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Keywords:

  • adnexa;
  • diagnosis;
  • Doppler;
  • torsion

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Patients and Methods
  5. Results
  6. Discussion
  7. References

Objective

To propose, in cases with coiling of the ovarian vessels, a classification of severity of torsion based on Doppler and gray-scale ultrasound findings and to suggest a treatment strategy for each situation.

Methods

Seventeen patients were examined in a gynecological emergency room between December 1995 and February 2003 due to suspected adnexal torsion. Doppler and gray-scale ultrasound were used to visualize coiling of the ovarian blood vessels. Intraovarian flow was assessed by spectral Doppler and on this basis, along with the patient's clinical condition, the decision was made as to whether surgery was necessary. Findings on surgery were recorded.

Results

All 17 patients showed coiling of the ovarian vessels. Nine had arterial and venous blood flow within the ovary and ultrasound and surgical findings usually demonstrated normal sized or mildly enlarged ovaries. Five had only arterial blood flow within the ovary and surgery usually revealed enlarged ovaries with normal color or mild discoloration. Three had neither arterial nor venous blood flow within the ovary, with vessel coiling evident only on gray-scale and not on Doppler examination, and surgical findings included signs of ovarian ischemia or necrosis.

Conclusion

In cases of coiling of the ovarian vessels, Doppler flow analysis of the ovary can help differentiate between ischemic adnexal torsion and coiling of the ovarian blood vessels without strangulation, aiding in the choice of treatment. According to type of blood flow seen on Doppler examination, we suggest the following classification of severity of adnexal torsion and treatment strategy: Class 1, coiling with arterial and venous ovarian blood flow; a conservative approach may be considered if the clinical condition permits; Class 2, coiling with arterial ovarian flow but no venous flow; surgical intervention is required; and Class 3, true strangulation, with no ovarian blood flow; urgent surgical intervention is required. Copyright © 2009 ISUOG. Published by John Wiley & Sons, Ltd.


Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Patients and Methods
  5. Results
  6. Discussion
  7. References

Adnexal torsion is a medical emergency caused by twisting of the ovary on its pedicle, causing lymphatic and venous stasis and consequently ovarian edema, followed by ischemia and necrosis when left untreated. There is no specific clinical sign or manifestation, nor any sensitive biochemical marker, available for diagnosing adnexal torsion or ischemia1, 2. Gray-scale ultrasound and color and power Doppler are important diagnostic tools that may assist in cases of suspected ovarian torsion. There are several reports of sonographic findings in cases of ovarian torsion, including enlargement of the ovary, free fluid in the cul-de-sac and small cystic structures scattered around the periphery of the ovary3–6. Several case reports have proposed Doppler as a reliable tool for diagnosing ovarian torsion2, 7, 8. Willms et al.9 hypothesized that the viability of the ovary following surgery depends on the internal flow within the ovary beforehand. Fleischer et al.10, in their study of 13 patients, claimed that ovarian viability is marked by central venous blood flow within the ovary. A report by Lee et al.11 found that, of 32 patients with surgically confirmed ovarian torsion, 28 (88%) had demonstrated a twisted ovarian vascular pedicle on ultrasound. In 16 of these 28 patients, arterial and venous flow had been present within the pedicle on color Doppler. Fifteen (94%) of these patients had non-necrotic ovaries on pathological examination or viable ovaries on follow-up sonography after detorsion. They suggested that flow within the vascular pedicle is a predictor of ovarian viability. Contrary to these reports, Peña et al.12 found that 60% of patients with surgically confirmed ovarian torsion had normal flow within the ovary on Doppler examination prior to surgery, concluding that Doppler is not a sensitive modality for diagnosing ovarian torsion, and that normal flow does not rule out torsion.

Our group has described a finding on Doppler examination in four women with suspected adnexal torsion13: color and power Doppler studies demonstrated the ovarian blood vessels twisting, forming loops of vessels in the shape of a coil. We named this finding ‘coiling’ of the ovarian blood vessels due to its spiral pattern. It is present when there is spiral rotation of the ovarian pedicle. Adnexal torsion was confirmed surgically in all cases. Since our initial report we have diagnosed more women with coiling of the ovarian vessels, but have found different results with respect to flow within the ovary, some women having both arterial and venous flow, some only arterial flow and others no flow within the ovary. The objective of this report was to form a classification based on Doppler findings in cases of ovarian torsion, and to determine severity and required treatment in each situation.

