Ovarian torsion tog Tubo-ovarian abscess TOA tog

Ovarian torsion tog 

🔸Torsion of the ovary, tube or both is responsible for between 2.7% and 7.4% of all gynaecological emergencies but is a common diagnostic challenge in the emergency setting.

 🔸It most commonly occurs in women of reproductive age (including during pregnancy) however, pre-pubertal girls and postmenopausal women can also be affected. Delay or misdiagnosis can result in the loss of the affected ovary and subsequent reduced reproductive capacity.

🔅 Ovarian torsion is far less common than other causes of acute 

pelvic pain such as pelvic inflammatory disease (PID), ovarian cyst haemorrhage and appendicitis.

🔅Diagnosis usually relies on a combination of detailed clinical history 

and ultrasound findings, with a high index of suspicion for torsion.

 📝Clinical features of adnexal torsion 

Symptoms 

General Pelvic or abdominal pain, fluctuating, radiating to loin or thigh 

Nausea and Vomiting 

🔅Signs 

▪️General➡️ Pyrexia, Tachycardia 

▪️Abdominal examination ➡️ Generalised abdominal tenderness, localised guarding, rebound 

Vaginal examination ➡️Cervical excitation, adnexal tenderness, 

adnexal mass

🔅 The clinical presentation of adnexal torsion, like other pathologies, is with acute onset of pelvic pain but can be non-specific, frequently presenting diagnostic difficulties. 

👉Nausea and vomiting are also common presenting features, occurring in 85% of cases of ovarian torsion.

🔷Differential diagnoses in acute lower abdominal pain

▪️PID ➡️Sexually active ➡️Non-migratory pain, bilateral tenderness, no nausea or vomiting.

▪️Appendicitis ➡️Typically <40 years old ➡️Migratory pain, anorexia, vomiting . 

▪️Functional ovarian cyst ➡️Natural cycles ➡️Sudden onset, sharp stabbing pain .

▪️OHSS➡️➡️ History of ovulation induction➡️➡️Bloating, pelvic pain, nausea and vomiting .

▪️Adnexal torsion ➡️History of ovarian cyst, PCOS, ovulation induction 

➡️➡️ Intermittent, colicky acute pain, nausea, vomiting, pyrexia

🔸 Ultrasound scan 

The affected ovary may appear as a solid mass with hypo- and 

hyperechoic areas in keeping with haemorrhage and necrosis . The pedicle that is twisted may be seen as a ‘whirlpool’ that is visible both in grey scale and on colour Doppler and has been shown to increase the 

diagnostic sensitivity for torsion.

Of the above appearances, unilateral ovarian enlargement and oedema appears to be the most consistent finding in the literature.

🔸 Abnormal Doppler signals in the ovarian vessels have been 

identified in up to 100% of cases of adnexal torsion; however, a complete absence of perfusion may be a relatively late event, so the presence of flow within the ovary does not exclude the diagnosis of torsion.

🔸 Computed tomography (CT) and magnetic resonance imaging (MRI) have been shown to be useful in the diagnosis of adnexal torsion and findings include enlargement of the ovarian stroma, tube thickening, ascites and uterine deviation to the affected side, with a good 

negative predictive value.

🔸 Blood is routinely taken from women presenting to thenemergency department (ED) with acute pelvic pain, to detect evidence of infection, anaemia and inflammation. 

🔸No single or combined markers have been identified that improve 

diagnostic accuracy in adnexal torsion.

📝An ovarian cyst ( 25 mm simple or complex cyst) can be found in up to 5% of pregnancies,with a 1–3% torsion rate.

 The risk of torsion appears to decrease with increasing gestation, is unusual after 20 weeks and becomes harder to diagnose. The use of laparoscopy in pregnancy has been shown to be safe in any trimester, 

providing the appropriate surgical expertise is available.

📝Management 

 The surgical management of adnexal torsion is clearly determined by many factors in addition to the macroscopic appearance of the adnexum; including age, menopausal status, presence of pre-existing ovarian pathology and desire to preserve fertility.

👉there are good outcome data to support conservative management with laparoscopic de-torsion in the majority of cases with little short or long-term associated morbidity, even if the ovary appears dark purple or 

black.

👉Follow up of women who have undergone de-torsion, suggests that in the majority of cases, function appears to recover (based on the presence of follicular activity on follow-up ovarian ultrasound, pregnancy rates, response to ovulation induction or second-look laparoscopy).

 👉In cases where torsion has occurred in the presence of a true ovarian cyst, cystectomy at the time of de-torsion is often risky due to the friable nature of the tissues, but early elective cystectomy has been described after an interval of 2–3 weeks to allow time for the oedema and 

congestion to resolve.

Tubo- Ovarian abscess TOA 

🔅60% of women with TOA are nulliparous 

🔅When associated with severe systemic sepsis, the mortality rate is 5–10%. 

