VIGNETTE MODEL TO UROGENITAL SYSTEM
(a real good vignette)
A 20-year-old gravida 1, para 1 female presented to the ED complaining of severe right-sided flank pain that began suddenly four hours prior to arrival. Her pain was sharp and constant, radiating to the right lower abdomen with associated nausea and one episode of vomiting. She denied fevers or chills, dysuria, hematuria, constipation or diarrhea. She was currently on her normal menstrual cycle. She denied recent trauma or any personal or family history of kidney stones. She had not previously experienced similar pain.
General appearance: The patient was a well-nourished, well-hydrated female in moderate discomfort.
Temperature 36.6◦C, pulse 96 beats/minute, blood pressure 109/79 mmHg, respirations 20 breaths/minute, oxygen saturation 98% on room air
Heent: PERRL, EOMI, oropharynx clear with moist mucous membranes.
Cardiovascular: Regular rate and rhythm without rubs, murmurs or gallops.
Lungs: Clear to auscultation bilaterally.
Abdomen: Soft, nontender, nondistended. No costovertebral angle tenderness.
Pelvic: No discharge or bleeding, normal-sized, nontender uterus, os closed, right adnexal mass palpable with mild tenderness.
Neurologic: Nonfocal. Noncontrast CT of the pelvis from a 20-year-old female with right flank pain.
A clean catch urinalysis demonstrated a large amount of blood but was otherwise normal. Her creatinine was within the normal range. A urine pregnancy test was negative.
A peripheral intravenous line was placed, blood was drawn and sent for laboratory testing.
A noncontrast CT of the abdomen and pelvis was obtained.
and morphine sulfate, ketorolac, and ZofranR were administered intravenously for pain and nausea, respectively.
Task: what is your diagnosis
Key teaching points
1. Ovarian torsion is a gynecologic emergency requiring prompt diagnosis and emergency surgical treatment.
2. Torsion is the most common complication of dermoid cysts, occurring in approximately 3.5% of cases.
3. The pain of ovarian torsion is proportional to the degree of circulatory compromise; if tor-sion is complete, the pain is acute and severe, typically accompanied by nausea and vomiting.
4. On physical examination, the most consistent finding in patients with ovarian torsion is a palpable mass.
5. Abnormal flow on color Doppler sonography increases the likelihood of identifying torsi-on, but torsion may occur with incomplete vascular obstruction; therefore, evidence of vascu- lar flow does not rule out torsion with certainty.
6. Treatment of a torsed ovary with a dermoid cyst or other abnormality requires detorsion of the ovary and removal of the cyst if the ovary is viable; a nonviable ovary requires removal.
The diagnosis is right ovarian (adnexal) torsion due to a 6-cm dermoid cyst. The noncontrast CT scan of the abdomen and pelvis demonstrated a 6.8 cm × 5.1 cm heterogenous mass lesion with components of soft tissue, calcium and fat in the right para-midline anterior pelvis, suggestive of a dermoid cyst. The pelvic organs appeared otherwise unremarkable. The gynecology service was consulted, and the patient was taken to the OR. During laparoscopy, a 6-cm dermoid cyst was discovered, causing torsion of the right ovary.
The ovary was detorsed and the dermoid cyst was excised from the ovary. The ovary was viable, and the ovarian bed was subsequently cauterized with excellent hemostasis. The patient recovered uneventfully. Pathology identified the cyst as a mature cystic teratoma.
Ovarian torsion resulting from a dermoid cyst
A dermoid (cystic teratoma) is a benign, cystic lesion containing tissue from all three embryonic layers: endoderm, mesoderm and ectoderm. Ovarian dermoids constitute 10–15% of ovarian tumors. They tend to occur in young women during their reproductive years, although they have been reported in prepubertal and elderly patients.1 Ovarian dermoids present with discomfort, pain or pressure symptoms, or when a complication occurs. Torsion is the most common complication of dermoid cysts, occurring in approximately 3.5% of cases.
