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Ovarian Cyst/Torsion, Emergency Medicine

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Ovarian Cyst/Torsion, Emergency Medicine

Basics

Description

Torsion in pregnancy usually occurs in the 1st trimester, and in vitro fertilization or ovarian induction are risk factors.

15% of adnexal torsions occur in children

Cysts found in postmenopausal women suggest carcinoma

US sensitivity for diagnosis of ovarian torsion is not well established; continue workup if high clinical suspicion

  • Ovarian cysts:Generally asymptomatic until complicated by hemorrhage, torsion, rupture, or infectionFollicular cysts:Most commonOccur from fetal life to menopauseUnilocular; diameter 3 " “8 cmThin wall predisposes to rupture, which usually causes minimal or no bleedingRupture during ovulation at midcycle is known as mittelschmerzCorpus luteal cysts:Most significantDiameter 3 cm, but usually <10 cmRapid bleeding from intracystic hemorrhage causes ruptureRupture is most common just before menses beginsCan cause severe intraperitoneal bleedingGradual bleeding into cyst or ovary distends capsule and may cause pain without rupture
  • Adnexal torsion:5th most prevalent surgical gynecologic emergencyTwisting of vascular pedicle of ovary, fallopian tube, or paratubal cystCauses adnexal ischemia leading to necrosisOcclusion of lymphatics and venous drainage lead to rapid enlargement of adnexaGreatest risk with cysts 8 " “12 cm
  • Generally asymptomatic until complicated by hemorrhage, torsion, rupture, or infection
  • Follicular cysts:Most commonOccur from fetal life to menopauseUnilocular; diameter 3 " “8 cmThin wall predisposes to rupture, which usually causes minimal or no bleedingRupture during ovulation at midcycle is known as mittelschmerz
  • Corpus luteal cysts:Most significantDiameter 3 cm, but usually <10 cmRapid bleeding from intracystic hemorrhage causes ruptureRupture is most common just before menses beginsCan cause severe intraperitoneal bleedingGradual bleeding into cyst or ovary distends capsule and may cause pain without rupture
  • Most common
  • Occur from fetal life to menopause
  • Unilocular; diameter 3 " “8 cm
  • Thin wall predisposes to rupture, which usually causes minimal or no bleeding
  • Rupture during ovulation at midcycle is known as mittelschmerz
  • Most significant
  • Diameter 3 cm, but usually <10 cm
  • Rapid bleeding from intracystic hemorrhage causes rupture
  • Rupture is most common just before menses begins
  • Can cause severe intraperitoneal bleeding
  • Gradual bleeding into cyst or ovary distends capsule and may cause pain without rupture
  • 5th most prevalent surgical gynecologic emergency
  • Twisting of vascular pedicle of ovary, fallopian tube, or paratubal cyst
  • Causes adnexal ischemia leading to necrosis
  • Occlusion of lymphatics and venous drainage lead to rapid enlargement of adnexa
  • Greatest risk with cysts 8 " “12 cm

Risk Factors

  • Reproductive-age women
  • Ovarian cysts, especially >5 cm
  • Ovarian hyperstimulation
  • Tumors: Serous cystadenoma most common; teratomas
  • Pelvic surgery: Tubal ligation; hysterectomy
  • Pregnancy
  • History of pelvic inflammatory disease
  • Anticoagulated patients at increased risk of:Hemorrhagic corpus luteal cystSignificant bleed from ruptured cyst, including with ovulation
  • Hemorrhagic corpus luteal cyst
  • Significant bleed from ruptured cyst, including with ovulation

Etiology

  • Ovarian cyst:Follicular cysts result from nonrupture of mature follicle or failure of atresia of immature follicleCorpus luteal cysts result from unrestrained growth in early pregnancy or from normal intracystic hemorrhage days after ovulationOther cysts:Theca luteinCystic teratomaEndometrioma (chocolate cyst)
  • Adnexal torsion:Right > leftHighest frequency in reproductive women
  • Follicular cysts result from nonrupture of mature follicle or failure of atresia of immature follicle
  • Corpus luteal cysts result from unrestrained growth in early pregnancy or from normal intracystic hemorrhage days after ovulation
  • Other cysts:Theca luteinCystic teratomaEndometrioma (chocolate cyst)
  • Theca lutein
  • Cystic teratoma
  • Endometrioma (chocolate cyst)
  • Right > left
  • Highest frequency in reproductive women

