Abstract
Adnexal torsion is the fifth most common gynecologic surgical emergency, requiring clinician and radiologist awareness. It involves the rotation of the ovarian tissue on its vascular pedicle leading to stromal edema, hemorrhagic infarction, and necrosis of the adnexal structures with the subsequent sequelae. Expedient diagnosis poses a difficult challenge because the clinical presentation is variable and often misleading. Adnexal torsion can mimic malignancy as it can take a subacute, intermittent, or chronic course, and thereby can be complicated to diagnose. The torsion may occur in the normal ovary but is usually secondary to a preexisting adnexal mass. Early surgery is necessary to avoid irreversible adnexal damage and to preserve ovarian function especially in children and young women. Pelvic ultrasound forms the foundation of diagnostic evaluation due to its ability to directly and rapidly evaluate both ovarian anatomy and perfusion. Moreover, it is a noninvasive and accessible technique. However, the color Doppler appearance of the ovary should not be relied upon to rule out torsion because a torsed ovary or adnexa may still have preserved arterial flow due to the dual blood supply. MR and CT may be used as problem-solving tools needed after the ultrasound examination but should not be the first-line imaging modalities in this setting due to ionizing radiation and potential time delay in diagnosis. The goal of this article is to review the adnexal anatomy, to familiarize radiologists with the main imaging features, and to discuss the main mimickers and the most common pitfalls of adnexal torsion.
Main points
-
Adnexal torsion is an uncommon gynecological disorder caused by partial or complete rotation of the ovary and/or the Fallopian tube about the infundibulopelvic ligament.
-
The ovaries receive a dual blood supply from the ovarian artery and uterine artery.
-
The lack of pathognomonic symptoms and specific findings on physical examination makes this entity difficult to diagnose. Since the right adnexa are most commonly involved, symptoms may mimic acute appendicitis.
-
Persistence of adnexal vascularization does not exclude torsion.
-
In the pediatric age group, gray-scale ultrasound is the best modality of choice. Obtaining CT and/or MR images should not delay treatment in order to preserve ovarian viability.
Similar content being viewed by others
References
Rha SE, Byun JY, Jung SE et al (2002) CT and MR imaging features of adnexal torsion. Radiographics 22(2):283–294
Rey-Bellet Gasser C, Gehri M, Joseph JM, Pauchard JY (2016) Is it ovarian torsion? A systematic literature review and evaluation of prediction signs. Pediatr Emerg Care 32(4):256–261
Huchon C, Fauconnier A (2010) Adnexal torsion: a literature review. Eur J Obstet Gynecol Reprod Biol 150(1):8–12
Pavlik EJ, DePriest PD, Gallion HH et al (2000) Ovarian volume related to age. Gynecol Oncol 77(3):410–412
Buy JN, Ghossain MA. Embryology, anatomy, and histology. In: Gynecological imaging. France, Springer, 2013; 57–66.
Hiller N, Appelbaum L, Simanovsky N, Lev-Sagi A, Aharoni D, Sella T (2007) CT features of adnexal torsion. AJR Am J Roentgenol 189(1):124–129
Warnock NG, Brown BP, Barloon TJ, Hemann LS (1994) Spontaneous detorsion of the ovary demonstrated by ultrasonography. J Ultrasound Med 13(1):57–59
Graziano A, Lo Monte G, Engl B, Marci R (2014) Recurrent ovarian torsion in a pregnancy complicated by ovarian hyperstimulation syndrome. J Minim Invasive Gynecol 21(5):723–724
Shalev J, Mashiach R, Bar-Hava I et al (2001) Subtorsion of the ovary: sonographic features and clinical management. J Ultrasound Med 20(8):849–854
Boyd CA, Riall TS (2012) Unexpected gynecologic findings during abdominal surgery. Curr Probl Surg 49(4):195–251
Chang HC, Bhatt S, Dogra VS (2008) Pearls and pitfalls in diagnosis of ovarian torsion. Radiographics 28(5):1355–1368
Deffieux X, Thubert T, Huchon C et al (2013) Complications of presumed benign ovarian tumors. J Gynecol Obstet Biol Reprod 42(8):816–832
Asfour V, Varma R, Menon P (2015) Clinical risk factors for ovarian torsion. J Obstet Gynaecol 35(7):721–725
