{"paper_id":"d158b1ce-3deb-47cf-a087-8d5eaae22814","body_text":"Case Report\nVolume 9 Issue 3 -  January   2023\nDOI:  10.19080/GJORM.2023.09.555762\nGlob J Reprod Med\nCopyright © All rights are reserved by Aziz Slaoui\nTorsion of an Ovarian Endometrioma:  \nAbout an Uncommon Case Report\nMahtate M1, Slaoui A²*,  Lakhder K1, Najia Zeraidi1, Lakhdar A1, Kharbach A² and Baydada A1\n1Department of Gynecology-Obstetrics and Endoscopy, Maternity Souissi, University Hospital Center IBN SINA, University Mohammed V, Rabat, Morocco\n2Department of Gynecology-Obstetrics and Endocrinology, Maternity Souissi, University Hospital Center IBN SINA, University Mohammed V, Rabat, \nMorocco\nSubmission: December 12, 2022; Published: January  06, 2023\n*Corresponding author: Aziz Slaoui, Department of Gynaecology-Obstetrics and Endocrinology, University Hospital Center IBN SINA, Mohammed \nV of Rabat, Morocco\nGlob J Reprod Med 9(3): GJORM.MS.ID.555762 (2023)  001\nIntroduction\nTorsion of endometriomas is uncommon due to associated \npelvic adhesions [1]. Nevertheless, it constitutes the fifth \ngynecological emergency [2]. We report an interesting case of a \n35-year-old patient; who presented to our department for acute \npelvic pain; To our knowledge, our patient had no particular \nmedical or surgical history; gynecological examination and the \nultrasound was in favor of a torsion of a huge ovarian cyst; the \ntreatment was surgical with the realization of a conservative \ntreatment: detorsion and cystectomy. The histological examination \ncame back in favor of an endometrioma.\nCase Report\nA 35-year-old woman presented to our emergency department \ncomplaining of acute pelvic pain associated with vomiting for \nthe last five hours which responded poorly to the analgesics .no \nvaginal bleeding or discharge was present. She had no relevant \nmedical or surgical history G3P3. \n In our physical examination, the patient was conscious,  \n \nthere was no notion of digestive transit disorders, nor \nmicturition disorders. The abdomen was tender to palpation. The \ngynecological examination was unremarkable. The clinical picture \nwas mainly dominated by acute pelvic pain in a patient with no \nparticular history.\nGiven the urgency, we immediately performed an ultrasound \ncoupled with Doppler of the abdomen objectifying a left ovarian \ncyst measuring 12 cm in diameter (Figure 1). However, torsion \nwas not excluded. There was neither leukocytosis nor raised CRP . \nBHCG was negative.\nLaparotomy was performed. Intraoperative findings revealed a \nlarge cystic arising from the left ovary; it was around 12 cm in size. \nThere was torsion of this cyst on its pedicle by two turns (Figure \n2), the right ovary was normal. the detorsion and cystectomy was \nperformed (Figure 3). Thereafter. The histology report described \nan endometrioma with extensive hemorrhagic.\nThe postoperative period was uneventful, and the patient was \ndischarged from the hospital 3 days after surgery.\nAbstract \nEndometrioma, when its size is ≥ 5 cm, can be complicated by a torsion of the ovary. In this case it is a diagnostic and therapeutic emergency with \nrespect to the many complications of ovarian torsion including necrosis.\nWe report a case of endometrioma diagnosed by a torsion of the ovary. The context clinic was dominated by acute pelvic pain; the ultrasound \nshowed a huge left cystic ovary, and the laparotomy revealed a torsion of the left adnexa. A detorsion and cystectomy was performed and the \nconfirmation of the endometrioma was provided by the histology of the surgical specimen.\nThe difficulty lies in the diagnostic and therapeutic choice to preserve or not the ovary. The indications are therefore discussed on a case-by-case \nbasis and depend on many parameters, the most important of which is the intraoperative viability of the ovary after its detorsion.