B.25. Jinekolojik Kaynaklı Ağrılar (I): Over Torsiyonu ve Kist Rüptürü
Özet
Adneksiyel torsiyon ve over kist rüptürü, üreme çağındaki kadınlarda akut karın ağrısının önemli ve zamanla yarışılan jinekolojik nedenleri arasında yer almaktadır. Adneksiyel torsiyon, over ve sıklıkla tuba uterinanın vasküler pedikülü etrafında dönmesi sonucu venöz ve lenfatik akımın bozulmasıyla başlar; tedavi edilmediğinde arteriyel iskemi, infarkt ve over kaybına kadar ilerleyebilir. Tanı, nonspesifik klinik bulgular ve görüntüleme yöntemlerinin sınırlılıkları nedeniyle güçtür ve gecikmiş tanı fertilite kaybı ile ciddi medikolegal sonuçlara yol açabilmektedir. Over kist rüptürü ise çoğunlukla fonksiyonel kistlere bağlı gelişen, genellikle kendini sınırlayan ancak bazı olgularda masif hemoperitoneum ve hemodinamik instabiliteye neden olabilen bir acil durumdur. Her iki tablo da klinik olarak birbirini taklit edebilir ve ayırıcı tanı sürecinde ektopik gebelik, akut apandisit ve pelvik inflamatuar hastalıklar mutlaka dışlanmalıdır. Her iki klinik tanı da acil tedavi gerektiren klinik durumlarla karşımıza çıkabileceği gibi, konservatif izlem gerektiren klinik ile de prezente olabilir. Bu bölümde adneksiyel torsiyon ve over kist rüptürünün etiyoloji, epidemiyoloji, patofizyoloji, klinik bulgular, tanı yöntemleri, ayırıcı tanı, tedavi yaklaşımları ve özel durumları güncel literatür ışığında ele alınmış; erken tanının ve tedavide cerrahi ya da konservatif yönetim açısından uygun hastaların doğru şekilde seçilmesinin, over fonksiyonunun korunmasında kritik bir rol oynadığı vurgulanmıştır.
Adnexal torsion and ovarian cyst rupture are among the most important gynecological causes of acute abdominal pain in women of reproductive age and represent true time-sensitive emergencies. Adnexal torsion results from twisting of the ovary, often together with the fallopian tube, around its vascular pedicle, leading initially to venous and lymphatic obstruction and, if untreated, to arterial ischemia, infarction, and potential loss of ovarian function. Diagnosis is challenging due to nonspecific clinical findings and limitations of imaging modalities, and delayed diagnosis may result in infertility as well as significant medicolegal consequences. Ovarian cyst rupture, most commonly associated with functional cysts, is usually a self-limiting condition but may occasionally cause massive hemoperitoneum and hemodynamic instability requiring urgent surgical intervention. These two entities may present with overlapping clinical features and should be carefully differentiated from ectopic pregnancy, acute appendicitis, and pelvic inflammatory disease. Both clinical diagnoses may present as conditions requiring urgent treatment, or they may present with a clinical picture that warrants conservative management. ın this section, adnexal torsion and ovarian cyst rupture are discussed in light of the current literature with respect to their etiology, epidemiology, pathophysiology, clinical findings, diagnostic methods, differential diagnosis, management approaches, and special considerations. It is emphasized that early diagnosis and the appropriate selection of patients for either surgical or conservative management play a critical role in preserving ovarian function.
Referanslar
Asfour V, Varma R, Menon P. Clinical risk factors for ovarian torsion. J Obstet Gynaecol (Lahore). 2015 Oct 3;35(7):721–5. doi:10.3109/01443615.2015.1004524 PubMed PMID: 26212687.
Taufiq Dawood M, Naik M, Bharwani N, Sudderuddin SA, Rockall AG, Stewart VR. Adnexal torsion: Review of radiologic appearances. Radiographics. 2021;41(2):609–24. doi:10.1148/rg.2021200118 PubMed PMID: 33577417.
Robertson JJ, Long B, Koyfman A. Myths in the Evaluation and Management of Ovarian Torsion. J Emerg Med. 2017 Apr 1;52(4):449–56. doi:10.1016/j.jemermed.2016.11.012 PubMed PMID: 27988260.
Berek JS, Kraus L, Professor L, Berek DL. Berek & Novak’s Gynecology (Berek and Novak’s Gynecology) [Internet]. 2020. Report. Available from: https://lccn.loc.gov/2018052861
Cass DL. Ovarian torsion. Semin Pediatr Surg. 2005 May 1;14(2):86–92. doi:10.1053/j.sempedsurg.2005.01.003 PubMed PMID: 15846564.
Dasgupta R, Renaud E, Goldin AB, Baird R, Cameron DB, Arnold MA, et al. Ovarian torsion in pediatric and adolescent patients: A systematic review. J Pediatr Surg. 2018 Jul 1;53(7):1387–91. doi:10.1016/j.jpedsurg.2017.10.053 PubMed PMID: 29153467.
