Left ovarian torsion

Sivaranjani S1*, Sonya Mercy Anbu2, Dhariniya S3, Ruby Ravichandran4

1Staff Nurse, Emergency Ward, Maa Kauvery Hospital, Trichy , Tamil Nadu

2Assistant Nursing Superintendent, Maa Kauvery Hospital, Trichy , Tamil Nadu

3Nursing Educator, Senior DNS, Maa Kauvery Hospital, Trichy , Tamil Nadu

4Senior Deputy Nursing Superintendent, Maa Kauvery Hospital, Trichy, Tamil Nadu

*Correspondence

Abstract

Left ovarian torsion is a medical emergency where the left ovary twists around its supporting ligaments, restricting blood flow and potentially causing tissue death (necrosis). It causes sudden, severe left-side pelvic pain, often with nausea and vomiting. Immediate surgery is required to detorse (untwist) the ovary and restore blood flow. This case report describes a 16-year-old female who presented with severe lower abdominal pain and vomiting. Clinical examination revealed abdominal tenderness, while ultrasonography demonstrated an enlarged left ovary with a cystic lesion suggestive of torsion. Emergency laparoscopic surgery confirmed left ovarian cyst torsion with gangrenous changes. The patient underwent successful detorsion and left salpingo- oophorectomy, along with right oophoropexy. Postoperative recovery was uneventful, with complete resolution of symptoms and stable clinical status at discharge. This case highlights the importance of early recognition, timely imaging, prompt surgical intervention, and comprehensive nursing care in achieving favorable outcomes and preventing complications associated with ovarian torsion.

Key words: Left ovarian torsion; Necrosis

Introduction

Left ovarian torsion is a rare gynecological emergency caused by the partial or complete rotation of the ovary around its ligamentous supports, resulting in compromised blood flow to the ovary and occasionally the fallopian tube. It commonly presents with sudden onset lower abdominal pain, nausea, vomiting, and adnexal tenderness. Ovarian torsion accounts for approximately 2-3% of all gynecological emergencies and is more frequently observed in women of reproductive age, although it can occur in pediatric and postmenopausal patient as well. Predisposing factors include ovarian cysts, benign ovarian masses, enlarged ovaries, pregnancy, and assisted reproductive techniques. Ultrasonography with Doppler imaging is the preferred initial diagnostic modality, however definitive diagnosis is usually confirmed during surgical exploration. Prompt surgical intervention is essential to preserve ovarian function and prevent complications such as ovarian necrosis, infection, and infertility. Laparoscopic detorsion with ovarian conservation has become the preferred management approach whenever feasible.

Case presentation

A 16-year-old female was referred from outside hospital for ovarian cyst with the complaints of Lower abdominal pain since 1-day, Vomiting x 1 episode in the morning. On presenting ER the patient was alert, a febrile, conscious, oriented, abdomen tenderness present. She was hemodynamically stable. MRI done prior to admission was suggestive of torsion Left ovarian cyst, and she was admitted for further management

Systemic Examination

On systemic examination, the cardiovascular system revealed normal heart sounds S1, S2 with no audible murmurs. Auscultation revealed bilateral equal air entry with no added sounds. Abdomen was soft with normal bowel sounds and mild tenderness in suprapubic region. Central nervous system assessment indicated a Glasgow coma scale score of 15/15, with no focal neurological deficits.

Clinical Signs & Symptoms

The patient presented with complaints of lower abdomen pain associated with vomiting. On clinical examination, abdominal tenderness was noted, with mild tenderness observed in the suprapubic region

Relevant Investigations and Results

The patient laboratory investigations revealed a hemoglobin level of 11.5g/dl   and packed cell volume (PCV) of 32.4%, both slightly below the normal range. The total red blood cell count was decreased at 3.70million cells/mm, suggestive of an inflammatory response, platelet count was within normal limits at 230,000cells/cu/mm. Serum beta-human chorionic gonadotropin level was less than 2.39mlU/ml, which was negative for pregnancy. Renal functions tests showed blood urea of 13mg/dl and serum creatinine of 0.53mg/dl, both within normal range. Liver function tests revealed SGOT of 19u/l and SGPT of 13u/l, which were also within normal limits, serology was non-reactive.

