What is the treatment for a twisted ovarian cyst on the right side?

Treatment for Twisted Ovarian Cyst on the Right Side

Immediate surgical intervention is the standard treatment for a twisted ovarian cyst (adnexal torsion) as it is a gynecologic emergency requiring prompt action to preserve ovarian function and prevent severe morbidity. 1

Diagnostic Approach

Before proceeding to treatment, confirmation of the diagnosis is essential:

• Imaging: Transvaginal ultrasound (TVUS) is the first-line imaging modality for suspected adnexal torsion 2

  • Look for an asymmetrically enlarged ovary with or without an underlying mass
  • CT evaluation has 74-95% sensitivity and 80-90% specificity for adnexal torsion 2
  • MRI may be useful in specific cases but is not first-line

• Clinical presentation: Acute onset of pelvic pain is the most common symptom, often accompanied by nausea and vomiting 1

Treatment Algorithm

1. Emergency Surgery:

   • Laparoscopic approach is preferred for detorsion and management of the ovarian cyst 3
   • Surgery should be performed promptly to maximize ovarian preservation

2. Surgical Management Options:

   • Conservative approach (preferred in premenopausal women):

     • Detorsion of the adnexa
     • Cystectomy with ovarian preservation
     • This approach is particularly important for adolescents and women of reproductive age 4

   • Definitive approach:

     • Salpingo-oophorectomy if:
       • Tissue is clearly necrotic with no viable recovery
       • Patient is postmenopausal
       • Malignancy is suspected
       • Cyst is very large or complex

3. Specific Considerations:

   • Use of an impermeable bag for cyst removal to prevent spillage of contents 3
   • Assessment of the contralateral ovary during surgery
   • Evaluation for any anatomical factors that may have contributed to torsion

Important Clinical Considerations

• Historical practice change: Previously, oophorectomy was routinely performed for torsed ovaries, but current practice favors ovarian preservation when possible 4

• Risk factors: The main risk factor for ovarian torsion is the presence of an ovarian mass 1

• Potential complications:

  • Recurrent torsion (especially with paratubal cysts) 5
  • Loss of ovarian function if intervention is delayed
  • Peritonitis if cyst ruptures

• Anatomical challenges: Left-sided adnexal masses may present surgical challenges due to the overlying sigmoid colon, especially in post-hysterectomy patients 6

Follow-up Care

• Post-operative follow-up with pelvic ultrasound at 6-12 weeks
• Monitoring for recurrence, especially in cases where only detorsion was performed
• Consider hormonal contraception to prevent recurrent functional cysts in appropriate patients

Pitfalls to Avoid

1. Delayed diagnosis: Ovarian torsion is often misdiagnosed as appendicitis or gastroenteritis, delaying appropriate gynecologic referral 4

2. Needle aspiration: Fine-needle aspiration of ovarian masses is contraindicated as it may spread malignant cells if the cyst is malignant 2

3. Overlooking malignancy: While most twisted cysts are benign, appropriate preoperative assessment for malignancy markers should be performed when possible 6

4. Inadequate surgical approach: Failure to use appropriate techniques such as impermeable bags for cyst removal can lead to complications 3