ORIGINAL RESEARCH

Spectrums and Outcomes of Adnexal

Torsion at Different Ages
Jie-Ling Feng, MD, Ting Lei, MD, Hong-Ning Xie, PhD, Li-Juan Li, MD, Liu Du, MD

Objectives—To investigate the role of ultrasound in the preoperative diagnosis of

adnexal torsion and describe its histological spectrum and outcomes at different
ages.
Methods—This study comprised a retrospective investigation of a data set that
included 195 female patients with clinically suspected adnexal torsion between Janu-
ary 2010 and July 2015. Each patient received a detailed pelvic ultrasound examina-
tion by an experienced ultrasound examiner, and a definitive diagnosis was achieved
via surgery. The accuracy of an ultrasonic diagnosis of adnexal torsion was assessed.
The patients were divided into three groups: female children and adolescents, fertile
women, and postmenopausal women. The size, type, histological spectrum, and out-
come of adnexal torsion in the different groups were also described.
Results—The sensitivity, specificity, and accuracy of ultrasound were 0.84, 0.77, and
0.81, respectively. There were significant differences in the presence of ultrasonic
hallmarks among the true positive, false positive, and false negative cases of adnexal
torsion. Ovarian torsion was identified in 94 cases, and isolated tubal torsion was
identified in 15 cases. The most common histologic diagnoses of the pediatric group
and the other two groups were a normal ovary and teratoma, respectively. The most
common histologic diagnoses in the cases of isolated tubal torsion were mesosalpinx
cyst and oviduct inflammation.
Conclusions—Ultrasonography plays an important role in the preoperative diagno-
sis of adnexal torsion. Despite ovarian involvement in most of the cases, isolated ovi-
duct torsion was not uncommon. The spectrum of histological diagnoses varied
among the age groups.
Key Words—adnexal torsion; surgical treatment; ultrasonography

Received November 14, 2016, from the Depart-

ment of Ultrasonic Medicine, Fetal Medical
Center, First Affiliated Hospital of Sun Yat-sen
University, Guangzhou, Guangdong, China.
Manuscript accepted for publication November
28, 2016.
This study was supported by research
grant 81571687 from the National Scientific
Foundation Committee of China and grant
2014BAI06B05 from the National Science-
technology Support Plan Projects. J.-L.F. and
T.L. contributed equally to this work.
Address correspondence to Hong-Ning
Xie, PhD, Department of Ultrasonic Medicine,
Fetal Medical Center, First Affiliated Hospital
of Sun Yat-sen University, #58 ZhongShan Er
Road, Guangzhou 510080, Guangdong, China.
E-mail: hongning_x@126.com
doi:10.1002/jum.14225
A
dnexal torsion is defined as the twisting by at least one com-
plete turn of the ovary, or more rarely the tube alone, around
a centerline that consists of the infundibulopelvic ligament
and tubo-ovarian ligament.1 Thus, adnexal torsion includes either
ovarian torsion with or without fallopian tube, or isolated tubal tor-
sion. The estimated incidence of adnexal torsion is approximately 2.7
to 3.0%.2
Adnexal torsion is regarded as a gynecologic emergency.3
Female reproductive function is often affected if treatment is delayed
as a result of uncertainty in the diagnosis. The clinical symptoms of
adnexal torsion are nonspecific and include the sudden onset of
severe pelvic pain, nausea, vomiting, and a palpable adnexal mass.4
Pelvic ultrasonic examination is commonly performed before surgery;
however, the findings are nonspecific. The diagnosis of adnexal tor-
sion may only be confirmed by surgery. The accuracy of ultrasound
in the diagnosis of adnexal torsion confirmed at surgery varies