Diagnosis

Signs and Symptoms

  • Ovarian cyst:Abdominal painSharp, unilateralIntermittent vs. constantMigrationPrevious episodesMay occur with exercise, intercourse, trauma, or pelvic examFever is rareIrregular menses (may suggest polycystic ovary syndrome)InfertilityPregnancy statusPrevious STDsHistory of breast or GI cancer (may metastasize)
  • Adnexal torsion:Variable historyAbdominal pain:Sudden, sharp, colickyLocalized vs. diffuseReferred pain to groin or flankMay be chronic or recurring with torsion/detorsionFeverNausea/vomitingVaginal bleedingUTI symptoms
  • Abdominal painSharp, unilateralIntermittent vs. constantMigrationPrevious episodesMay occur with exercise, intercourse, trauma, or pelvic exam
  • Fever is rare
  • Irregular menses (may suggest polycystic ovary syndrome)
  • Infertility
  • Pregnancy status
  • Previous STDs
  • History of breast or GI cancer (may metastasize)
  • Sharp, unilateral
  • Intermittent vs. constant
  • Migration
  • Previous episodes
  • May occur with exercise, intercourse, trauma, or pelvic exam
  • Variable history
  • Abdominal pain:Sudden, sharp, colickyLocalized vs. diffuseReferred pain to groin or flankMay be chronic or recurring with torsion/detorsion
  • Fever
  • Nausea/vomiting
  • Vaginal bleeding
  • UTI symptoms
  • Sudden, sharp, colicky
  • Localized vs. diffuse
  • Referred pain to groin or flank
  • May be chronic or recurring with torsion/detorsion
  • Ovarian cyst:Abdominal tenderness (mild to severe with peritonitis)Adnexal tendernessPelvic massHemorrhagic shock possible:Usually from corpus luteal cyst ruptureOrthostasis, hypotension, tachycardia
  • Adnexal torsion:Abdominal tenderness (mild to severe)Adnexal tendernessAdnexal mass
  • Abdominal tenderness (mild to severe with peritonitis)
  • Adnexal tenderness
  • Pelvic mass
  • Hemorrhagic shock possible:Usually from corpus luteal cyst ruptureOrthostasis, hypotension, tachycardia
  • Usually from corpus luteal cyst rupture
  • Orthostasis, hypotension, tachycardia
  • Abdominal tenderness (mild to severe)
  • Adnexal tenderness
  • Adnexal mass

Essential Workup

  • Pregnancy test essential to rule out ectopic pregnancy
  • Rapid hemoglobin or hematocrit

Diagnosis Tests & Interpretation

  • Urine or serum human chorionic gonadotropin determination
  • CBC
  • Urinalysis
  • If significant hemorrhage, type and cross packed RBCs
  • Cervical cultures to rule out PID
  • Transvaginal US:Adnexal cysts and masses:Cystic masses <5 cm in premenopausal women generally benignShould be re-evaluated at the end of menstruationPelvic free fluidEnlarged, edematous ovary (suggests torsion)
  • Doppler:May show decreased flow with torsionImportant to document normal blood flow on Doppler in ED, even though does not rule out recent torsion of ovary
  • MRI:Consider in pregnant patients with right lower quadrant pain and nondiagnostic US and Doppler
  • CT:May demonstrate cysts or evidence of torsion or suggest alternative diagnosisMay provide enough information to proceed to laparoscopy if abnormal ovary and no other cause of pain identifiedUterus may be shifted to side of torsed adnexaAscites may be present
  • Adnexal cysts and masses:Cystic masses <5 cm in premenopausal women generally benignShould be re-evaluated at the end of menstruation
  • Pelvic free fluid
  • Enlarged, edematous ovary (suggests torsion)
  • Cystic masses <5 cm in premenopausal women generally benign
  • Should be re-evaluated at the end of menstruation
  • May show decreased flow with torsion
  • Important to document normal blood flow on Doppler in ED, even though does not rule out recent torsion of ovary
  • Consider in pregnant patients with right lower quadrant pain and nondiagnostic US and Doppler
  • May demonstrate cysts or evidence of torsion or suggest alternative diagnosis
  • May provide enough information to proceed to laparoscopy if abnormal ovary and no other cause of pain identified
  • Uterus may be shifted to side of torsed adnexa
  • Ascites may be present
  • Culdocentesis:No longer commonly doneMay yield serosanguinous fluid with ruptured cystHematocrit >15% suggests significant hemoperitoneum
  • Laparoscopy is gold standard for torsed adnexa and definitive diagnosis
  • No longer commonly done
  • May yield serosanguinous fluid with ruptured cyst
  • Hematocrit >15% suggests significant hemoperitoneum
  • Early detorsion of adnexa by laparoscopy is now advocated to preserve ovarian function
  • Followed by frequent follow-up visits to monitor for malignancy

