Ovarian Torsion Presentation, Treatment and Iatrogenic Surgical Management

Ovarian torsion is among the gynecological life-threatening conditions that may require urgent surgical intervention among the appearance of clinical manifestations. The most common clinical manifestations include severe abdominal pain, nausea extending to vomiting. The ovarian torsion is not limited to children only. However, it can also occur in adult females, either pregnant or nonpregnant. The etiology of the disease tends to be related to the weakness of the uterine ligaments or malpositioning of it due to known and unknown causes. Despite that, the surgical intervention is Review Article Sabahath et al.; JPRI, 33(54A): 70-76, 2021; Article no.JPRI.78054 71 needed to release the torsion. Sometimes, it can lead to adverse events or side effects such as decreased blood flow to the surrounding structures. Which by role may lead to unpleasant complications and clinical manifestations of hemorrhage and shock. In this article, we reviewed the topic of ovarian torsion from different aspects, including the definition, causes, clinical evaluation, and clinical management and its common complications.


Epidemiological Characteristics
Torsion can occur in females of all age ranges, although it is more common in women of reproductive age. In a multiyear review of clinical emergencies at a girls' hospital, ovarian torsion was the sixth most prevalent, adjusted to account for 2.7%. Only 20% of individuals are premenstrual, and 50% of these might have had a normal ovary. Torsion was most commonly associated with a benign ovarian tumor in sexually active women [8]. Being pregnant is also a separate risk factor for torsion. Eight to fifteen percent of individuals diagnosed with torsion were pregnant in a population-based study [9].

Etiological Philosophy
An ovarian lump five centimeters or more is the major risk factor for ovarian torsion. The bulk makes it more likely that the ovary will swivel on the axis of the two ligaments, keeping it suspended. This twisting obstructs venous permeability and, ultimately, arterial input [10]. In a study of torsions substantiated by surgical intervention, 46% were connected to malignancy, and 48% had attributed to cysts. Eighty-nine percent of these concentrations were benign, and 80 percent of participants were under 50. As a result, females of sexual maturity are more vulnerable to torsion [10]. Torsion can, however, develop in normal ovaries, specifically in the pediatric age group. Due to various larger follicles on the ovary, pregnant women and patients receiving medical interventions have a higher probability of conceiving [9].

Pathobiology
Torsion arises when the ovary bends over through the utero-ovarian ligament and, indeed, the infundibulopelvic ligament. This causes edema and blood float constriction. To begin with, the venous outflow is impeded, and eventually, arterial inflow is also hindered due to increasing edema, resulting in ovarian necrosis, infarction, bleeding, and potentially peritonitis. Ordinarily, the right side of the torsion is more apparent than for the left side, which is thought to be due to a larger space inside the right pelvis due to the location of the sigmoid colon on the left [11]. As in adulthood, most children with ovarian torsion have disease within the affected ovary or tube, which is likely to cause the unusual twisting [12,13]. A causal cause for adnexal torsion in adolescent cohorts is found in 64% to 80% of instances [8]. In extensive pediatric studies, the prevalence of associated ovarian disease ranged from 51% to 84% [14,15]. Pathologic observations in the pediatrics age group with adnexal torsion include benign cystic teratomas, hematoma or follicular cysts, para tubal cysts, cystadenoma, and hydrosalpinx.
Torsion is another frequent complication of ovarian cysts. In children, functional ovarian cysts frequently expand as a result of disrupted endocrinal changes. This is generally placed at different peak periods: the fetal stage within the first 12 months of life and throughout the birth. Ovarian cyst development in the latter stage is linked to changes through gonadotropin secretion, and upwards to 20% of women could also have multicystic and larger ovaries at the start of menstruation [16]. The follicular cysts and corpus luteal cysts grow throughout the menstrual period but usually resolve within months.

