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A subtle (yet critical) sign for possible impending ovarian torsion

Recently, I had emergency surgery for ovarian torsion of my left ovary. According to RSNA: "Ovarian torsion is defined as partial or complete rotation of the ovarian vascular pedicle and causes obstruction to venous outflow and arterial inflow. Ovarian torsion is usually associated with a cyst or tumor, which is typically benign; the most common is mature cystic teratoma."


Being a sonographer, I was aware I had an ovarian cyst, but I missed a critical subtle sign for torsion that I want to share with you today. Going forward, I hope that you learn to recognize this sign and why I was so high risk for ovarian torsion as I'm pretty sure I personally will never forget it.


A few weeks before my ovarian torsion I was having left lower quadrant/flank pain. So as sonographers, what do we do? We take a peek ourselves of course! At that time I had a simple 4.5cm left ovarian cyst located high and anterior in my left adnexa. Now I know from previous ultrasounds that this is my left ovary's normal position. This ovary has always been very sensitive when I ovulated and I attributed it to it's anterior position in my adnexa. My right ovary sits low and posterior in my pelvis, therefore I get very minimal ovarian pain with ovulation or when it creates any type of cyst.


So my cyst looked something like this image when I first found it: (This image was taken from The Cleveland Clinic) I was very unconcerned. Ok- it's simple 4.5 cm and I had good blood flow along the periphery.



Now a few days after I found this cyst my symptoms started to improve. I no longer had that dull achy feeling in my LLQ or in my flank. I assumed the cyst had ruptured as I was around the ovulation point in my cycle, and I thought "how lucky was I to not feel anything!" Boy was I wrong! Around this time I started to have a subtle pain in my low back. I actually went to my chiropractor because I thought my SI joints needed to be realigned. I assumed that maybe I was leaning over during an exam too long and my hips were a little off? She adjusted me and commented that my hips didn't seem off to her at all.

In hindsight, I now recognize that this was my 1st symptom of ovarian torsion.


A few days into my cycle I thought, maybe I should just check and see that my cyst has completely resolved. Again, I was having NO PAIN.


On that scan my ovary looked something like this: This is not my image- but you get the general idea... The cyst had doubled in size from 5 cm to approximately 9 cm. It had also moved from an anterior to a posterior position in my adnexa. I was surprised by the quick change in size but again, I wasn't concerned. It wasn't painful and it was still simple. I did not attempt to see blood flow around the periphery of the ovary.




At that point I called my Gynecologist to make an appointment. Just thought it should get it documented!


I made an appointment for a few days later. I still wasn't in any pain so I wasn't in any rush. The morning of my appointment I wanted to let me make sure that cyst is even still there as I would have felt guilty taking my NP's time if my cyst had already ruptured. Prior to my visit I saw that:

The cyst was still present but now it had moved back to an anterior location.




WHAT DID I MISS??


What piece of information did I not realize made me high risk for ovarian torsion??


Other than having a large cyst??


MOBILITY!!


A mobile ovary increases the risk for ovarian torsion! Makes perfect sense doesn't it?


According to RSNA: Ovarian torsion is uncommon after pelvic inflammatory disease, endometriosis, or malignant neoplasms; this may be due to the presence of adhesions, rendering the ovaries relatively immobile.


Ovarian torsion is typically fast in it's presentation but it's diagnosis is often delayed due to it's non-specific nature. Acute abdominal pain is what most women are diagnosed with upon beginning of symptoms. Generally, women present with sharp, localized pain. A palpable abdominal mass is present. Nausa, fevers, and vomitting are also a sign of torsion. In some cases of intermittent torsion the symptoms themselves are intermittent making the diagnosis even more difficult.


I cannot begin to explain how lucky I was in the next few hours. At 11am the morning of my torsion I started to have low pelvic pain. My pelvis was a little achy and my left hip was uncomfortable. I was very thankful that I had made an appointment with my gynecologist before I was having pain. When I went to her office at 1pm I was struggling to sit down and was extremely tender upon a pelvic exam. She immediately sent me to the ER. By 3pm I could neither sit down nor bear any weight on my left leg. All my pain was in my left hip and back. My surgeon was an amazing OBGYN who I had never met before. He was kind and compassionate and exactly who I needed in that critical moment. We did an ultrasound TOGETHER (LOL) on a SonoSite in the ER. My cyst looked exactly as it had that morning. I was in surgery by 4pm.


When my surgeon went in he did not see any current torsion, but my left ovary was so large it had pulled my ligament and vascular pedicle so tight I was experiencing intermittent torsion. He subsequently removed my left ovary and fallopian tube.


I had never thought about mobility making me high risk for ovarian torsion. But when I told my NP in office that I had seen the cyst anterior THEN posterior THEN anterior again she knew I had torsion, without a doubt. She did not want me to wait over the weekend and have this turn into a gynecological emergency. Had I gone into my Gyncologist's office the day I wasn't having pain, I would have been sent with in order for a pelvic ultrasound and a follow up in 6 weeks.


I'm so thankful that I had an appointment when I did and that I was in the right place at the right time.


Going forward, sonographers need to be aware of the location of the ovary especially when it comes to following up a large ovarian cyst or mass. If you are able to, look at the previous images! Is the ovary in the same place? Does it have mobility?! Mobility puts our patients at high risk for ovarian torsion.



Images taken from:


Info taken from:

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