Chang-Patel EJ, Palacios-Helgeson LK, Gould CH. Adnexal torsion: A review of diagnosis and management strategies. Current Opinion in Obstetrics and Gynecology. Lippincott Williams and Wilkins; 2022. p. 196–203. doi:10.1097/GCO.0000000000000787 PubMed PMID: 35895961.
Canavan TP. Determining the right tool for diagnosing adnexal torsion. BJOG: An International Journal of Obstetrics and Gynaecology. Blackwell Publishing Ltd; 2021. p. 45. doi:10.1111/1471-0528.16374 PubMed PMID: 32570280.
Seyhan A, Korkut İU, Urman B. Autoamputation of the ovary after missed diagnosis of ovarian dermoid cyst torsion: a case report and review of literature. Journal of the Turkish German Gynecology Association. Galenos Publishing House; 2025. p. 304–8. doi:10.4274/jtgga.galenos.2025.2025-1-10
Hansen WF, Peacock AE, Yankowitz J. SAFE PRESCRIBING PRACTICES IN PREGNANCY AND LACTATION. J Midwifery Womens Health [Internet]. 2002. Report. Available from: www.fda.gov;
Gavriilidis P, de’Angelis N, Tobias A. To Use or Not to Use Opioid Analgesia for Acute Abdominal Pain Before Definitive Surgical Diagnosis? A Systematic Review and Network Meta-Analysis. J Clin Med Res. 2019;11(2):121–6. doi:10.14740/jocmr3690
Vargas-Schaffer G. Commentary Is the WHO analgesic ladder still valid? Canadian Family Physician • Le Médecin de famille canadien [Internet]. 2010. Report. Available from: www.cfp.ca
Senarath S, Ades A, Nanayakkara P. Ovarian cysts in pregnancy: a narrative review. Journal of Obstetrics and Gynaecology. Taylor and Francis Ltd.; 2021. p. 169–75. doi:10.1080/01443615.2020.1734781 PubMed PMID: 32347749.
Smorgick N, Pansky M, Feingold M, Herman A, Halperin R, Maymon R. The clinical characteristics and sonographic findings of maternal ovarian torsion in pregnancy. Fertil Steril. 2009 Dec;92(6):1983–7. doi:10.1016/j.fertnstert.2008.09.028 PubMed PMID: 18990375.
Balasubramaniam D, Duraisamy K, Ezhilmani M. Laparoscopic detorsion and fertility preservation in twisted ischemic adnexa - A single-center prospective study. Gynecol Minim Invasive Ther. 2020 Jan 1;9(1):24–8. doi:10.4103/GMIT.GMIT_20_19
Yasa C, Dural O, Bastu E, Zorlu M, Demir O, Ugurlucan FG. Impact of laparoscopic ovarian detorsion on ovarian reserve. Journal of Obstetrics and Gynaecology Research. 2017 Feb 1;43(2):298–302. doi:10.1111/jog.13195 PubMed PMID: 27928855.
Al Zahidy ZA. Causes and Management of Ovarian Cysts. Egypt J Hosp Med. 2018 Jan;70(10):1818–22. doi:10.12816/0044759
Kim JH, Lee SM, Lee JH, Jo YR, Moon MH, Shin J, et al. Successful conservative management of ruptured ovarian cysts with hemoperitoneum in healthy women. PLoS One. 2014 Mar 7;9(3). doi:10.1371/journal.pone.0091171 PubMed PMID: 24608424.
Journal of Clinical and Investigative Surgery [Internet]. doi:10.25083/2559-5555
Mobeen S, Apostol R. StatPearls Publishing. 2023. Ovarian Cyst.
Bottomley C, Bourne T. Diagnosis and management of ovarian cyst accidents. Best Pract Res Clin Obstet Gynaecol. 2009 Oct 1;23(5):711–24. doi:10.1016/j.bpobgyn.2009.02.001 PubMed PMID: 19299205.
Medvediev M V., Malvasi A, Gustapane S, Tinelli A. Hemorrhagic corpus luteum: Clinical management update. Turkish Journal of Obstetrics and Gynecology. Turkish Society of Obstetrics and Gynecology; 2020. p. 300–9. doi:10.4274/tjod.galenos.2020.40359
Katzung BG. Basic and Clinical Pharmacology. 15th ed. new york: McGraw-Hill Education; 2021.
Referanslar
Asfour V, Varma R, Menon P. Clinical risk factors for ovarian torsion. J Obstet Gynaecol (Lahore). 2015 Oct 3;35(7):721–5. doi:10.3109/01443615.2015.1004524 PubMed PMID: 26212687.
Taufiq Dawood M, Naik M, Bharwani N, Sudderuddin SA, Rockall AG, Stewart VR. Adnexal torsion: Review of radiologic appearances. Radiographics. 2021;41(2):609–24. doi:10.1148/rg.2021200118 PubMed PMID: 33577417.
Robertson JJ, Long B, Koyfman A. Myths in the Evaluation and Management of Ovarian Torsion. J Emerg Med. 2017 Apr 1;52(4):449–56. doi:10.1016/j.jemermed.2016.11.012 PubMed PMID: 27988260.