CLINICAL EVALUATION
Torsion discomfort is mainly caused by obstruction of the vascular pedicle, which results in tissue damage [17]. Torsion often manifests as an acute onset of discomfort in the pelvic area, with emission to the backline or thighs. Nevertheless, around half of individuals may also appear with this type of discomfort [18]. The pain can manifest more subtly, particularly in individuals with a history of ovarian cysts, polycystic ovarian syndrome, or other pelvic disorders [19,20]. All such pain bouts might occur over many days to months before the analysis is completed on occasion [17]. Manifestations can sometimes be ambiguous, ranging from asymptomatic to significant pelvic or abdominal discomfort, stomach cramping, nausea, or vomiting [21]. Because the ovary can torse and de-torse with changes in activity, the pain may be consistent or inconsistent [17]. Patients may indeed present with fever, hypertension, and sinus tachycardia [19]. Various sequelae of pain, such as appendicitis, renal colic, pyelonephritis, ectopic pregnancy, or even colitis, might have important clinical implications [22]. Ovarian torsion may just be the forecast in certain suspected situations because of the widespread nature of the presentations. If early laboratory and radiological testing are negative and the patient's discomfort persists, an assessment for ovarian torsion might be considered.
As many as 30% of torsion patients seem to have no soreness on examination, which may mistakenly deceive the practitioner [18]. Notwithstanding the discomfort, the proprioceptive exam has not even been proven to be very useful in ruling in or ruling out pelvic disease. In a prospective cohort study of 186 female patients with severe stomach pain, emergency doctors were graded entirely on their agreement among different results on the proprioceptive assessment. The existence or lack of palpable cervical movements' compassion, uterine tenderness, adnexal tenderness, adnexal masses, and uterine size were also considered [23]. On average, emergency physician interexaminer reliability for detecting pelvic burdens on proprioceptive exam was just 23%. A similar investigation discovered an inter-examiner remarkable concurrence on the existence of adnexal tenderness of just 32% [23]. The investigators did not discuss variations in emergency physicians' abilities to find adnexal hundreds of any particular size, which is a flaw in this study.
On proprioceptive inspection, gynecologists appear to go above and beyond when checking for adnexal burdens, discomfort, or other anomalies. Padilla et al. discovered in a 2000 study that independent of training level or comprehension, the responsiveness of identifying an adnexal mass > five cm by gynecological physical exam underneath anesthesia fluctuated from 15-36 percent, but the specificity increased 79-92 percent [24]. The significant predictive values varied from 26 to 69 percent. As a result, the researchers note that the sensitivity of a proprioceptive assessment to identify ovarian tumors more significant than five cm was extremely poor. Furthermore, regardless of skills or experience, the pelvic inspection somehow does not appear to be especially beneficial for diagnosing ovarian disease [24].
Even though ultrasonography appears to be superior to proprioceptive inspection, it has limits. Transvaginal ultrasonography with Doppler is the preferred standard step in the assessment of ovarian torsion [25]. However, ultrasonography is restricted by operator inconsistency, and it is designed to perceive non-gynecologic causes of lower abdominal pain [26]. Despite Doppler, ultrasound is not a perfect or distinct tool for identifying ovarian torsion [27]. Torsion cannot be ruled out entirely with recurrent Doppler arterial slide. This is presumably because twisting primarily creates lymphatic and venous blockage and subsequently disrupts arterial dispersion [28]. In a retrospective examination of 58 instances of ovarian torsion, 34 participants underwent sonography, and 26 of these individuals also had Doppler visualization [29]. Only 11% of those without Doppler scanning were accurately defined with torsion, but 81 percent of people with Doppler imaging were appropriately distinguished [29].
Patients diagnosed with ovarian torsion showed normal vascular perfusion among the 26 females assessed with Doppler imaging [29]. Ben-Ami et al. performed a prospective study on 65 nonpregnant women who had ultrasonography and, after that, laparoscopy [30]. Relying on laparoscopic results, 50 patients were free of torsion, whereas 15 were eventually diagnosed with ovarian torsion. All 15 patients had normal venous Doppler flow, but only five had periodic vascular progression. In this study, the highquality prediction fee for torsion in the lack of vascular slide was reported to be 94 percent [30].
Ordinarily, vascular displacement is affected first when torsion occurs. As a result, for some time, Doppler ultrasonography may discern peripheral arterial glide [31]. Doppler ultrasonography constraints in pregnant patients with ovarian torsion have also been observed [27]. A dynamical slip could be present in another few torsion patients due to periodic torsion, incomplete torsion, or the availability of additional blood flow via uterine artery collaterals [20].

CONCLUSIONS
Ovarian torsion is a rare yet life-threatening condition in females. To protect the efficacy of the ovaries and tubes and avoid excessive comorbidity, an initial diagnosis is required. Ovarian torsion is the total or partial twisting of the adnexal underpinning structure in the presence of hypoperfusion. It has the potential to affect females of all ages. Ovarian torsion develops in around 10% of patients who have had adnexal burdens surgically treated. An ovarian mass is the most common danger in ovarian torsion. The most typical sign of ovarian torsion seems to be a severe complication of pelvic agony accompanied by nausea and vomiting.

CONSENT
It is not applicable.

ETHICAL APPROVAL
It is not applicable.