Ovarian and fallopian tube

torsion
Clinical significance
Ovarian torsion refers to the complete or partial
rotation of the ovary on its ligamentous supports,
often resulting in ischemia
It is one of the most common gynecologic
emergencies and prompt diagnosis is important to
preserve ovarian and/or tubal function and to
prevent other associated morbidity. The fallopian
tube often twists along with the ovary; when this
occurs, it is referred to as adnexal torsion.
Epidemiology
• Ovarian torsion occurs in females of all
ages, but most cases occur in patients of
reproductive age. It is one of the most
common gynecologic emergencies.
• the mean age of patients with torsion was
between 29.0 and 33.5 years
Risk factors
• The primary risk factor for ovarian torsion is an
ovarian mass, especially when the ovary is larger
than 5 cm in diameter.
• torsion may also occur without an underlying lesion,
particularly in the pediatric population.
• a history of prior ovarian torsion.
• Some data suggest that tubal ligation is associated
with an increased risk of ovarian torsion, but the
degree of this risk is uncertain
Clinical presentation
• The classic presentation of ovarian torsion is the
acute onset of pelvic pain, often with nausea and
vomiting, in a patient with an adnexal mass.
• A history of recent vigorous activity or a sudden
increase in abdominal pressure may be an inciting
event
• Fever is typically low grade and may be a marker
of adnexal necrosis, particularly in the setting of
leukocytosis.
CLINICAL FINDINGS
• Findings on physical examination are variable:
• pelvic and/or abdominal tenderness,
• A palpable pelvic mass may or may not be
present.
• Peritoneal signs are present in a small number
of patients and should raise concern for adnexal
necrosis.
• A low-grade fever may be present
Laboratory findings
• Laboratory abnormalities are absent in many
patients.
• In rare cases, hemorrhage from a torsed ruptured
corpus luteal cyst may result in anemia,
• adnexal necrosis may lead to infection with
associated leukocytosis.
• If these laboratory findings are present in a
patient with suspected torsion, they raise concern
for severe adnexal damage
Imaging studies
Ultrasound:
• The ovary may be rounded, enlarged, and have a
heterogenous appearance compared with the contralateral
ovary, due to edema, engorgement, and/or hemorrhage
• may be located anterior to the uterus, rather than in the
normal location lateral or posterior to the uterus.
• Multiple small follicles (ie, "string of pearls,"
"peripheralization of the follicles") may be present
peripherally due to displacement by edema.
• An ovarian or tubal cyst/mass may be present
Diagnostic evaluation
• Pelvic imaging, preferably with ultrasound,
is the mainstay of evaluation in patients in
whom ovarian torsion is suspected.
• Human chorionic gonadotropin and a
complete blood count are also obtained to
aid in the differential diagnosis.
DIFFERENTIAL DIAGNOSIS
• Ectopic pregnancy
• Ruptured ovarian cyst
• Tubo-ovarian abscess
• Appendicitis
• also includes other conditions, including an
ovarian cyst or neoplasm that is not torsed,
endometriosis, or a degenerating leiomyoma
Doppler flow:
• may be present (normal), decreased, or absent
• The ovarian vessels may display the "whirlpool
sign," a round hyperechoic structure with
concentric hypoechoic stripes or a tubular
structure with internal heterogeneous echoes.
It is thought to represent the twisting of the
vascular pedicle.
Diagnosis
• A definitive diagnosis of ovarian torsion is made by direct
visualization of a rotated ovary at the time of surgical
evaluation.
• A presumptive diagnosis of torsion can be made with a fair
degree of confidence in the presence of acute pelvic pain
and imaging demonstrating an adnexal mass with an
appearance consistent with torsion (particularly if pain is
elicited when scanning over the adnexa with a vaginal
ultrasound probe).
• Additional findings, such as nausea, fever, and pelvic
tenderness on examination, further support the diagnosis.
Management
• For most premenopausal patients with torsion of a
nonmalignant ovary, we suggest detorsion and ovarian
conservation rather than salpingo-oophorectomy,
even in the case of a darkened, enlarged ovary.
• Detorsion is standard practice for such patients, given
a possible improvement in fertility outcomes with this
strategy. Ovarian cystectomy is often performed along
with detorsion if a benign mass is present.
• Patients with an obviously necrotic ovary or an
ovarian mass that is suspicious for malignancy require
salpingo-oophorectomy. Salpingo-oophorectomy is
also performed in postmenopausal patients.
• Patients with normal ovaries may be at higher risk of
recurrent torsion than those with an ovarian mass.
Detorsion without oophoropexy (but with cyst
drainage or cystectomy) is performed when a mass is
present.
• Cystectomy is often performed in addition
to detorsion if a benign mass is present. If
cystectomy cannot be performed because
of surrounding edema and concern that
dissection may further compromise vascular
perfusion, the cyst can be drained and
cystectomy performed at a later date.
PREVENTION OF RECURRENCE
• Suppression of ovarian cysts – Low-dose
estrogen-progestin contraceptives
• Oophoropexy – Unilateral or bilateral
oophoropexy following ovarian detorsion
Torsion of other structures
• Isolated torsion of the fallopian tube is
uncommon but may also occur and result in an
adverse impact on tubal function.
• Tubal torsion occurs most commonly in the
midportion of the tube itself but may also occur
around the ligamentous supports of the tube.
• torsion of paratubal or paraovarian cysts may
occur.
thanks for your attention