Berek JS, Kraus L, Professor L, Berek DL. Berek & Novak’s Gynecology (Berek and Novak’s Gynecology) [Internet]. 2020. Report. Available from: https://lccn.loc.gov/2018052861
Cass DL. Ovarian torsion. Semin Pediatr Surg. 2005 May 1;14(2):86–92. doi:10.1053/j.sempedsurg.2005.01.003 PubMed PMID: 15846564.
Dasgupta R, Renaud E, Goldin AB, Baird R, Cameron DB, Arnold MA, et al. Ovarian torsion in pediatric and adolescent patients: A systematic review. J Pediatr Surg. 2018 Jul 1;53(7):1387–91. doi:10.1016/j.jpedsurg.2017.10.053 PubMed PMID: 29153467.
Chang-Patel EJ, Palacios-Helgeson LK, Gould CH. Adnexal torsion: A review of diagnosis and management strategies. Current Opinion in Obstetrics and Gynecology. Lippincott Williams and Wilkins; 2022. p. 196–203. doi:10.1097/GCO.0000000000000787 PubMed PMID: 35895961.
Canavan TP. Determining the right tool for diagnosing adnexal torsion. BJOG: An International Journal of Obstetrics and Gynaecology. Blackwell Publishing Ltd; 2021. p. 45. doi:10.1111/1471-0528.16374 PubMed PMID: 32570280.
Seyhan A, Korkut İU, Urman B. Autoamputation of the ovary after missed diagnosis of ovarian dermoid cyst torsion: a case report and review of literature. Journal of the Turkish German Gynecology Association. Galenos Publishing House; 2025. p. 304–8. doi:10.4274/jtgga.galenos.2025.2025-1-10
Hansen WF, Peacock AE, Yankowitz J. SAFE PRESCRIBING PRACTICES IN PREGNANCY AND LACTATION. J Midwifery Womens Health [Internet]. 2002. Report. Available from: www.fda.gov;
Gavriilidis P, de’Angelis N, Tobias A. To Use or Not to Use Opioid Analgesia for Acute Abdominal Pain Before Definitive Surgical Diagnosis? A Systematic Review and Network Meta-Analysis. J Clin Med Res. 2019;11(2):121–6. doi:10.14740/jocmr3690
Vargas-Schaffer G. Commentary Is the WHO analgesic ladder still valid? Canadian Family Physician • Le Médecin de famille canadien [Internet]. 2010. Report. Available from: www.cfp.ca
Senarath S, Ades A, Nanayakkara P. Ovarian cysts in pregnancy: a narrative review. Journal of Obstetrics and Gynaecology. Taylor and Francis Ltd.; 2021. p. 169–75. doi:10.1080/01443615.2020.1734781 PubMed PMID: 32347749.
Smorgick N, Pansky M, Feingold M, Herman A, Halperin R, Maymon R. The clinical characteristics and sonographic findings of maternal ovarian torsion in pregnancy. Fertil Steril. 2009 Dec;92(6):1983–7. doi:10.1016/j.fertnstert.2008.09.028 PubMed PMID: 18990375.
Balasubramaniam D, Duraisamy K, Ezhilmani M. Laparoscopic detorsion and fertility preservation in twisted ischemic adnexa - A single-center prospective study. Gynecol Minim Invasive Ther. 2020 Jan 1;9(1):24–8. doi:10.4103/GMIT.GMIT_20_19
Yasa C, Dural O, Bastu E, Zorlu M, Demir O, Ugurlucan FG. Impact of laparoscopic ovarian detorsion on ovarian reserve. Journal of Obstetrics and Gynaecology Research. 2017 Feb 1;43(2):298–302. doi:10.1111/jog.13195 PubMed PMID: 27928855.
Al Zahidy ZA. Causes and Management of Ovarian Cysts. Egypt J Hosp Med. 2018 Jan;70(10):1818–22. doi:10.12816/0044759
Kim JH, Lee SM, Lee JH, Jo YR, Moon MH, Shin J, et al. Successful conservative management of ruptured ovarian cysts with hemoperitoneum in healthy women. PLoS One. 2014 Mar 7;9(3). doi:10.1371/journal.pone.0091171 PubMed PMID: 24608424.
Journal of Clinical and Investigative Surgery [Internet]. doi:10.25083/2559-5555
Mobeen S, Apostol R. StatPearls Publishing. 2023. Ovarian Cyst.
Bottomley C, Bourne T. Diagnosis and management of ovarian cyst accidents. Best Pract Res Clin Obstet Gynaecol. 2009 Oct 1;23(5):711–24. doi:10.1016/j.bpobgyn.2009.02.001 PubMed PMID: 19299205.
Medvediev M V., Malvasi A, Gustapane S, Tinelli A. Hemorrhagic corpus luteum: Clinical management update. Turkish Journal of Obstetrics and Gynecology. Turkish Society of Obstetrics and Gynecology; 2020. p. 300–9. doi:10.4274/tjod.galenos.2020.40359
Katzung BG. Basic and Clinical Pharmacology. 15th ed. new york: McGraw-Hill Education; 2021.
