Teaching Case

35 year-old female came to the emergency department complaining about an acute abdominal pain with a duration of 3 days.
As a relevant medical history she was diagnosed of cervical cancer 6 months before (pT1N0M0) and treated with hysterectomy+salpingectomy. No oophorectomy was performed and the right ovary was pexed to the abdominal wall.

After physical examination, surgeons ordered a US scan on suspicion of appendicitis.

US: Heterogeneous mass on the right lumbar region, adjacent to the abdominal wall and the colon with a diameter of 8.5 cm and multiple peripheral cysts ( Fig1a, b). No doppler was proved at the mass (Fig1c). Perilesional free-fluid was identified(Fig1a, b). No inflammatory changes were identified at cecal appendix region(Figure not included). Pexed ovarian torsion suspicion was raised.

The gynecology department accepted the patient and ordered a CT due to the impossibility of making a transvaginal US and the exclusion of other entities.

CT: Pexed right ovary adjacent to the abdominal wall with increased size, edematous and in-homogeneous. Peripheral cysts and free-fluid were observed(Figure 2a, b, c, d). Cecal appendix was normal ( Figure not included)

Ovarian torsion is a gynecological emergency, leading to the fifth cause of acute surgical abdominal pain in gynecology[1, 2]. Although the term "ovarian torsion" is commonly used, the isolated torsion of the ovary is rare, being the ovary-Fallopian tube complex the most frequently involved[1, 4].
Reproductive-age women are the most frequently affected, while ovarian torsion during pregnancy has been increasing in frequency due to hormonal ovarian therapies[5]. The most frequent causes of torsion are benign masses, giant cysts or elongated infundibule-pelvic ligaments. Idiopathic torsion has a low frequency[1, 2, 3, 4]. Pexed ovary torsions have been reported in other studies, the majority due to the formation of adhesions after the procedure[4].
The symptomatology is nonspecific. Acute onset of abdominal pain with or without nausea is the most common symptom[1, 2].
The first line imaging technique is the US, being the findings that suggest torsion[1]:
- An unilateral rounded and enlarged ovary
- Peripheral cysts (increased size of cortical follicles)
- Peripheral free-fluid
- A mass or giant cyst, causing the torsion, could be identified if present
-Twisted vascular pedicle (whirlpool sign) may be seen.
Doppler-US is a helpful tool, where decreased/absent flow may be identified. However, ovarian torsion cannot be dismissed if flow is present due to double arterial flow of the ovary [1, 2, 3].
As the clinical presentation is nonspecific a CT may be also a good point to start. It is recommended in the study of acute abdominal pain for the exclusion of appendicitis/diverticulitis but it has less sensibility than the US for ovarian torsion[1, 2, 3].
The MRI can demonstrate the components of a mass with more detail than the US, although it is more expensive and not routinely performed.[1]
Once there is clinical and imaging suspicion, the patient should go to surgical laparotomy/laparoscopic detorsion. Surgery is the gold standard and the only way to confirm the diagnosis. Early diagnosis is essential to protect the ovary and prevent complications[1, 3, 4, 5].
In our case, after the US a CT was performed. After the imaging suspicion, patient went to laparoscopic treatment. A torsioned pexed ovary was identified with no flow restoration after the detorsion. Oophorectomy was performed with no oophoropexy of the contralateral.
In conclusion, the suspicion of ovarian torsion should be raised in all reproductive women with acute abdominal pain, considering that the presence of flow at Doppler-US and oophoropexy does not exclude the possibility of torsion.