Cases of dermoid tumors with ovarian torsion presenting as appendicitis or renal colic have been described. Less than 1% of dermoid cysts are malignant. Although ovarian dermoids can be detected by ultrasound, CT or MRI, CT is the best imaging procedure for identifying cystic teratomas of the ovary.
Torsion of the uterine adnexa is a gynecologic emergency, requiring prompt diagnosis and emergency surgical treatment. It can involve the fallopian tube, the ovary or other adnexal structures. Risk factors for ovarian torsion include ovarian enlargement, adnexal masses (including tumors), pregnancy, ovulation induction, and previous pelvic surgery. The most common risk factor associated with torsion is the presence of a dermoid cyst (32%).5 Torsion may also occur in a normal ovary. Although adnexal torsion is generally viewed as uncommon, studies suggest that adnexal torsion is the fifth most common gynecological emergency, representing 2–3% of acute surgical emergencies.
Ovarian torsion results from partial or complete rotation of the ovarian pedicle on its long axis, potentially compromising venous and lymphatic drainage. If the rotation is partial or intermittent, venous and lymphatic congestion and its associated symptoms may subside quickly.6 If rotation of the ovarian pedicle is complete and prolonged, venous and arterial thrombosis may occur, resulting in adnexal infarction.
The pain is proportional to the degree of circulatory compromise from torsion. If torsion is complete, the pain is acute and severe, typically accompanied by nausea and vomiting. However, spontaneous detorsion may occur and the pain will subside. Adnexal torsion is rarely bilateral and is more common on the right side. It is more common in young women, with the greatest incidence in the 20- to 30-year age group.
Physical findings and characteristics of pain in ovarian torsion are variable. The “classic” history of ovarian torsion is theabrupt onset of colicky pain in a lower quadrant, with radiation to the flank or groin, mimicking renal colic. However, only 44% of patients diagnosed with ovarian torsion in one study had such crampy or colicky pain. Additionally, 51% of patients in the same study had radiation of pain to the flank, back or groin. Fifty-nine percent of patients had abrupt onsetof pain, whereas 43% of patients had prior episodes of this pain. The majority of patients in this study had nausea and vomiting (70%) and lower quadrant pain (90%), but these findings mimic many other causes of abdominal pain and are
not specific to ovarian torsion.
On physical examination, the most consistent finding of ovarian torsion is a palpable mass felt 50–80% of the time during pelvic examination.5 Laboratory tests should include a urine or serum β-hCG to rule out ectopic pregnancy and a urinalysis to evaluate for infection or stone. Studies have demonstrated elevated white blood cell counts in 16–38% of cases of ovarian torsion but this finding is nonspecific.6 In cases of suspected ovarian torsion, immediate ultrasound is the investigation of choice; greater than 93% of patients with torsion
will have abnormal ultrasound findings. Ultrasonographic findings depend on the duration of torsion and the degree of ovarian ischemia; the most common finding is ovarian enlargement. In the early stages of ovarian torsion, the ovar is enlarged with prominent peripheral follicles. With prolonged and complete torsion, infarction may appear as cystic, clotted areas on the ovary. Abnormal flow on color Doppler sonography increases the likelihood of identifying torsion, but torsion may occur with incomplete vascular obstruction; therefore, evidence of vascular flow does not rule out torsion with certainty.
Treatment of a torsed ovary with a dermoid cyst or other abnormality requires detorsion of the ovary and removal of the cyst if the ovary is viable; a nonviable ovary must be removed. The procedure can be done by laparoscopy or laparotomy. In the past, oophorec-tomy was considered the standard of care because of concern that untwisting of the adnexa might precipitate pulmonary embolism from a thrombosed vein. Several studies have shown that in the absence of a grossly necrotic ovary, untwisting of the adnexa can be performed and the ovary salvaged without significant risk of thromboembolism. Conversely, hemor-rhagic infarction or a gangrenous adnexal structure requires surgical removal without attempts at detorsion.