The Case Files

Abstract

Image A.: Transvaginal ultrasound revealed a multiloculated right adnexal cystic mass with little evidence of adequate blood flow to the ovary.FigureFigureA 30-year-old woman presented to the ED complaining of pelvic pain. She said she felt an acute onset of sharp lower right pelvic pain during intercourse two days earlier. The pain continued to worsen, becoming diffuse. She was also experiencing nausea, vomiting, malaise, anorexia, and vaginal spotting. She had no history or concern for sexually transmitted disease, and had no fever or vaginal discharge. She had had a previous Cesarean section and bilateral tubal ligation. Her vital signs were a heart rate of 110 bpm, a respiratory rate of 25 bpm, a blood pressure of 113/88 mm Hg, and a pulse ox of 100% on room air. She was in distress, lying flat, and diaphoretic, and she did not want to move. Her abdominal exam revealed a mildly distended abdomen, diffuse tenderness to palpation, with a palpable mass in the right lower quadrant with guarding and rebound. Her genital/urinary exam revealed clotted blood within the posterior vaginal vault, right adnexal tenderness, and no evidence of cervical motion tenderness. A bedside FAST exam showed no evidence of free fluid within her abdomen or pelvis, but showed a large cystic mass within the right lower quadrant. Urine hCG and total beta hCG were negative. Transvaginal ultrasound revealed a multiloculated right adnexal cystic mass measuring 9 cm x 8 cm x 6 cm with little evidence of adequate blood flow to the ovary. (Image A.) The patient was taken emergently to the operating room for a diagnostic laparoscopy, removal of the cystic mass, and reduction of the ovarian torsion. (Image B.) The right adnexal mass was most likely a mucinous tumor that had undergone an ovarian torsion during intercourse. Her hospital stay was uncomplicated; she did well post-operatively and was discharged on day two. An ovarian torsion represents about three percent of all gynecological emergencies. Ovarian torsion is the result of a partial or complete rotation of the ovary at its pedicle leading to obstructed venous and arterial vascular flow that can ultimately end in ischemia, necrosis, hemorrhage, peritonitis, and septic shock. (BMJ Best Practice September 2017; http://bit.ly/2Qe1cyh.) Venous and lymphatic flow is affected first in torsion. Arterial flow is maintained because the arteries' thick, muscular walls are less collapsible. This leads to ovarian edema and ovarian enlargement, causing increased pressure on the ovary and eventually leading to an obstruction of arterial flow. (Radiographics 2008:28[5]:1355; http://bit.ly/2DxVt4U.)Image B.: The patient was taken emergently to the operating room for a diagnostic laparoscopy, removal of the cystic mass, and reduction of the ovarian torsion.Underlying abnormalities, like neoplasms and ovarian cysts, represent the majority of all cases. (BMJ Best Practice September 2017; http://bit.ly/2Qe1cyh.) Major risk factors include ovarian neoplasms larger than 5 cm in diameter, which represent 40 percent of all cases of ovarian torsion, and ovarian cysts larger than 5 cm in diameter, which represent another 40 percent of ovarian torsion cases. It is considered rare to see torsion in patients with a cyst smaller than 5 cm. (Radiographics 2008:28[5]:1355; http://bit.ly/2DxVt4U.) Other risk factors include infertility treatment (secondary to ovarian enlargement), pregnancy, strenuous exercise, intercourse, and sudden increases in intra-abdominal pressure (secondary to defecating, vomiting, coughing, and hiccups, causing the ovary to rotate about the pedicle). (BMJ Best Practice September 2017; http://bit.ly/2Qe1cyh.) Our patient had a preexisting 9 cm adnexal mass that resulted in ovarian torsion during intercourse. The majority of patients will present to the ED with a sudden onset of abdominal pain located within the lower quadrant and pelvis associated with nausea and vomiting. The pain can be constant or intermittent, acute or chronic, and radiating to the flank, back, or groin. Left-sided ovarian torsion is less common because the sigmoid colon occupies the space in the left lower quadrant, leaving less space for rotation at the pedicle. Diagnosis requires a thorough clinical history, ultrasound, and high index of suspicion in any female patient with risk factors and presenting with lower quadrant abdominal pain. No specific labs indicate ovarian torsion, but they are often performed to rule out other causes of lower abdominal pain. A transvaginal ultrasound is performed to evaluate for vascular flow and ovarian cysts, but the findings depend on the degree and duration of the torsion. (BMJ Best Practice September 2017; http://bit.ly/2Qe1cyh.) Routine imaging findings necessary to make the diagnosis are often not present in many cases. Early in the process, the most commonly detected finding seen on ultrasound is unilateral ovarian enlargement larger than 4 cm. (Radiographics 2008:28[5]:1355; http://bit.ly/2DxVt4U.) As it progresses, other findings may include free fluid (87% of cases), a twisted vascular pedicle, and a string of pearls sign. A retrospective study of 21 patients with surgically confirmed ovarian torsion found that 10 had a normal ultrasound with Doppler findings. (Fertil Steril 2000;73[5]:1047; http://bit.ly/2zyPVTD.) The presence of vascular flow on ultrasound does not rule out an ovarian torsion, but it may suggest that the ovary is still viable if intervention is performed quickly. Prompt recognition and immediate treatment can yield an excellent prognosis. The likelihood of saving a viable ovary decreases over time with some evidence suggesting that symptoms lasting more than 48 hours results in irreversible ischemia (more than six hours for testicular torsion). (Obstet Gynaecol 2012;14[4]:229; http://bit.ly/2zA8Jlx.) Ovarian torsion is a diagnostic challenge, especially in patients with intermittent symptoms. A high index of suspicion and clinical judgment are paramount in saving an ovary.