Patients and Methods

  1. Top of page
  2. Abstract
  3. Introduction
  4. Patients and Methods
  5. Results
  6. Discussion
  7. References

An analysis was performed of all patients who were evaluated in the Carmel Medical Center's Department of Obstetrics and Gynecology between December 1995 and January 2004 in whom adnexal torsion was suspected clinically and in whom coiling of the ovarian vessels was then documented by color Doppler or power Doppler studies and/or gray-scale imaging. The studies were performed by the same operator (R.A.), and typically took up to 10 min. All studies were performed on the ATL HDI 3000, ATL HDI 5000 or Diasonics DRF 400 ultrasound machine using 4–8-MHz transvaginal and 2–5-MHz transabdominal probes. We evaluated flow within the vascular pedicle and within the ovary as well as additional sonographic signs, including the size and shape of the ovary and the presence of free peritoneal fluid. When color Doppler failed to demonstrate the twisted pedicle, gray-scale imaging was used. Color or power Doppler was used at an appropriate pulse repetition frequency to detect low flows, especially within the ovary. An appropriate low-velocity setting was used for assessing intraovarian flow, with gradually decreasing pulse repetition frequency down to 500 Hz, especially when flow was difficult to detect. The ovary was systematically scanned for flow using these low settings. Based on the patient's clinical condition as well as the Doppler and gray-scale imaging, we decided whether surgical intervention was required. When strangulation, i.e. complete cessation of blood supply to the ovary, was suspected, surgery was performed immediately. Ovarian torsion was confirmed during laparoscopy or laparotomy when performed.

Results

  1. Top of page
  2. Abstract
  3. Introduction
  4. Patients and Methods
  5. Results
  6. Discussion
  7. References

A total of 17 patients aged between 17 and 47 (mean, 30.4) years were included in the study. All were referred for unilateral lower abdomen pain, some with nausea and vomiting, which had been present for a period of 1–14 (average, 3.2) days before our examination. All patients had coiling of the ovarian vessels on Doppler or gray-scale ultrasound examination. Among these 17 patients, nine had arterial and venous blood flow documented within the ovary (Figure 1), five had arterial flow but no venous flow (Figure 2) and three had neither arterial nor venous flow (Figure 3). The three patients who had no flow within the ovary had coiling of the ovarian vessels demonstrated only by gray-scale sonography, while in the others coiling was evident on Doppler examination.

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Figure 1. Coiling of ovarian blood vessels in a case with preserved arterial and venous blood flow.

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Figure 2. An edematous ovary in a case of adnexal coiling with preserved arterial flow but no venous flow.

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Figure 3. Adnexal coiling in a case of strangulation (neither arterial nor venous ovarian blood flow is seen).

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Among the nine patients who had both arterial and venous blood flow detected within the ovary, ultrasound demonstrated five patients with a mildly enlarged ovary and mild free peritoneal fluid. The other four patients had normal-sized ovaries with no free peritoneal fluid. Laparoscopy was performed on seven of the nine patients while two were managed conservatively with no surgical intervention. All seven patients demonstrated adnexal torsion during laparoscopy. The adnexa had been rotated between one and five times, with no signs of ischemia or necrosis. Detorsion was performed in six of these patients; the seventh underwent salpingo-oopherectomy due to an ovarian mass which was sent for pathological examination. In addition to detorsion, surgery included an ovarian cystectomy in one case and suction drainage of the cyst in another. Follow-up of the patients showed that two had a recurrence of adnexal coiling and therefore underwent repeat laparoscopy with detorsion and ovarian fixation. Another complained of unilateral lower abdomen pain 4 months after surgery. Sonographic work-up showed an enlarged ovary with free peritoneal fluid and no blood flow on Doppler examination. Diagnostic laparoscopy showed a necrotic ovary and a salpingo-oopherectomy was performed. Of the two patients who were managed conservatively, one had an enlarged ovary with a simple cyst and no free peritoneal fluid. The other was diagnosed with ovarian hyperstimulation syndrome (OHSS) with mild free peritoneal fluid on ultrasound examination. Coiling was seen on the side of the larger ovary. Both patients had spontaneous resolution of symptoms and repeat Doppler examination showed normal blood flow within the adnexa. Follow-up of these two patients 12–14 months after surgery suggested normal functioning ovaries with spontaneous ovulation on the side of the torsion as documented by ultrasound.

In the five patients who had preserved arterial flow but no venous blood flow within the ovary, ultrasound demonstrated enlarged ovaries with increased intrafollicular distance and mild to moderate free peritoneal fluid. Four of these patients underwent laparoscopic surgery and one patient who had OHSS was managed conservatively since her symptoms resolved spontaneously before surgery was performed. Repeat transvaginal ultrasound examination revealed normal flow to the ovary. Follow-up 3 months later suggested normal follicular activity. In all four cases of laparoscopy, torsion of the ovarian vessels was demonstrated. The adnexa were twisted two to four times, with signs of mild ischemia in one case and necrosis in another. Detorsion was performed in three of the cases and one patient had a salpingo-oopherectomy performed due to a large necrotic ovarian mass, confirmed pathologically. During follow-up, one patient had a recurrence of adnexal torsion 2 weeks after surgery with ovarian necrosis, so repeat laparoscopy including a salpingo-oopherectomy was performed.