C 2017 by the American Institute of Ultrasound in Medicine | J Ultrasound Med 2017; 36:1859–1866 | 0278-4297 | www.aium.org
V
Feng et al—Spectrums and Outcomes of Adnexal Torsion
between 23 and 75% in different studies.2,5–8 The preop-
erative diagnosis of adnexal torsion remains a challenge.
Adnexal torsion can occur at all ages, but the peak
prevalence is in women of reproductive age.3 The most
common overall histologic diagnosis varied in different
studies.4,9–13 Furthermore, the spectrum of histologic
diagnosis of adnexal torsion at different ages has not
been thoroughly investigated. The histologic diagnosis
of adnexal torsion at different ages may be helpful to
improve the accuracy of diagnosis before operation.
The aim of this study was to investigate the role of
ultrasound in the preoperative diagnosis of adnexal tor-
sion, and describe its histological spectrum and out-
comes in different age groups.
Materials and Methods
This study consisted of a retrospective investigation of
data obtained for 195 female patients with clinically sus-
pected adnexal torsion at the First Affiliated Hospital of
Sun Yat-sen University, which is a multidisciplinary terti-
ary center that includes gynecology & obstetrics and
pediatrics, between January 2010 and July 2015. Each
patient received a detailed pelvic ultrasound examina-
tion, including the uterus and adnexa, by an experienced
sonographer, and a definitive diagnosis was achieved via
surgery. Each sonographer specialized in obstetrics and
gynecology and had at least 5 years of experience in per-
forming obstetric and gynecological ultrasonic diagnoses.
The study was approved by the institutional review
board of the First Affiliated Hospital of Sun Yat-sen
University.
The value of sonography in the diagnosis of adnexal
torsion was investigated via diagnostic testing. A cohort
of 109 surgically confirmed cases of adnexal cases was
divided into three groups by age. Group 1 included
female children and adolescents who were 18 years old
and younger14; Group 2 included fertile women who
were older than 18 years old and were not postmeno-
pausal; and Group 3 included postmenopausal women.
The types of adnexal torsion included ovarian torsion
with and without the fallopian tube (referred to as ovar-
ian torsion) and isolated tubal torsion. The size, type,
histological diagnosis, and outcome of adnexal torsion in
the different groups were described.
Sonography was performed using a transabdominal,
transvaginal, transrectal, or combined approach as appro-
priate using a GE Voluson730 Expert system with a 5-
1860
to 9-MHz transvaginal probe or an abdominal 4- to 8-
MHz probe (GE Healthcare, Kretztechnik, Zipf, Aus-
tria). A transabdominal/transrectal approach was per-
formed in virgin patients with consent by the individual
or her guardian, and a transvaginal approach was per-
formed in patients who were sexually active.
The ultrasonic hallmarks of adnexal torsion include
a unilateral ovarian enlargement (>4 cm) with or with-
out an ovarian mass (Figure 1) or adnexal mass; ovarian
edema with the presence of a hyperechogenic ovary and
peripherally displaced follicles with echogenic stroma
(Figure 1); abnormal adnexal position; free fluid in the
Douglas pouch; the absence of or decreased blood flow
in the ovary, as demonstrated using Doppler ultrasound
(Figure 1); and the presence of coiled, twisted, or circu-
lar (ie, “whirlpool”) vessels (Figure 2).15–17 Two of
these ultrasound criteria were required for a diagnosis of
adnexal torsion.
The sensitivity, specificity, positive predictive value,
negative predictive value, and accuracy of the ultrasound
were evaluated to determine its ability to diagnose ad-
nexal torsion. The ultrasonic characters in true positive,
false positive, and false negative cases of adnexal torsion
were compared using chi-square or Fisher’s exact tests.
The mean and standard deviation were calculated for all
measured data. The size of the torsed appendages were
compared among the different groups using analysis of
variance and the least-significant difference t-test. P val-
ues were considered statistically significant at P < .05.
Figure 1. Transabdominal sonogram indicating a unilateral ovary in
adnexal torsion. A, Enlarged ovary with ovarian edema. The ovary is
hyperechogenic. The ovarian blood flow decreases. B, Normal-
appearing contra lateral ovary.
J Ultrasound Med 2017; 36:1859–1866

