Ovarian Torsion: Report of 27 Cases at Surgical Department of Aristide Le Dantec Teaching Hospital of Dakar,Senegal

Introduction

An ovarian cyst is a tumor with variable content occurring from the ovary's epithelial covering or from germinal cells. ¹ The main complication is the cyst's torsion ² —the twisting of the ovary around a center line, consisting of the infundibulopelvic ligament and tubo-ovarian ligament. ³ The consequences, ischemia, and then necrosis, can affect the fertility of a patient. The challenge is early diagnosis, which can avoid the necessity for oophorectomy. The aim of the current study was to describe the epidemiologic, clinical, and management aspects of ovarian torsion in under-resourced settings.

Materials and Methods

This retrospective study was conducted in the General Surgery Department of the Aristide Le Dantec Teaching Hospital of Dakar in Dakar, Senegal over 10 years, from January 1, 2000, to December 31, 2010. The study included all women operated on in that department during this study period and whose surgical examinations showed ovarian torsion with histologic testing confirmation. The studied parameters were related to age, gynecologic and obstetric history, circumstances of discovery, clinical history, surgical management of the condition, and outcomes.

Results

Over this study period, 217 patients were operated on for ovarian cysts, and 27 had ovarian torsion (12.4%). The average age of these patients was 30.4 years. Twenty-five patients were of reproductive age (92.6%), and 2 were postmenopausal (7.4%). No patients were of premenarchal age. There was a history of abortion in 7 cases (25.9%), stillbirth in 3 cases (11.1%), and oophorectomy in 1 case (3.7%). There was no history of previous ovarian torsion.

The patients were admitted after an average evolution time of 3.7 days. Only 4 of the patients (14.8%) were admitted in the first 24 hours from the beginning of the symptoms. The clinical presentation was mostly pelvic pain (Table 1). Vomiting was also frequent, occurring in 16 cases (59.3%). On general examination, 4 patients were noted to have fever (14.8%). Abdominal examination revealed pain in all cases. There was adnexal tenderness in 12 cases (44.4%) and an adnexal mass in 10 cases (37%). No patients had vaginal bleeding. According to laboratory tests, 10 patients (37%) had high white blood cell counts, and none had anemia. Abdominal sonography showed ovarian enlargement in 88.9% of the cases. No patient was submitted to Doppler examination alone or given ultrasonography alone. An abdominal scan was carried out for 5 patients to complete the ultrasonography and showed the same results as the sonography. No patients had magnetic resonance imaging.

All of the patients had surgery. Laparotomy was performed in 23 cases (85.2%), and laparoscopy was performed in 4 cases (14.8%). The ovarian torsion was located on the right side in 18 cases (66.7%) and on the left side in 9 cases (33.3%). The average size of the ovarian mass was 13.4 cm. The smallest was 5 cm, and the largest was 30 cm. Six patients had nontwisted contralateral ovarian cysts. The number of torsion circles varied between one and three. The de-torsion was systematic. The surgical management was salpingo-oophorectomy in 24 cases (88.9%), oophorectomy in 2 cases (7.4%), and oophoropexy in 1 case (3.7%). Cystectomy was performed on the nontwisted side in 6 cases, myomectomy in 2 cases, and appendectomy in 1 case for appendicitis that developed via contact.

With respect to surgical outcomes, 3 patients had parietal infections, corresponding to a morbidity of 11.1%. There was no mortality. The patients were discharged, on average, by 4.8 days, with a range between 2 and 14 days. No cases of relapse, contralateral torsion, or pregnancy were noted at an 18-month follow-up. Histologic testing showed that 26 cases were benign (96.3%) and 1 was a cancer (3.7%). There was a dermoid cyst in 17 cases (62.9%).