Differential Diagnosis

  • Ectopic pregnancy
  • PID
  • Round ligament pain
  • Endometriosis
  • Neoplasm
  • Torsion of uterus
  • Appendicitis

Follow-up Recommendations

  • If pain is resolved and cyst is <4 " “5 cm, close follow-up is recommended with gynecology for further studies

Pearls and Pitfalls

  • Torsion is a clinical diagnosis:US may show flow to an ovary that has detorsed
  • Symptoms can be varied and nonspecific
  • Always include adnexal torsion in differential of abdominal pain
  • US may show flow to an ovary that has detorsed

Additional Reading

  • Becker ‚ JH, de Graaff ‚ J, Vos ‚ CM. Torsion of the ovary: A known but frequently missed diagnosis. Eur J Emerg Med. 2009;16:124 " “126.
  • Bottomley ‚ C, Bourne ‚ T. Diagnosis and management of ovarian cyst accidents. Best Pract Res Clin Obstet Gynaecol. 2009;23:711 " “724.
  • Chang ‚ HC, Bhatt ‚ S, Dogra ‚ VS. Pearls and pitfalls in diagnosis of ovarian torsion. Radiographics. 2008;28:1355 " “1368.
  • Houry ‚ D, Abbott ‚ JT. Ovarian torsion: A fifteen-year review. Ann Emerg Med. 2001;38:156 " “159.
  • McWilliams ‚ GD, Hill ‚ MJ, Dietrich ‚ CS 3rd. Gynecologic emergencies. Surg Clin North Am. 2008;88:265 " “283.
  • Moore ‚ C, Meyers ‚ AB, Capostato ‚ J, et al. Prevalence of abnormal CT findings in patients with proven ovarian torsion and a proposed triage schema. Emerg Radiol. 2009;16:115 " “120.
  • Oltmann ‚ SC, Fischer ‚ A, Barber ‚ R, et al. Pediatric ovarian malignancy presenting as ovarian torsion: Incidence and relevance. J Pediatr Surg. 2010;45:135 " “139.
  • Smorgick ‚ N, Pansky ‚ M, Feingold ‚ M, et al. The clinical characteristics and sonographic findings of maternal ovarian torsion in pregnancy. Fertil Steril. 2009;92:1983 " “1987.

See Also (Topic, Algorithm, Electronic Media Element)

  • Abdominal Pain
  • Ectopic Pregnancy
  • Endometriosis
  • Pelvic Inflammatory Disease

Codes

ICD9

  • 620.0 Follicular cyst of ovary
  • 620.2 Other and unspecified ovarian cyst
  • 620.5 Torsion of ovary, ovarian pedicle, or fallopian tube
  • 620.1 Corpus luteum cyst or hematoma
  • 220 Benign neoplasm of ovary

ICD10

  • N83.0 Follicular cyst of ovary
  • N83.20 Unspecified ovarian cysts
  • N83.51 Torsion of ovary and ovarian pedicle
  • N83.1 Corpus luteum cyst
  • D27.9 Benign neoplasm of unspecified ovary

SNOMED

  • 79883001 Cyst of ovary (disorder)
  • 13595002 Torsion of ovary (disorder)
  • 2615004 Follicular cyst of ovary (disorder)
  • 386762009 Corpus luteum cyst (disorder)
  • 119421006 Serous cystadenoma of ovary