\n\nHow to cite this article: Mariam M, Aziz S, Khawla L, Najia Z, Amina L, et al. Torsion of an Ovarian Endometrioma: About an Uncommon Case Report. \nGlob J Reprod Med. 2023; 9(3): 555762. DOI: 10.19080/GJORM.2022.09.555762002\nGlobal Journal of Reproductive Medicine\nFigure 1: Ultrasonographic appearance of endometrioma\nFigure 1: The torsion of the endometrioma on its pedicle\nFigure 3: Intraoperative image of the cystic mass after cystectomy.\n\n\nHow to cite this article: Mariam M, Aziz S, Khawla L, Najia Z, Amina L, et al. Torsion of an Ovarian Endometrioma: About an Uncommon Case Report. \nGlob J Reprod Med. 2023; 9(3): 555762. DOI: 10.19080/GJORM.2022.09.555762003\nGlobal Journal of Reproductive Medicine\nDiscussion\nEndometrioma is one of the most frequent localizations \nof endometriosis.  According to the theory of Hughesdon and \nBroosens, the endometriosis cyst is formed either from an \nendometrial implant in the ovarian fossa, or from an inversion and \ninvagination of the ovarian cortex. This cyst can grow and reach a \nsize of 5 cm at most [2] rarely exceeds 10–15 cm in diameter [1].\nTheoretically, the most common cysts associated with torsion \nare cystic teratomas and cystadenomas, accounting for 60% and \n30% of all cases, respectively [4]. Ovarian endometrioma are less \nlikely to twist because of accompanying adhesions [1].\nThe clinical diagnosis of ovarian torsion is difficult to establish. \nAbdominal pain is the ubiquitous symptom in all cases of ovarian \ntorsion [3]. The onset of this pain is often sudden and localized \n[4]. But it can have extremely different characteristics [3,5]. \nIndeed, pain can occur intermittently before the torsion, which \ncorresponds to phenomena of torsion detorsion of the ovary \n[4,5]. The clinical picture presented by our patient was essentially \ndominated by acute pelvic pain.\nTorsion of an endometrioma is a diagnostic and therapeutic \nemergency. Indeed, torsion of the ovarian pedicle is responsible \nfor ischemia and then edema of the ovary which, untreated, \nprogresses to ovarian necrosis, thrombophlebitis, hemorrhage \nand, in extreme cases, peritonitis [6].\nThe typical appearance of torsion in ultrasound is manifested \nby unilateral ovarian enlargement with edema and peripheral \narrangement of the follicles [7]. The presence of a spiral pattern \nhas been shown to increase the sensitivity of the examination \n[8]. The absent arterial flow on Doppler is associated with 100% \nof cases of torsion [9]. However, this sign has a low negative \npredictive value since the complete absence of flow is only visible \nin the late phase. MRI has shown a higher sensitivity for detecting \na pelvic mass than ultrasonography [10].\nIn our case, the ultrasound showed an ovarian cyst without \nobjectifying the intra cystic vascular changes. The rapidity of the \ndiagnosis allowed management and the conversative treatment \nbefore the onset of complications. \nAlthough endometriomas are usually a benign entity, there is \na 1% rate of malignant transformation. Endometrioid tumors of \nthe ovary and clear cell ovarian carcinomas are the most common \nhistological patterns seen [11,12].\nEndometrioma, particularly in cases of torsion, raises the \nissue of whether the ovary is preserved. The therapeutic choice is \nguided by age, parity, ovarian reserve, cyst size, history of ovarian \nsurgery and ovarian viability [1]. The European Society of Human \nReproduction and Embryology (ESHRE) and other authors \nrecommend laparoscopic cystectomy for an endometrioma ≥ 4 cm \n[1,2].  \nTo maintain fertility, conservative surgery should be favored. \nDetorsion and cystectomy is the gold standard management. In all \ncases, it is recommended to combine a GnRH analogue with the \nchosen treatment [13]. This helps to contain endometriosis and \nprevent recurrences.