Statistical analyses were performed using the statistical
software SPSS 13.0 for Windows (IBM Corp, Armonk,
NY).
Results
Of the 195 clinically suspected cases, 109 cases were
confirmed to be adnexal torsion during surgery. Of the
111 cases diagnosed as adnexal torsion by ultrasonogra-
phy, 91 cases agreed with the surgical findings, whereas
of the 84 cases not indicated to be adnexal torsion by
ultrasonography, 66 cases agreed with the surgical find-
ings. Thus, the sensitivity of the ultrasound was 0.84, the
specificity was 0.77, the positive predictive value was
0.82, the negative predictive value was 0.79, and the
overall accuracy was 0.81. The diagnoses of the false
positive cases included ovarian tumor (9 of 20), pelvic
inflammatory disease (4 of 20), heterotopic pregnancy
Figure 2. Transvaginal sonogram with a whirlpool sign, indicating the
presence of coiled, twisted, or circular vessels with Doppler.
Table 1. Ultrasound Findings in True Positive, False Positive, and False Negative Cases of Adnexal Torsion
True Positive
Ultrasound Findings Cases (91)
Unilateral ovarian enlargement/adnexal mass 91
Ovarian edema 50
Abnormal adnexal position 7 8
Free fluid in the pouch of Douglas 26
Absence/decreased of blood flow in the ovary 67
Whirlpool sign 63
a
Unilateral ovarian enlargement/adnexal mass occurred in all cases; therefore, no statistics were computed.
b
Comparisons were done using Fisher’s exact tests.
c
Comparisons were done using chi-square test.
J Ultrasound Med 2017; 36:1859–1866
Feng et al—Spectrums and Outcomes of Adnexal Torsion
(2 of 20), ovarian cyst rupture (2 of 20), corpus luteum
hemorrhage (2 of 20), and appendicitis (1 of 20). The
diagnoses of the true negative cases included ectopic
pregnancy (46 of 66), ovarian cyst rupture (13 of 66),
ovarian tumor (6 of 66), and tubal mesosalpinx cyst (1
of 66).
A unilateral ovarian enlargement/adnexal mass was
identified in all true positive (91), false positive (20),
and false negative (18) cases of adnexal torsion. There
were 50 true positive cases with ovarian edema; none of
the false positive and false negative cases had ovarian
edema. Abnormal adnexal positions in the true positive,
false positive, and false negative cases were identified in
7, 8, and 2 cases, respectively. Free fluid in the pouch of
Douglas in the true positive, false positive, and false neg-
ative cases was present in 26, 9, and 1 case(s), respec-
tively. The absence of or decreased blood flow in the
ovary in the true positive, false positive, and false nega-
tive cases occurred in 67, 10, and 9 cases, respectively.
The presence of coiled, twisted or circular (ie, whirl-
pool) vessels in the true positive, false positive, and false
negative cases occurred in 63, 8, and 1 case(s), respec-
tively. There were significant differences in the presence
of ultrasonic hallmarks with the exception of the unilat-
eral ovarian enlargement/adnexal mass among the true
positive, false positive, and false negative cases of adnexal
torsion (Table 1).
The 109 true cases of adnexal torsion were divided
into three groups. There were 19 (17.4%) cases in
Group 1 (female children and adolescents); 78 (71.6%)
cases in Group 2 (fertile women), including 19 cases
who were pregnant and 2 cases who induced abortion
within 1 week; and 12 (11.0%) cases in Group 3 (post-
menopausal women). The mean patient age, mean mass
size, torsion side, and torsion types of each group
are listed in Table 2. The mean age of all patients was
False Positive False Negative
Cases (20) Cases (18) P
20 18 —a
0 0 <.001b
2 .01b
9 1 .02c
10 9 .04c
8 1 <.001b
1861
Feng et al—Spectrums and Outcomes of Adnexal Torsion

29.8 6 14.9 years old. The average sizes of the twisted
mass among all patients and Groups 1, 2, and 3 were
96.4 6 35.3 mm, 77.2 6 33.0 mm, 95.5 6 34.0 mm,
and 119.3 6 37.3 mm, respectively. The difference in
the mean mass size was significant between Groups 1
and 3 as well as Groups 2 and 3, whereas the difference
between Groups 1 and 2 was not significant. There were
48 (44%) cases that twisted on the left, whereas 61
(56%) cases twisted on the right.
The two types of adnexal torsion included ovarian
torsion and isolated tubal torsion. Ovarian torsion was
identified in 94 (86%) patients. All of these cases had
combined ovarian and tubal torsion (Figure 3). Isolated
tubal torsion occurred in 15 (14%) patients. In Group 1,

Table 2. Patient Mean Age, Mean Mass Size, Torsion Side, and Torsion Types at Different Ages

Torsion Side Torsion Types

Group (N) Patient Age (Years) Mass Size (mm) Left Right Ovarian Torsion Tubal Torsion
Group 1 (19) 12.2 6 4.2 77.2 6 33.0 9 10 15 4
Group 2 (78) 29.4 6 8.8 95.5 6 34.0 34 44 67 11
Group 3 (12) 60.0 6 8.4 119.3 6 37.3 5 7 12 0
Total 29.8 6 14.9 96.4 6 35.3 48 61 94 15

Group 1, female children and adolescents; Group 2, fertile women; Group 3, postmenopausal women; ovarian torsion, ovarian torsion
with or without fallopian tube; tubal torsion, isolated tubal torsion.