Discussion

According to studies, adnexal torsion is the fifth most common gynecologic surgical emergency, accounting for 2.7%–7.4% of all gynecologic emergencies. ⁴ In the current study, the prevalence is ∼12.4%. Adnexal torsion can occur at any age, but it is most common in women of reproductive age. Cases have been reported in infants and adolescents.^5,6 In the current study, the average age was 30 years, which was approximately the same as ages reported by other studies.^7,8

The preoperative diagnosis of ovarian torsion is challenging. Indeed, the symptoms are nonspecific, and there are many differential diagnoses for acute abdominal pain for woman. Examples include pelvic inflammatory disease, ovarian hyperstimulation syndrome, polycystic ovary syndrome, and even appendicitis. However, ovarian torsion can be suspected in all woman presenting with acute pelvic pain, although torsion might present as chronic pain. Abdominal tenderness is reported in 30%–90% of cases in the medical literature.^7,9 In the current study, pelvic tenderness was noted in 44.4% of cases, and a mass was found in 37% of the cases.

Using ultrasonography has often helped with diagnosis. This medical imagery enables providers to research adnexal enlargement and an absence of flow into ovarian vessels. The Doppler effect in sonography is the reference. ¹⁰ Ultrasound has become the routine means of investigation. It reveals a unilateral ovarian enlargement in most cases. In the current study, ultrasound has revealed an adnexal mass in almost 89% of the cases. The Doppler effect in sonography shows abnormal signals in the ovarian vessels in up to 100% of cases of adnexal torsion.^10,11 However, a complete absence of perfusion in the ovarian vessels may be a late event. Thus, the presence of flow within the ovary cannot be used to exclude an adnexal torsion.^3,12 None of the patients in the current study benefited from Doppler imagery alone nor with sonography, because the current authors do not have Doppler experience in their emergency room. The current authors make the diagnosis when faced with a woman of reproductive age presenting with abdomino-pelvic pain and an ovarian enlargement is seen on ultrasound.

The right side is affected most frequently.^2,9 This can be explained by the fact that the right utero-ovarian ligament is physiologically longer than the left one. In addition, the presence of the sigmoid on the left reduces the space needed for torsion to occur. ⁹ This torsion can occur with a benign ovarian cyst or with ovarian cancer. ¹³ However, ovarian cancer torsion is rare, occurring in only 2% of cases. ¹⁴ There was just 1 case in the current study. There are often cancerous adhesions of the ovary with the surrounding tissues, which reduce the risk of torsion. The ovarian cyst is likely a dermoid cyst. ¹³ In the current study, the right side was also the most affected side, occurring in 67% of the cases. The cysts were dermoid cysts in 62.9% of the cases.

An adnexal torsion history is an adnexal torsion relapse hazard factor if the annex has ever been preserved. ¹³ The current authors did not find any ovarian torsions or relapses after an 18 month-follow-up of the patients. Although torsion can occur in normal adnexa, the risk is greater when the cyst measures >5 cm on an ultrasound.^13,15,16 The torsion in normal adnexa could be due to development of abnormalities in the ovary. ⁴

Early detection and prompt management can preserve fertility and ovarian function. In the current study, surgical management was determined by the macroscopic appearance of the adnexum, age of each patient, her menopausal status and desire to preserve fertility, and presence of preexisting ovarian pathology. Treatment ranges from simple conservative de-torsion and oophoropexy to radical salpingo-oophorectomy. To avoid excessive treatment, some researchers have cited techniques for evaluating ovarian vitality.^10,17

In the current authors' context, there are two main constraints related to management of this condition: (1) the long average length of consultation for this country's patients and (2) the lack of equipment in this country's hospitals. The combination of these constraints leads most often to necrosis of the ovary, which will then require oophorectomy. However, this radical surgery should only be indicated for women who do not have a desire for pregnancy or who are postmenopausal. ¹⁸ Shalev et al. ¹⁹ suggest that, even with the appearance of necrosis, conservative treatment to preserve ovarian function should be used when the patient desires to get pregnant. There is evidence to suggest that there is no correlation between the clinical appearance of twisted adnexae and ovarian function. ⁴ However, in the current authors' hospital, there is no means for evaluating ovarian function before surgical management of ovarian torsion.

Conclusions

Adnexal torsion is often found in women who are of reproductive age. The torsion is usually on the right side because of the anatomical impact. Adnexial conservation is recommended for all women with a desire for pregnancy because this conservation preserves fertility and ovarian function after de-torsion. All women should undergo medical checkups as soon as possible in cases of sudden pelvic pain.