Rosen & Barkin's 5-Minute Emergency Medicine Consult (502 page)

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

• 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
    

DIAGNOSIS

• 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
    

• 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
    

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

• 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 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
    

• 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
  

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

Ovarian cyst

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

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
  

• 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

• 620.0 Follicular cyst of ovary
  
• 620.2 Other and unspecified ovarian cyst
  
• 620.5 Torsion of ovary, ovarian pedicle, or fallopian tube
  

BASICS

• Paget disease involves resorption of normal bone and its replacement with fibrous and sclerotic tissue
  
• Also known as osteitis deformans
  
• Usually focal, bones most frequently involved include:
  
  • Pelvis (70%)
    
  • Femur (55%)
    
  • Skull (42%)
    
  • Tibia (32%)
    
  • Spine (53%, lumbar spine)
    
  • Flat bones
    
• Usually found incidentally and generally asymptomatic
  
• Occurs in ∼1–2% of patients >55 yr old
  
• Incidence increases with age
  
• Starts with resorptive or osteolytic phase, during which osteoclasts remove healthy bone
  
• Hypervascularity begins in resorptive phase:
  
  • Predisposes to hematoma and fracture
    
• Resorbed bone is eventually replaced by irregular, dense, disorganized trabecular bone in sclerotic or osteoplastic phase forming “mosaic pattern”
  
• Malignant transformation is rare:
  
  • Osteosarcoma is malignancy of concern
    
  • Usually malignant transformation occurs in 1%
    
• More common in men
  
• More common in European descent
  
• Less common in Asian or Scandinavian descent
  
• Typically involves 1 bone (monostotic)
  
• May involve a few bones (polyostotic)