🔅TOAs in postmenopausal women are rare, with an incidence of 1.7% of all TOAs. 

🔅In 30–40% of cases, PID is polymicrobial. 

📝Risk factors for developing PID and a subsequent TOA:

 non-use of barrier contraception, intrauterine contraceptive devices, previous episode(s) of PID, earlier age at first intercourse, multiple sexual partners, diabetes and an immunocompromised state. 

👉The incidence of a TOA was 2.3% in women with co-existing PID and endometriomas compared with 0.2% in women without endometriomas. 

📝Symptoms and signs of PID and/or a TOA include some or all of the following: 

 Adnexal tenderness (bilateral or unilateral), Cervical excitation , Pyrexia 

 Abnormal cervical or vaginal discharge  

 Elevated white cell count 

 Elevated erythrocyte sedimentation rate 

 Elevated C-reactive protein 

 Neisseria gonorrhoeae and/or Chlamydia trachomatis test positive 

 An adnexal mass on abdominal palpation/bimanual examination or seen by imaging (TOA only). 

👉Fever and diarrhoea aremore common in women with TOA than in women with PID (90% versus 60%, respectively). 

👉A screen for sexually transmitted disease such as N. gonorrhea and C. trachomatis is important, although in the UK may only be positive in one-quarter of cases.

 

📝Differential diagnoses include an appendicular mass, an endometrioma (or other ovarian cyst), an extrauterine pregnancy, diverticulitis or underlying malignancy.

 

👉TOA by ultrasound, appearing as a complex solid/cystic mass , unilateral or bilateral.  

👉A pyosalpinx may be seen as an elongated, dilated, fluid-filled mass with partial septae and thick walls. 

Incomplete septae within the tubes is a sensitive sign of tubal inflammation. 

👉cogwheel’ sign resulting from thickened endosalpingeal folds and cogwheel sign is a sensitive marker of a TOA.

🔷tubo-ovarian complex lies in the pouch of Douglas POD , compared with ovarian tumours which are often located anterior and superior to the uterus.

 

Further imaging if ultrasound is inconclusive or symptoms suggest other pathology. 

CT scan had a sensitivity and specificity of 94% and 100%. 

Magnetic resonance imaging (MRI) has the advantage over CT of being a non-irradiating mode of imaging. 

 

📝Management of TOA 

🔅MDT. 

Initial management of the woman with a suspected TOA is dictated by clinical findings and ultrasound. 

‘sepsis six’ protocol should be followed:  

1. administer oxygen,  

2. take blood cultures prior to commencing antibiotics,  

3. commence intravenous antibiotics,  

4. measure serum lactate, 

5. commence intravenous fluids and  

6. accurately measure urine output.

🅰️ Medical treatment  

👉Medical treatment of a TOA with antibiotics can be effective in up to 70% of patients but is associated with a high recurrence rate.

 

👉Successful antibiotic therapy is based on the ability to penetrate the abscess cavity, remain active within the abscess environment and be active against the commonest pathogens. 

 

👉👉Intravenous clindamycin, metronidazole and cefoxitin have higher abscess cavity penetration and have been shown to reduce abscess size. 

Once clinical improvement is noted and pyrexia has resolved, antibiotics should be changed to an oral preparation and continued for 14 days. 

Careful monitoring of pulse, blood pressure, temperature, respiratory rate and oxygen saturations.  

Fluid balance and urine output must be carefully monitored. 

 Blood parameters should be checked daily, particularly the white cell count and the C-reactive protein levels. 

Prophylaxis against venous thromboembolism should be initiated with compression stockings. 

The woman should be reviewed at least twice every 24 hours by a senior clinician.

A higher level of care in a high-dependency unit or intensive care unit may be needed if the woman becomes systemically unwell.

 

🅱️Surgical management  

Failure to respond to medical treatment (clinical signs and blood markers) will necessitate surgical intervention or image-guided drainage of the TOA.

 

Rapid clinical deterioration may need prompt surgical intervention in up to 25% of women. 

Different approach to surgical intervention for TOA:  

laparoscopy or laparotomy with drainage of the abscess, unilateral or bilateral salpingooopherectomy or pelvic clearance.  

 

If fertility is to be preserved, drainage of the pelvic abscess with copious irrigation of the abdominal cavity can be considered. A large drain should be considered to allow any remaining pus or wash to be  

expelled.

Laparoscopy and drainage of abscesses should be considered for all women with TOAs who desire future fertility.

 

If the woman has completed her family, consideration should be given to salpingo-oophorectomy, thereby reducing the chance of recurrence and the consequent need for potential further surgery.

 

Laparoscopic adhesiolysis and drainage of abscess with antibiotic cover , 90% of women, the approach was successful, with only 10% needing further surgery.BASHH advises offering all partners of women with PID/TOA infection screening to avoid reinfecting the patient.