Adnexal Torsion

GABRIEL OELSNER, MD* and DAVID SHASHAR, MDw

*Maaynei-Hayeshua Hospital, Bnei Brak, Israel; and
w Chaim Sheba Medical Center, Tel Hashomer, Tel-Aviv
University Sackler School of Medicine, Tel-Aviv, Israel
Abstract: This review provides timely information
concerning clinical, surgical, and pathologic findings
of adnexal torsion (AT). AT mostly occurs in the
child-bearing age group, but is not uncommon in
premenarchal girls or postmenopausal women. When
AT is suspected, urgent surgical intervention is
indicated, and is usually performed by laparoscopy.
Incidence of AT is 3.5% of all benign cystic
teratomas. Despite the necrotic appearance of
the twisted ischemic ovary, detorsion is the only
procedure which should be performed at surgery.
Adnexectomy should be avoided as ovarian function
is preserved in 88% to 100% of cases. Awareness and
suspicion of the diagnosis of AT is needed in patients
who present with lower abdominal pain.
Key words: torsion, adnexal, ovary, operative laparo-
scopy
Torsion of the ovary, tube, or both is
responsible for 2.7% of all gynecologic
emergencies.
1
Adnexal torsion (AT)
mostly occurs in the child-bearing age
group, but is not uncommon in preme-
narchal girls or postmenopausal women
(17.2% of cases).
2
AT usually presents as
a sudden, continuous, nonspecific pain in
the lower abdomen. Delay and misdiag-
nosis are rather common, and may result
in loss of the ovary, fallopian tube, or
both.
3
Isolated absence of the ovary or
fallopian tube may be the result of
undiagnosed previous AT.
46
Ultrasonic
findings and Doppler flow studies may
help to achieve diagnosis in addition to
the clinical symptoms.
7
When AT is suspected, urgent surgical
intervention is indicated, and is usually
performed by laparoscopy.
3,8
The etiology of AT is as yet unknown.
In most cases an ovarian tumor is
present. Torsion of a normal sized ovary
is extremely rare. Large and heavy
ovarian cysts such as benign cystic
teratoma or polycystic ovaries seem to
be prone to torsion. Comerci et al
9
reported an incidence of 3.5% torsions
in a series of 517 cases with benign cystic
teratomas. Houry et al found in a series
of 87 women with torsion 12 (13.7%) to
be pregnant.
Cysts smaller than 5 cm rarely cause
AT.
In cases of isolated fallopian tube,
torsion risk factors include hematosal-
pinx, hydrosalpinx, pregnancy, and
paraovarian cysts.
10,11
However, after pelvic inflammatory
disease and pelvic endometriosis, torsion
is rare owing to associated pelvic adhe-
sions, even if an endometrioma is present.
AT occurs because of the mobility of
both supporting pedicles, infundibulo-
pelvic, and ovarian ligaments. During
torsion, both pedicles are partially
459
Correspondence: Gabriel Oelsner, MD, Maaynei-
Hayeshua Hospital, Bnei Brak, Israel. E-mail:
goelsner@013.net.il
CLINICAL OBSTETRICS AND GYNECOLOGY / VOLUME 49 / NUMBER 3 / SEPTEMBER 2006
CLINICAL OBSTETRICS AND GYNECOLOGY
Volume 49, Number 3, 459463
r 2006, Lippincott Williams & Wilkins
strangulated causing impairment to
blood flow. Venous flow is the first to
be impaired, followed by compromized
arterial blood flow. This pathophysiol-
ogy leads to congestion, adnexal edema,
discolorization, ischemia, and necrosis.
12
The adnexal damage may be irreversible.
The ability to retain viability, despite
prolonged ischemia, as shown by
preservation of ovarian function, in
apparently severely injured ovaries, in-
dicates that complete arterial obstruction
does not usually occur. Some blood
supply is obtained from either the
ovarian or uterine arteries. The mis-
leading ischemic-hemorrhagic, black-
bluish appearance of the adnexa is a
result of venous and lymphatic stasis
rather than gangrene.
13
The duration of ischemia causing
irreversible damage is unknown.
The majority of patients with AT have
a delayed diagnosis. The time span from
the onset of symptoms to operation has
been reported to vary from hours to
several days.
2
It may be difficult to differentiate the
diagnosis of AT from other conditions
involving the lower abdomen. Awareness
and suspicion of the diagnosis are needed
to intervene as early as possible and
avoid irreversible ovarian damage.
The classical signs of AT include,
acute onset of lower abdominal pain
with peritonial irritation, and the pre-
sence of an adnexal mass.
Nausea and vomiting are quite
common occuring in 70% of patients.
Pyrexia may also be present.
2
Bouguizane et al
14
reported that
57.8% of patients were diagnosed accu-
rately at the first clinical examination in
their series.
Cohen et al
15
summarized 66 emer-
gency laparoscopies, performed for sus-
pected AT. AT was confirmed in 29
(44%) patients. It is our opinion that
although 56% of laparoscopies were
found to have no torsion, laparoscopy
should still be performed in all cases of
suspected torsion as delay in diagnosis
may result in loss of the ovary. It should
also be emphasized that the pain relief
often seen during observation may be the
result of perceptive nerve death and
tissue degeneration in the affected
ovary.
2,8
There are no specific laboratory find-
ings in AT. Although the white blood
count may be elevated, there is no
correlation between leukocyte count
and tissue necrosis.
Ultrasound scanning is important in
making a prompt diagnosis of AT. It is
usually the first imaging tool used in
evaluating pelvic pain.