Figure 3. Ovarian torsion occurring in a 9-year-old girl with severe pelvic pain for 19 hours. A, Transrectal sonogram with color Doppler indicating
an enlarged ovary with ovarian edema and decreased ovarian blood flow. B, Intra-operative findings confirming that the ovary was enlarged and
edematous. C, Transrectal sonogram with color Doppler indicating a torsed pedicle (whirlpool sign). D, Intra-operative findings confirming that
the ovary and tube twisted 7208.

1862 J Ultrasound Med 2017; 36:1859–1866


ovarian torsion was identified in 15 patients, whereas iso-
lated tubal torsion was identified in 4 patients. In Group
2, ovarian torsion was identified in 67 patients, whereas
isolated tubal torsion was identified in 11 patients. All
cases in Group 3 had ovarian torsion. There were no sig-
nificant differences in the torsion patterns among the
three groups.
The patients were subjected to laparotomy or lapa-
roscopy: Of the 65 cases treated via adnexectomy, which
removed the affected ovary and fallopian tube, 53 cases
were performed by laparotomy and 12 cases were per-
formed by laparoscopy; of the 9 cases treated via salpin-
gectomy, 3 cases were performed by laparotomy and 6
cases were performed by laparoscopy; of the 33 cases
treated via adnexa detorsion and tumorectomy, 19 cases
were performed by laparotomy and 14 cases were per-
formed by laparoscopy; moreover, 2 cases were treated
by adnexa detorsion via laparotomy. Thirty-five patients
were treated via conservative surgery that involved
adnexa detorsion with or without tumorectomy, and the
salvage rate of the ovary was 32% (35 of 109). Sixty-five
patients lost adnexa, and 9 patients lost the fallopian
tube. None of the patients experienced other postopera-
tive complications. The surgical procedures according to
age group are listed in Table 3. The average hospi-
talization times of all patients and Groups 1, 2, and 3
were 6.8 6 3.6, 5.8 6 1.9, 6.7 6 3.3, and 9.0 6 6.3
days, respectively.
The histological diagnoses were as follows in des-
cending order: teratoma (35 of 109) (Figure 4), normal
ovary (25 of 109), ovarian cyst (17 of 109), cystade-
noma (11 of 109), mesosalpinx cyst (9 of 109), oviduct
inflammation (6 of 109), sex cord stromal tumor (4 of
109), and cystadenocarcinoma (2 of 109). The most
common histological diagnoses of Groups 1, 2, and 3
were normal ovary, teratoma, and teratoma, respectively.
Table 3. Treatment of Adnexal Torsion at Different Ages
Operation
Laparotomy Adnexectomy
Salpingectomy
Adnexa detorsion and tumorectomy
Adnexa detorsion
Laparoscopy Adnexectomy
Salpingectomy
Adnexa detorsion and tumorectomy
Total
Group 1, female children and adolescents; Group 2, fertile women; Group 3, postmenopausal women.
J Ultrasound Med 2017; 36:1859–1866
Feng et al—Spectrums and Outcomes of Adnexal Torsion
The most common histologic diagnoses in cases of iso-
lated tubal torsion were mesosalpinx cyst (Figure 5) and
fallopian tubal inflammation. The histological diagnoses
according to age groups are summarized in Table 4.
Discussion
Adnexal torsion is a gynecologic emergency that involves
the suspensory ligament of the ovary within the broad
ligament, which contains the lymphatic vessels, veins,
arteries, and nerves that supply the adnexa.17 The differ-
ential diagnosis of adnexal torsion includes corpus
luteum hemorrhage/rupture, pelvic inflammatory dis-
ease, appendicitis, and ectopic pregnancy.5 A pre-
operative diagnosis is critical, because the complications
of a delayed diagnosis include the loss of the adnexa or
ovary, fatal thrombophlebitis, or peritonitis.18 Early and
precise ultrasonic diagnosis of adnexal torsion comprises
the basis of treatment. However, the concordance
between ultrasound and surgical diagnoses of adnexal
torsion varies widely and is predominately affected by
the ultrasound operator.2,5–8 In our study, we deter-
mined the presence of ultrasonic hallmarks varied, with
the exception of a unilateral ovarian enlargement/
adnexal mass, among the true positive, false positive, and
false negative cases of adnexal torsion. This finding sup-
ported that ultrasound examination plays an important
role in the preoperative diagnosis of adnexal torsion.
Ovarian edema was present in 50 true positive cases;
however, it was not present in the false positive or false
negative cases, which indicated that ovarian edema was a
reliable ultrasonic marker for adnexal torsion. We
obtained a high rate of agreement between ultrasound
examination and surgery for the diagnosis of adnexal tor-
sion as a result of the use of a specialized obstetrics and
Group 1 Group 2 Group 3 Subtotal
9 35 9 53
0 3 0 3
5 14 0 19
0 2 0 2
1 8 3 12
2 4 0 6
2 12 0 14
19 78 12 109
1863
Feng et al—Spectrums and Outcomes of Adnexal Torsion

