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Adnexal Torsion

By S. Gene McNeeley, MD, Clinical Professor;Chief of Gynecology, Center for Advanced Gynecology and Pelvic Health, Michigan State University, College of Osteopathic Medicine;Trinity Health

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Adnexal torsion is twisting of the ovary and sometimes the fallopian tube, interrupting the arterial supply and causing ischemia.

Adnexal torsion is uncommon, occurring most often during reproductive years. It usually indicates an ovarian abnormality.

Risk factors for adnexal torsion include the following:

  • Pregnancy

  • Induction of ovulation

  • Ovarian enlargement to > 4 cm (particularly by benign tumors)

Benign tumors are more likely to cause torsion than malignant ones. Torsion of normal adnexa, which is rare, is more common among children than adults.

Typically, one ovary is involved, but sometimes the fallopian tube is also involved. Adnexal torsion can cause peritonitis.

Symptoms and Signs

Torsion causes sudden, severe pelvic pain and sometimes nausea and vomiting. For days or occasionally weeks before the sudden pain, women may have intermittent, colicky pain, presumably resulting from intermittent torsion that spontaneously resolves. Cervical motion tenderness, a unilateral tender adnexal mass, and peritoneal signs are usually present.

Diagnosis

  • Color Doppler transvaginal ultrasonography

Adnexal torsion is suspected based on typical symptoms (ie, intermittent, severe pelvic pain) and unexplained peritoneal signs plus severe cervical motion tenderness or an adnexal mass. The pain may be unilateral.

Diagnosis of adnexal torsion is usually confirmed by color Doppler transvaginal ultrasonography.

Treatment

  • Surgery to salvage the ovary

If adnexal torsion is suspected or confirmed by ultrasonography, laparoscopy or laparotomy is done immediately to attempt to salvage the ovary and fallopian tube by untwisting them. Salpingo-oophorectomy is required for nonviable or necrotic tissue. If an ovarian cyst or mass is present and the ovary can be salvaged, cystectomy is done. Otherwise, oophorectomy is required.

Key Points

  • Adnexal torsion, which is uncommon, is more likely to result from benign tumors than from malignant ones.

  • Torsion causes sudden, severe pelvic pain and sometimes nausea and vomiting; it may be preceded by days or occasionally weeks of intermittent, colicky pain, presumably resulting from intermittent torsion.

  • Suspect adnexal torsion based on symptoms, and confirm by Doppler transvaginal ultrasonography.

  • Immediately attempt to salvage the ovary and fallopian tube by untwisting them via laparoscopy or laparotomy; if nonviable or necrotic tissue or an ovarian cyst or mass is present, surgery (salpingo-oophorectomy, cystectomy) is required.