In the three patients who had no flow within the ovary, the coiling of the ovarian vessels was demonstrated by gray-scale sonography only. All three patients had torsion on surgery, with a black ovary. In one case, laparoscopic detorsion was performed as the adnexa was twisted three times. Within 20 min, improved vascularization of the ovary was documented by a reddish change in the ovary's color. The second (45-year-old) patient had an ovarian mass suspected to be malignant on ultrasound. Diagnostic laparotomy was performed which revealed a necrotic adnexal mass twisted twice, with free peritoneal fluid. Frozen sections suggested a stromal tumor of the ovary with ischemia. Total abdominal hysterectomy with bilateral salpingo-oopherectomy was performed according to the patient's prior consent. The third patient, who was 47 years old, had suspected bilateral ovarian dermoid cysts with no blood flow within the left ovary. On laparotomy a left necrotic black ovary was documented and bilateral salpingo-oophorectomy was performed. Pathological examination revealed a necrotic benign cystic teratoma.

Discussion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Patients and Methods
  5. Results
  6. Discussion
  7. References

This study demonstrates the importance of gray-scale and color Doppler ultrasound in the work-up and management of patients with suspected ovarian torsion.

Ben Ami et al.14 found, among 15 women with adnexal torsion with edematous and blue ovary, that no venous flow was detected within the mass in all cases, while others15 have shown that Doppler studies, of arterial or venous vessels, from intraovarian vessels cannot reliably rule out torsion. Clearly, the data in the literature are in conflict regarding the ability to predict or rule out torsion and ovarian necrosis by non-invasive methods. After our preliminary report on coiling13, a similar observation on transabdominal ultrasound was made by Vijayaraghavan16, who reported on 21 patients with a ‘whirlpool sign’, describing coiling of the ovarian pedicle. Positive and negative predictive values of this sign of torsion were excellent. Color Doppler was used successfully to predict ovarian viability.

In the present study, all seventeen cases had clinical signs suggesting possible torsion of the adnexa, and had sonographically visible coiling of the ovarian vascular pedicle. There was significant variation with respect to intraovarian flow parameters between the different cases. In all cases when surgery was performed, adnexal torsion was confirmed.

Based on our clinical and ultrasound findings we suggest the following classification of adnexal torsion: Class 1, coiling of the vascular pedicle with detectable arterial and venous intraovarian flow; this Doppler profile is typically associated with a normal or mildly enlarged ovary, little or no peritoneal fluid, a lack of necrosis and favorable outcome; Class 2, coiling of the ovarian vessels with detectable arterial blood flow but no venous flow within the ovary; this profile is typically associated with enlarged edematous ovaries, increased intrafollicular distance, follicular halos, mild to moderate free peritoneal fluid and intermediate outcome in terms of ovarian viability, 50% of our cases eventually losing the twisted ovary; and Class 3, coiling with absent intraovarian arterial and venous flow; this situation is typically associated with an ischemic or necrotic ovary.

The major concerns in the clinical management of patients with suspected torsion of the adnexa are whether there is a need for surgical intervention and if so the urgency of the procedure, or whether a conservative approach can be adopted. The decision algorithms are influenced by the clinician's suspicion of whether the adnexa are jeopardized by ischemia. Our observations suggest that visible coiling of the pedicle reliably predicts adnexal torsion. In cases when coiling of the ovarian vessels is demonstrated with preserved arterial and venous blood flow (Class 1), ischemia is unlikely and a conservative approach may be considered if the clinical condition allows. If necessary, elective laparoscopic detorsion can be performed at a later stage. In some cases, the cause for adnexal coiling is transient in nature and, with expectant management, spontaneous resolution may take place. Once the ovaries are no longer edematous, the adnexa can twist back to their normal state, leading to clinical as well as sonographic resolution. In cases in which intraovarian venous blood flow is undetectable but arterial blood flow is preserved (Class 2), we believe that surgical intervention is required, because spontaneous resolution is not common. In these cases, repeated attacks of pain caused by torsion and ischemia are to be expected, and delay may lead to worsening ischemia or necrosis. When absent intraovarian arterial and venous flow is documented (Class 3), ischemia has certainly set in. As previously suggested by others17, 18, we recommend an early diagnostic and therapeutic procedure in an attempt to preserve ovarian function.

This classification and suggested approach offer an option for conservative management for certain cases of ovarian torsion which have detectable intraovarian venous flow and visible pedicle coiling. A prospective study, with greater numbers and possibly utilizing three-dimensional sonographic tools19, to examine the predictive value of these signs is long overdue.

References

  1. Top of page
  2. Abstract
  3. Introduction
  4. Patients and Methods
  5. Results
  6. Discussion
  7. References