gynecology ultrasound unit and a combination of sono-
graphic signs to indicate adnexal torsion.16,17
Adnexal torsion may occur at all ages. It has been
most frequently reported in women of reproductive age;
however, 15% of cases occur during childhood, and 15%
of cases occur during or after menopause.3 Our study
confirmed these findings that torsion occurred primarily
in women of reproductive age (71.6%), with 17.4% of
cases in children and adolescents and 11.0% of cases in
postmenopausal women. There were 19 cases of preg-
nant women, and 2 cases occurred within 1 week of an
induced abortion in our cohort, which supports the idea
that pregnancy is a risk factor for adnexal torsion.11,19
The mean size of the torsion mass in the postmeno-
pausal women was increased compared with the other
groups. Our data also indicated that the right side was
dominant in cases of adnexal torsion, likely because the
right utero-ovarian ligament is physiologically longer
than the left ligament or because of the presence of the
sigmoid on the left, which reduces the space needed for
torsion to occur.19–21
The twist may involve the ovarian ligament and sus-
pensory ligament, or it may twist around the Fallopian
tube.22 We identified two types in adnexal torsion, which
presented as ovarian torsion (with or without the fallo-
pian tube) or isolated fallopian tubal torsion without dis-
tortion of the ovary. In our study, 94 cases involved
ovarian torsion, and 15 cases consisted of isolated tubal
torsion. The tube often twists with the ovary22; thus, iso-
lated fallopian tube torsion is rare and has been reported
to occur at a rate of 1 in 1.5 million in previous studies.23
In our data, isolated oviduct torsion was not uncommon
and represented approximately 13.8% (15 of 109) of the
total torsion cases, despite the majority of ovarian tor-
sion. Ovarian torsion was approximately three times as
common as isolated oviduct torsion in female children

Figure 4. Ovarian torsion occurring in a 6-year-old girl who presented with severe pelvic pain for 3 days. A, Transabdominal sonogram indicating
an enlarged ovary with teratoma, and the ipsilateral residual ovary is edematous. B, Transabdominal sonogram with color Doppler indicating a
torsed pedicle (whirlpool sign). C, Intra-operative findings confirming that the ovary was enlarged and edema was present, and the ovary and
tube twisted 7208. D, Patient was treated via adnexa detorsion and tumorectomy.

