Ovarian Cyst/Torsion, Emergency Medicine

Basics

Description

Ovarian cysts:
- Generally asymptomatic until complicated by hemorrhage, torsion, rupture, or infection
- Follicular cysts:
  - 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
- Corpus luteal cysts:
  - 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
Adnexal torsion:
- 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

Adnexal torsion:

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

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

Anticoagulated patients at increased risk of:
- 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 follicle
- Corpus luteal cysts result from unrestrained growth in early pregnancy or from normal intracystic hemorrhage days after ovulation
- Other cysts:
  - Theca lutein
  - Cystic teratoma
  - Endometrioma (chocolate cyst)
Adnexal torsion:
- Right > left
- Highest frequency in reproductive women

Cysts found in postmenopausal women suggest carcinoma

Diagnosis

Signs and Symptoms

History

Ovarian cyst:
- Abdominal pain
  - Sharp, unilateral
  - Intermittent vs. constant
  - Migration
  - Previous episodes
  - May 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)
Adnexal torsion:
- Variable history
- Abdominal pain:
  - Sudden, sharp, colicky
  - Localized vs. diffuse
  - Referred pain to groin or flank
  - May be chronic or recurring with torsion/detorsion
- Fever
- Nausea/vomiting
- Vaginal bleeding
- UTI symptoms

Physical Exam

Ovarian cyst:
- Abdominal tenderness (mild to severe with peritonitis)
- Adnexal tenderness
- Pelvic mass
- Hemorrhagic shock possible:
  - Usually from corpus luteal cyst rupture
  - Orthostasis, hypotension, tachycardia
Adnexal torsion:
- 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

Lab

Urine or serum human chorionic gonadotropin determination
CBC
Urinalysis
If significant hemorrhage, type and cross packed RBCs
Cervical cultures to rule out PID

Imaging

Transvaginal US:
- Adnexal cysts and masses:
  - Cystic masses <5 cm in premenopausal women generally benign
  - Should be re-evaluated at the end of menstruation
- Pelvic free fluid
- Enlarged, edematous ovary (suggests torsion)
Doppler:
- 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
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 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

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

Culdocentesis:
- No longer commonly done
- May yield serosanguinous fluid with ruptured cyst
- Hematocrit >15% suggests significant hemoperitoneum
Laparoscopy is gold standard for torsed adnexa and definitive diagnosis

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

Ovarian cyst

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

Pearls and Pitfalls

Adnexal torsion:

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

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.

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

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