDEMIOLOGY AND ETIOLOGY
Incidence: Ovarian torsion represents approximately 3% of all acute gynecologic complaints; up to 25% of these occur in children.1,2
The condition is most common in women of reproductive age, particularly women in their 20s.
Etiology:
At birth, the ovaries are positioned high in the pelvis. A surge of hormones during early puberty signals shortening of the ovarian ligaments, causing the ovaries to descend. Therefore,
prepubertal and early-pubertal girls have slack in the ovarian ligaments, a predisposition for torsion.1
Torsion is more common on the right, likely because twisting of the left ovary is hindered by the sigmoid colon.1
This condition is typically associated with the presence of an ovarian cyst or tumor (eg, a benign teratoma), especially if larger than 6 cm.3
However, up to 33% of torsion presents in children with normal ovaries.2
Ovarian torsion occurs most often owing to twisting of the broad ligament. At first, only venous obstruction occurs; owing to dual supply with high-pressured arteries, there is continued blood flow into the ovary. Maintained inflow without outflow leads to congestion and edema. Once pressure is great enough to also compress the arterial supply, hypoxia sets in, leading to a cyanotic organ (Figure 45.2).4
 Figure 45.1 Uterus, uterine tubes, and broad ligament. A, Relationship of the broad ligament to the ovary and its ligaments (anterior view). B, Sagittal sections showing the mesentery of the uterus (mesometrium), ovary (mesovarium), and uterine tube (mesosalpinx) (anterolateral view). (Reprinted with permission from Moore KL, Agur AMR, Dalley AF, Moore KL. Essential Clinical Anatomy. 5th ed. Philadelphia, PA: Lippincott Williams & Wilkins, a Wolters Kluwer Business; 2015.) |
 Figure 45.2 Ovarian torsion in a 15-year-old girl. A, Longitudinal transabdominal scan. B, Transverse transabdominal scans. Complex, predominantly cystic mass within the cul-de-sac and slightly to the right. Note balloon of Foley catheter within the urinary bladder. At surgery, a 6-cm blue necrotic mass compatible with torsion was found in the cul-de-sac originating from the left adnexa. (Reprinted with permission from Benrubi GI. Handbook of Obstetric and Gynecological Emergencies. 4th ed. Philadelphia, PA: Lippincott Williams & Wilkins, a Wolters Kluwer Business; 2010.) |
CLINICAL PRESENTATION
Classic presentation: an otherwise healthy teen who presents with acute-onset unilateral lower abdominal pain, severe and sharp in nature.
Most patients have associated nausea and vomiting.
Pain may radiate to the flank, groin, or thigh.
50% to 60% of patients will have a palpable pelvic mass.3
Low-grade fever at presentation suggests necrosis.
Note: This presentation is very similar to that of acute appendicitis, rupture of an ovarian cyst, and ectopic pregnancy.
Special Circumstances5
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