1864 J Ultrasound Med 2017; 36:1859–1866

 Feng et al—Spectrums and Outcomes of Adnexal Torsion

and adolescents; moreover, ovarian torsion was six times
as common as isolated oviduct torsion in fertile women.
Interestingly, isolated oviduct torsion was not identified
in postmenopausal cases.
The most common histological diagnosis has varied
among studies and includes teratoma, cystadenoma, and
ovarian cyst.3,4,10,11 In our cohort, the most common
diagnosis was teratoma, followed by normal ovary, which
supports the idea that ovarian torsion is not only associ-
ated with pathological changes but may also occur in the
normal ovary.13 The histological diagnosis varied among
the age groups. In children and adolescents, the most
Figure 5. Isolated tubal torsion occurring in a 47-year-old woman
who presented with pelvic pain for 1 day. Transvaginal sonogram indi-
cates the ovary, tubal mesosalpinx cyst, and torsed pedicle (arrow-
heads indicate the whirlpool sign) with 3D render mode. Ova: ovary;
Cyst: mesosalpinx cyst.
common histodiagnosis included a normal ovary, which
is in contrast to previous studies that reported benign
cystic teratomas and hemorrhagic or follicular cysts as
common causes of torsion.24 Teratoma, followed by a
normal ovary, was the most common diagnosis in fertile
women. In postmenopausal cases, teratoma was the
most common histological type, and none of the cases
was associated with a normal ovary or isolated tubal
related diseases. Malignant adnexal tumor rarely co-
occurred with torsion25; only two patients in our cohort
exhibited cystadenocarcinoma torsion at a reproductive
age. An isolated tubal mesosalpinx cyst was one of the
most common causes of isolated fallopian tubal torsion,
which was the fifth most common histology in our
cohort.
An adnexectomy was conducted when the adnexa
appeared necrotic or did not appear viable after untwist-
ing the ischemic adnexa, as a general rule.1 Recently,
conservative surgery has been advocated, which typically
involves detorsion of the twisted ischemic adnexa and
ovarian tumorectomy to protect ovarian function.1,9,21
In our cohort, 35 patients were subjected to conservative
surgery, 9 patients underwent a salpingectomy, and the
remaining 65 cases, including all postmenopausal cases,
underwent an adnexectomy because the adnexa were
considered nonviable. Sixty-five patients lost adnexa, and
9 patients lost a fallopian tube. However, none of the
patients experienced other postoperative complications.
These findings suggest that an early preoperational ultra-
sound diagnosis and timely operation are necessary to
improve outcomes.
The limitations of our study include its retrospective
nature and the exclusion of patients not undergoing

Table 4. Histologic Diagnosis at Different Ages

Histologic Diagnosis (N) Group 1 Group 2 Group 3

Ovary (94) Teratoma (35) 5 24 6
Ovary (25) 6 19 0
Ovarian cyst (17) Simple cyst (11) 3 7 1
Hematoma (6) 0 6 0
Cystadenoma (11) Serous cystadenoma (4) 1 2 1
Mucinous cystadenoma (7) 0 6 1
Sex cord stromal tumor (4) Thecoma (2) 0 1 1
Thecofibroma (2) 0 0 2
Malignant tumor (2) Serous cystadenocarcinoma (2) 0 2 0
Fallopian Tube (15) Mesosalpinx cyst (9) 2 7 0
Fallopian tubal inflammation (6) 2 4 0
Total 19 78 12

Group 1, female children and adolescents; Group 2, fertile women; Group 3, postmenopausal women.