Although there are no specific
ultrasonographic, computerized tomo-
graphic, or magnetic resonance imaging
findings in AT, in almost all cases a
pelvic mass is demonstrated.
12
Some
features have been described on compu-
terized tomography and magnetic reso-
nance imaging in the presence of torsion
such as fallopian tube thickening,
smooth wall thickening of the twisted
adnexal cystic mass, ascites, and uterine
deviation towards the twisted side.
16,17
Doppler flow studies have been in-
vestigated extensively. Reduced or even
absence of adnexal vascular flow is
suggestive of AT; however, the diagnosis
cannot be based solely on the absence or
presence of blood flow on color Doppler
sonography.
1822
If torsion is suspected, an emergency
laparoscopy should be performed to
establish the diagnosis and avoid ovarian
damage. Several studies
3,7
have shown
that estimation of the degree of necrosis
during surgery is inaccurate. Color, size,
and edema of the twisted ischemic
adnexa usually do not reflect the true
damage to ovarian tissue. Despite the
necrotic appearance of the twisted
ischemic ovary, detorsion is the only
procedure which should be performed.
Any additional procedure should be
460 Oelsner and Shashar
avoided. Careful manipulation of the
adnexa is mandatory. We try to use only
blunt tipped graspers during detorsion.
If the ovaries are hyperstimulated after
induction of ovulation, aspiration of
cysts might be warranted before detor-
sion. Adnexectomy should be avoided as
ovarian function is preserved in 88% to
100% of cases (Table 1).
Oelsner et al
13
in his series assessed
subsequent ovarian function by (a) ultra-
sound studies observing follicular devel-
opment, (b) the macroscopic appearance
of the adnexa at subsequent surgical
intervention, (c) fertilization of oocytes
retrieved during in vitro fertilization. The
latter is the ultimate proof that the
twisted ovary has recovered completely
(Table 2).
There is no need to extend the dura-
tion of operation to observe ovarian
reperfusion. The injured organ should
only be removed when there are obvious
signs of adnexal disruption such as
ligament detachment or ovarian tissue
decomposition.
Ovarian cystectomy during detorsion
of the black-bluish ischemic adnexal
should be avoided because: (a) handling
of the edematous friable and ischemic
adnexa is risky and may cause additional
damage to the ovary; (b) a high percen-
tage of the ovarian masses are functional
cysts, which should not be removed.
In Oelsner et al
13
series 58% of excised
cysts were found to be functional on
histology and, therefore, they should not
have been removed (Table 3). Patients
with true ovarian tumors should be
operated upon electively 4 to 6 weeks
later. In postmenopausal women, the
treatment of choice is bilateral oophor-
ectomy.
The assumption that detorsion of the
black-bluish adnexa is a dangerous
procedure, which may cause a throm-
boembolic event and should therefore be
avoided, is not borne out in the litera-
ture.
13,27,28
The incidence of pulmonary
emboli after AT is 0.2%. This incidence
is not increased after detorsion.
29
Recurrence of ovarian torsion is rare;
therefore, fixation of the ovary to the
pelvic wall is unnecessary as a routine
procedure,
30
especially as there is insuffi-
cient data on the effect of oophoropexy
on fertility. When repeat torsion occurs,
ovarian fixation is recommended, espe-
cially in patients with polycystic ovaries.
In these patients the heavy enlarged
ovaries are prone to retorsion. When
TABLE 1. Detorsion of Twisted Adnexa
and Subsequent Ovarian Func-
tion
Author No. Patients
Subsequent
Functioning
Ovaries
Mage et al
23
27 16/17 (94%)
Levy et al
24
3 3/3 (100%)
Shalev et al
25
58 49/52 (94%)
Pansky et al
26
8 7/8 (88%)
Oelsner et al
13
102 85/92 (91%)
Total 198 160/172 (93%)
TABLE 2. Preservation of Ovarian Func-
tion
13
Diagnostic Means
Proportion of Ovaries
Preserved
Ultrasound 85/92 (91.3%)
Subsequent surgery 13/14 (92.4%)
IVF 6/6 (100%)
IVF indicates in vitro fertilization.
TABLE 3. Histology of Cysts Excised at
Detorsion
13
Type of Cyst No.
Follicular 6
Corpus luteum 12
Dermoid 9
Serous cystadenoma 1
Mucinous cystadenoma 3
Total 31
Adnexal Torsion 461
fixation of the ovary is indicated 2 sutures
with nonabsorbable threads should be
used: 1 at the infundibulo-pelvic ligament
pole and the other at the ovarian ligament
pole. Both sutures should be applied to
the peritoneum of the adjacent pelvic
wall. Attention should be paid to the
location of the major pelvic vessels and to
the ureter.
In patients who have experienced tor-
sion with a functional ovarian cyst, oral
contraceptives are recommended. This to
avoid recurrence of a functional cyst,
which might predispose to repeat torsion.
Because of edema and enlargement of
the twisted adnexa, the pedicle of the
affected organ can be difficult to recog-
nize, and the direction of detorsion may
not be clear. In these cases, the surgeon
should try to twist the adnexa in both
directions usually the adnexa will more
easily turn in the proper direction.
In conclusion, awareness and suspicion
of the diagnosis of AT is needed in
patients who present with lower abdom-
inal pain associated with nausea, vomit-
ing, and presence of an adnexal mass. At
surgery, despite the necrotic appearance
of the twisted ischemic ovary, only detor-
sion should be performed and adnexect-
omy avoided, because ovarian function is
preserved in 88% to 100% of cases.
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