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 of Adnexal Torsion
Adnexal 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 of Adnexal Torsion
Clinical evaluation
Exploratory surgery to confirm
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. Other common causes of pelvic pain Pelvic Pain Pelvic pain is discomfort in the lower torso; it is a common complaint in women. It is considered separately from perineal pain, which occurs in the external genitals and nearby perineal skin... read more (eg, appendicitis Ectopic Pregnancy In ectopic pregnancy, implantation occurs in a site other than the endometrial lining of the uterine cavity—ie, in the fallopian tube, uterine cornua, cervix, ovary, or abdominal or pelvic cavity... read more , ectopic pregnancy Ectopic Pregnancy In ectopic pregnancy, implantation occurs in a site other than the endometrial lining of the uterine cavity—ie, in the fallopian tube, uterine cornua, cervix, ovary, or abdominal or pelvic cavity... read more , pelvic inflammatory disease Pelvic Inflammatory Disease (PID) Pelvic inflammatory disease (PID) is a polymicrobial infection of the upper female genital tract: the cervix, uterus, fallopian tubes, and ovaries; abscess may occur. PID may be sexually transmitted... read more , tubo-ovarian abscess Complications Pelvic inflammatory disease (PID) is a polymicrobial infection of the upper female genital tract: the cervix, uterus, fallopian tubes, and ovaries; abscess may occur. PID may be sexually transmitted... read more ) should be ruled out.
Clinical diagnosis of adnexal torsion is supported by imaging with transvaginal ultrasonography that shows an enlarged ovary or an ovarian mass. Color Doppler ultrasonography that shows decreased or absent blood flow in the ovary provides further support for the diagnosis.
If adnexal torsion is suspected, exploratory surgery is done immediately. The presence of a twisted ovary confirms the diagnosis.
Treatment of Adnexal Torsion
Surgery to salvage the ovary
If adnexal torsion is suspected, laparoscopy or laparotomy is done immediately to confirm the diagnosis and 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 Doppler transvaginal ultrasonography; follow immediately with exploratory surgery to confirm the diagnosis and treat it.
If adnexal torsion is diagnosed, 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, surgical removal (salpingo-oophorectomy, cystectomy) is required.