J Ultrasound Med 2017; 36:1859–1866 1865

Feng et al—Spectrums and Outcomes of Adnexal Torsion
surgery, which may result in the exclusion of patients
with adnexal torsion.
Despite these limitations, we conclude that ultraso-
nography performed by a specialized obstetrics and gyn-
ecology ultrasound unit plays an important role in the
preoperative diagnosis of adnexal torsion. Most adnexal
torsions occurred in women of reproductive age, and the
right side was dominant. Pregnancy was a risk factor for
adnexal torsion. Despite the involvement of the ovary in
most cases, isolated oviduct torsion was not uncommon.
The spectrum of histological diagnosis varied at different
ages.
References
1. Huchon C, Fauconnier A. Adnexal torsion: a literature review. Eur J
Obstet Gynecol Reprod Biol 2010; 150:8–12.
2. Mashiach R, Melamed N, Gilad N, Ben-Shitrit G, Israel Meizner.
Sonographic diagnosis of ovarian torsion accuracy and predictive fac-
tors. J Ultrasound Med 2011; 30:1205–1210.
3. Erdemoglu M, Kuyumcuoglu U, Guzel AI. Clinical experience of
adnexal torsion: evaluation of 143 cases. J Exp Ther Oncol 2011; 9:
171–174.
4. Nair S, Joy S, Nayar J. Five year retrospective case series of adnexal
torsion. J Clin Diagn Res 2014; 8:9–13.
5. Hibbard LT. Adnexal torsion. Am J Obstet Gynecol 1985; 152:456–
461.
6. Haskins T, Shull BL. Adnexal torsion: a mind-twisting diagnosis. South
Med J 1986; 79:576–577.
7. Argenta PA, Yeagley TJ, Ott G, Sondheimer SJ. Torsion of the uterine
adnexa. Pathologic correlations and current management trends.
J Reprod Med 2000; 45:831–836.
8. Bar-On S, Mashiach R, Stockheim D, Soriano D, Goldenberg M,
Schiff E, Seidman, DS. Emergency laparoscopy for suspected ovarian
torsion: are we too hasty to operate? Fertil Steril 2010; 93:2012–2015.
9. Erkal N, _Isenlik BS, Çaglar M, Sahillioglu B, Kumru S. Management
of adnexal torsion. J Clin Exp Invest 2014; 5:7–11.
10. Albayram F, Hamper UM. Ovarian and adnexal torsion: spectrum of
sonographic findings with pathologic correlation. J Ultrasound Med
2001; 20:1083–1089.
1866
11. Arab M, Tehranian A, Mohammadi AG, Hashemieh M. Review of
gray-scale ultrasonographic findings a valuble guide to suspect adexal
torsion. Pak J Med Sci 2010; 26:300–303.
12. Nur Azurah AG, Zainol ZW, Zainuddin AA, Lim PS, Sulaiman AS,
Ng BK. Update on the management of ovarian torsion in children
and adolescents. World J Pediatr 2015; 11:35–40.
13. Melcer Y, Sarig-Meth T, Maymon R, Pansky M, Vaknin Z, Smorgick
N. Similar but different: a comparison of adnexal torsion in pediatric,
adolescent, and pregnant and reproductive-age women. J Womens
Health (Larchmt) 2016; 25:391–396.
14. Poonai N, Poonai C, Lim R, Lynch T. Pediatric ovarian torsion: case
series and review of the literature. Can J Surg 2013; 56:103–108.
15. Valsky DV, Esh-Broder E, Cohen SM, Lipschuetz M, Yagel S. Added
value of the gray-scale whirlpool sign in the diagnosis of adnexal tor-
sion. Ultrasound Obstet Gynecol 2010; 36:630–634.
16. Chang HC, Bhatt S, Dogra VS. Pearls and pitfalls in diagnosis of ovar-
ian torsion. Radiographics 2008; 28:1355–1368.
17. Gerscovich EO, Corwin MT, Sekhon S, Runner GJ, Gandour-
Edwards RF. Sonographic appearance of adnexal torsion, correlation
with other imaging modalities, and clinical history. Ultrasound Q
2014; 30:49–55.
18. Bayer AI, Wiskind AK. Adnexal torsion: can the adnexa be saved? Am
J Obstet Gynecol 1994; 171:1506–1510; discussion 1510–1511.
19. Pena JE, Ufberg D, Cooney N, Denis AL. Usefulness of Doppler
sonography in the diagnosis of ovarian torsion. Fertil Steril 2000; 73:
1047–1050.
20. Warner MA, Fleischer AC, Edell SL, Thieme GA, Bundy AL, Kurtz
AB, James AE Jr. Uterine adnexal torsion: sonographic findings. Radi-
ology 1985; 154:773–775.
€
21. Ekin M, Yaşar L, Ozdemir IA, Idil S. The management of adnexal tor-
sion: ovaries can be saved by early diagnostic laparoscopy and detor-
sion. Med J Bakirk€oy 2011; 7:125–129.
22. Patil AR, Nandikoor S, Rao A, Janardan MG, Hari M, Basappa S.
Multimodality imaging in adnexal torsion. J Med Imaging Radiat Oncol
2015; 59:7–19.
23. Ferrera PC, Kass LE, Verdile VP. Torsion of the fallopian tube. Am J
Emerg Med 1995; 13:312–314.
24. Cass DL. Ovarian torsion. Semin Pediatr Surg 2005; 14:86–92.
25. Yildiz A, Erginel B, Akin M, et al. A retrospective review of the adnexal
outcome after detorsion in premenarchal girls. Afr J Paediatr Surg
2014; 11:304–307.
J Ultrasound Med 2017; 36:1859–1866