Ultrasonography (USG) Abdomen showed an enlarged left ovary with heterogeneous echotexture and of left ovary with cystic lesion with internal septation.

Diagnosis: Left Ovarian Cyst Torsion

Surgical Management

The patient underwent emergency laparoscopic surgery under general anesthesia consisting of left ovarian detorsion. Left salpingo –oophorectomy, and right oophoropexy. In the supine position, after painting and draping, the abdomen was entered using a three-port laparoscopic technique with one 10mm supraumbilical camera port and two 5 mm working ports following creation of pneumoperitoneum. Intraoperative findings revealed a normal sized uterus, an edematous, congested, and gangrenous left fallopian tube, and a twice-torsed gangrenous left ovarian cyst measuring 8x5cm. The right tube and ovary were normal, and approximately 300ml hemoperitoneum was noted. Detorsion of the left cystic ovary was performed, followed by left salpingo-oopherectomy due to gangrenous changes. The specimen was retrieved through the port using an endobag and sent for histopathological examination. Right oophoropexy was performed to preserve and secure the contralateral ovary. Hemostasis was achieved, port closure was done with 3-0 monocryl, and clear urine drainage was noted. The postoperative period was uneventful

Medical Management

  • The patient was managed with appropriate supportive and pharmacological therapy. Treatment included administration of intra venous fluids to maintain hydration and hemodynamic stability.
  • The Patient was managed with a combination of intravenous and subcutaneous medications as followed,
  • Taximax 1.5gm intravenously as antibiotic therapy
  • Tramadol 50mg intravenously for pain relief
  • Emeset 4mg intravenously for control of nausea & vomiting
  • Clexane 40mg subcutaneousas a prophylaxis for DVT

Nursing Management

Pain Management: Patient for regularly assessed for pain characteristics, severity and duration. Prescribed analgesics were administered to evaluate effectiveness. Patient was positioned comfortably to reduce discomfort.

Maintain Hemodynamic Stability: Monitored blood pressure, pulse, respiration rate, temperature and oxygen saturation

Emotional and Psychological Support: Procedures and treatment plans were explained clearly to reduce anxiety. Provided reassurance and emotional support was provided to the patient and family members. We encouraged the patient to express fears and concerns.

Post-Operative Nursing Care: During postoperative period monitored vital signs and level of consciousness. Assessed the surgical site for bleeding, swelling or infection. Managed postoperative pain effectively. Encouraged early ambulation to prevent complications. Monitored intake and output. Observed for complications such as fever, severe pain or infection.

Patient Education: The patient was educated regarding importance of early medical attention for severe abdominal pain, adherence to medication, wound care and hygiene. Advised to follow-up appointments. Educated to recognize warning signs such as fever, increasing pain or abnormal bleeding.

Outcome

The patient was diagnosed with left ovarian torsion and underwent timely surgical intervention. Intraoperatively, the left ovary was found to be torsed and was successfully detorsed, restoring adequate blood flow. The postoperative period was uneventful, with effective pain control and no signs of infection or complications. The patient showed satisfactory recovery, tolerated oral intake well, and resumed normal daily activities. Follow-up evaluation revealed stable vital signs, resolution of abdominal pain, and preserved ovarian function. The patient was discharged in stable condition with advice regarding medication compliance, wound care, and follow-up visits. No evidence of recurrent torsion or postoperative complications was noted at discharge

Conclusion

Effective nursing management of ovarian torsion focuses on rapid assessment, pain control, hemodynamic stabilization, preoperative preparation and post-operative care. Prompt nursing interventions and continuous monitoring improve patient outcomes, reduce complications and support recovery.

References

  • Aziz,D., Davis, V., Allen,L., & Langer,J.C.(2004). Ovarian torsion in children: is oophorectomy necessary? Journal of Pediatric surgery, 39(5), 750 – 753. https://doi.org/10.1016/j.jpedsurg.2004.01.041
  • Oltmann,S.C., Fischer,A.,Barber,R., Huang,R.,Hicks,B.,& Garcia,N.(2009). Cannot exclude torsion – A 15 year review. Journal of pediatric surgery, 44(6), 1212 – 1217.
    1. https://doi.org/10.1016/j.jpedsurg.2009.02.028.

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