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:
- 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 (eg, appendicitis, ectopic pregnancy, pelvic inflammatory disease, tubo-ovarian abscess) 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.
- 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.