\nConclusion\nAdnexal torsion induced by endometrioma has rarely \nbeen reported. Due to associated pelvic adhesions. However, it \nconstitutes the fifth gynecological emergency. It is important to be \naware of the possibility of adnexal torsion in all patients of all ages \npresenting with acute pelvic pain, as it can have consequences for \npotential fertility if not treated promptly. The therapeutic choices \nare discussed on a case-by-case basis and depends on many \nparameters, the most important of which is the intraoperative \nviability of the ovary after its detorsion.\nGuarantor of Submission\nThe corresponding author is the guarantor of submission.\nFunding\nThere are no funding sources to be declared.\nAvailability of Data and Materials\nSupporting material is available if further analysis is needed.\nCompeting Interests\nThe authors declare that they have no competing interests.\nConsent for Publication\nWritten informed consent was obtained from the patient for \npublication of this case report and any accompanying images. A \ncopy of the written consent is available for review by the Editor-\nin-Chief of this journal.\nEthics Approval and Consent to Participate\nEthics approval has been obtained to proceed with the current \nstudy. Written informed consent was obtained from the patient for \nparticipation in this publication.\nReferences\n1 Clement PB (1994) Diseases of the peritoneum. In: Kurman RJ (Edn) \nBlaustein’s pathology of the female genital tract, 4th edn. Springer, New \nYork, pp 664–667.\n2 Huang C, Hong MK, Ding DC (2017) A review of ovary torsion. Tzu Chi \nMed J 29: 143-147.\n3 Sasaki KJ and Miller CE (2014) Adnexal torsion: review of the literature. \nJ Minim Invasive Gynecol 21(2): 196–202.\n4 Rousseau V, Massicot R, Darwish AA, Sauvat F, Emond S, et al. (2008) \nEmergency management and conservative surgery of ovarian torsion \nin children: a report of 40 cases. J Pediatr Adolesc Gynecol 21(4): 201-\n206.  \n\nHow to cite this article: Mariam M, Aziz S, Khawla L, Najia Z, Amina L, et al. Torsion of an Ovarian Endometrioma: About an Uncommon Case Report. \nGlob J Reprod Med. 2023; 9(3): 555762. DOI: 10.19080/GJORM.2022.09.555762004\nGlobal Journal of Reproductive Medicine\n5 Cass DL (2005) Ovarian torsion. Semin Pediatr Surg 14(2): 86-92.\n6 Zengyan Wang, Dan Zhang, Huanxiao Zhang, Xu Guo, Jingxuan Zheng, et \nal. (2019) Medicine 98: 5e14321.\n7  Shadinger LL, Andreotti RF, Kurian RL (2008) Preoperative \nsonographic and clinical characteristics as predictors of ovarian \ntorsion. J Ultrasound Med Off J Am Inst Ultrasound Med 27(1): 7-13. \n8 Nizar K, Deutsch M, Filmer S, Weizman B, Beloosesky R, et al. (2009) \nDoppler studies of the ovarian venous blood flow in the diagnosis of \nadnexal torsion. J Clin Ultrasound JCU 37(8): 436-439. \n9 Peña JE, Ufberg D, Cooney N, Denis AL (2000) Usefulness of Doppler \nsonography in the diagnosis of ovarian torsion. Fertil Steril 73(5): \n1047-1050.\n10 Noventa M, Scioscia M, Schincariol M, Cavallin F, Pontrelli G, et al. (2019) Imaging \nModalities for Diagnosis of Deep Pelvic Endometriosis: Comparison between \nTrans-Vaginal Sonography, Rectal Endoscopy Sonography and Magnetic \nResonance Imaging. A Head-to-Head Meta-Analysis. Diagnostics (Basel, \nSwitzerland) 9(4): 225.\n11  Liang H, Li Y and Li T (2007) Torsion and rupture of ovarian chocolate \ncyst in full-term pregnancy: a case report. Medical Journal of National \nDefending Forces in Northwest China 5: 395.\n12 Jones J, Anan R, Rasuli B, et al. (2022) Endometrioma. Reference article, \nRadiopaedia.org.\n13 Selak V, Farquhar C, Prentice A, Singla A (2007) Danazol for pelvic \npain associated with endometriosis. 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