J, a 28-year-old engineer, would never forget the afternoon when she was rushed to the hospital for an emergency surgery.
J had a slight abdominal pain and nausea which started suddenly, shortly after taking her breakfast at a hawker center. “I thought I might have been sensitive to the food I just ate,” she recalled. She was not immediately alarmed. But the pain got progressively worse. She started to vomit and eventually fainted in her office. Her colleagues decided to rush her to the hospital.
J was conscious but in severe pain. Her body temperature was normal. Her pulse rate was 100/min. and her blood pressure 110/70mm Hg. The abdomen felt hard and stiff (rigidity)and was guarded with gentle pressure.
She was given intravenous fluids, anti-nausea treatment and pain medication. An ultrasound examination of the pelvis and a CT (computerized tomography) scan of the abdomen were done immediately. The investigations revealed that she had a 5 cm right ovarian cyst, which had twisted and was cutting off the blood supply to the ovary.
What is ovarian cyst torsion?
The ovaries are held in place in the pelvis by some suspending ligaments. In one of the ligaments, the ovary receives its blood supply.
Torsion occurs when the extra weight of the cyst causes the ovary to twist and rotate around its supporting ligaments. If the twist is minor there may be little or no consequences. However, if the twist is severe enough to ‘kink’ the blood vessels, the blood supply to the ovary may be compromised and may lead to tissue death eventually.
Figure 1
How common is torsion? Ovarian cyst torsion is generally thought to be uncommon. Studies have shown that around 2%–15% of gynecological surgeries for ovarian masses were done for torsion. Most ovarian torsions occur in the reproductive age group. It is less common before puberty and after menopause.
What are the symptoms and signs?
The symptoms of ovarian cyst torsion are somewhat non-specific. They include:
severe abdominal/pelvic pain
nausea and/or vomiting
fever occasionally
These symptoms usually present suddenly and without warning. If the cyst twists and then untwists, the symptoms may 'come and go', sometimes over hours, days or even weeks. If this occurs, the diagnosis may be challenging since these symptoms may mimic many other conditions.
How is it diagnosed?
A pelvic exam is done to locate areas of pain and tenderness. A pelvic ultrasound is done to view the ovary and its blood flow. A CT scan is usually done to rule out other potential diagnoses, such as:
Appendicitis
Acute pelvic infection
Ectopic pregnancy
Kidney stone
A definitive diagnosis is usually made by direct visualization of the ovary during surgery.
What is the treatment?
Laparoscopic surgery is the method of choice. It is done to ‘untwist’ the ovary and remove the cyst. If the ovarian damage is minimal, the ovary can be salvaged and its functions restored.
If tissue death has occurred, removal of the ovary along with the cyst should be done.
J had a laparoscopic surgery immediately. The ovary and the cyst appeared dark purple, indicating that the ovarian blood supply was compromised. After untwisting the cyst, which wound round the ovarian ligament twice, the ovary returned to its normal colour after a while. The cyst was then removed with conservation of the ovary.
J recovered well after the surgery. Her abdominal pain had disappeared the next day and she was discharged 2 days later.