Eftekhar Z, Rahimi-Moghaddam P, Yarandi F, Tahmasbi M (2005) An ovarian torsion in severe spontaneous ovarian hyperstimulation syndrome associated with a singleton pregnancy. J Obstet Gynaecol 25(4):393–394
Ginath S, Shalev A, Keidar R et al (2012) Differences between adnexal torsion in pregnant and nonpregnant women. J Minim Invasive Gynecol 19(6):708–714
Mashiach S, Bider D, Moran O, Goldenberg M, Ben-Rafael Z (1990) Adnexal torsion of hyperstimulated ovaries in pregnancies after gonadotropin therapy. Fertil Steril 53(1):76–80
Wan YL, Chen WJ, Chien CC, Lee TY, Tsai CC (1993) Ovarian dermoid cyst associated with tuberculosis, cystadenoma and torsion. J Formos Med Assoc 92(9):851–853
Kim YH, Cho KS, Ha HK et al (1999) CT features of torsion of benign cystic teratoma of the ovary. J Comput Assist Tomogr 23(6):923–928
Pinkert M, Klein Z, Tepper R, Beyth Y (2006) Hydrosalpinx with adnexal torsion in an adolescent virgin patient—a diagnostic dilemma: case report and review of the literature. J Pediatr Adolesc Gynecol 19(4):297–299
Sommerville M, Grimes DA, Koonings PP, Campbell K (1991) Ovarian neoplasms and the risk of adnexal torsion. Am J Obstet Gynecol 164(2):577–578
Lourenco AP, Swenson D, Tubbs RJ, Lazarus E (2014) Ovarian and tubal torsion: imaging findings on US, CT, and MRI. Emerg Radiol 21(2):179–187
Schuh AM, Klein EJ, Allred RJ, Christensen A, Brown JC (2016) Pediatric adnexal torsion: not just a postmenarchal problem. J Emerg Med 52(2):169–175
Van Der Zanden M, Nap A, van Kints M (2011) Isolated torsion of the fallopian tube: a case report and review of the literature. Eur J Pediatr 170(10):1329–1332
Spinelli C, Piscioneri J, Strambi S (2015) Adnexal torsion in adolescents: update and review of the literature. Curr Opin Obstet Gynecol 27(5):320–325
Aziz D, Davis V, Allen L, Langer JC (2004) Ovarian torsion in children: is oophorectomy necessary? J Pediatr Surg 39(5):750–753
Ozcan C, Celik A, Ozok G, Erdener A, Balik E (2002) Adnexal torsion in children may have a catastrophic sequel: asynchronous bilateral torsion. J Pediatr Surg 37(11):1617–1620
Chiou SY, Lev-Toaff AS, Masuda E, Feld RI, Bergin D (2007) Adnexal torsion: new clinical and imaging observations by sonography, computed tomography, and magnetic resonance imaging. J Ultrasound Med 26(10):1289–1301
Kupesic S, Plavsic BM (2010) Adnexal torsion: color Doppler and three-dimensional ultrasound. Abdom Imaging 35(5):602–606
Haque TL, Togashi K, Kobayashi H, Fujii S, Konishi J (2000) Adnexal torsion: MR imaging findings of viable ovary. Eur Radiol 10(12):1954–1957
Servaes S, Zurakowski D, Laufer MR, Feins N, Chow JS (2007) Sonographic findings of ovarian torsion in children. Pediatr Radiol 37(5):446–451
Sibal M (2012) Follicular ring sign: a simple sonographic sign for early diagnosis of ovarian torsion. J Ultrasound Med 31(11):1803–1809
Navve D, Hershkovitz R, Zetounie E, Klein Z, Tepper R (2013) Medial or lateral location of the whirlpool sign in adnexal torsion: clinical importance. J Ultrasound Med 32(9):1631–1634
Valsky DV, Cohen SM, Hamani Y, Lipschuetz M, Yagel S, Esh-Broder E (2009) Whirlpool sign in the diagnosis of adnexal torsion with atypical clinical presentation. Ultrasound Obstet Gynecol 34(2):239–242
Valsky DV, Esh-Broder E, Cohen SM, Lipschuetz M, Yagel S (2010) Added value of the gray-scale whirlpool sign in the diagnosis of adnexal torsion. Ultrasound Obstet Gynecol 36(5):630–634
Fleischer AC, Stein SM, Cullinan JA, Warner MA (1995) Color Doppler sonography of adnexal torsion. J Ultrasound Med 14(7):523–528
Ghossain MA, Buy JN, Bazot M et al (1994) CT in adnexal torsion with emphasis on tubal findings: correlation with US. J Comput Assist Tomogr 18(4):619–625
Beranger-Gibert S, Sakly H, Ballester M et al (2016) Diagnostic value of MR imaging in the diagnosis of adnexal torsion. Radiology 279(2):461–470
Ghossain MA, Hachem K, Buy JN et al (2004) Adnexal torsion: magnetic resonance findings in the viable adnexa with emphasis on stromal ovarian appearance. J Magn Reson Imaging 20(3):451–462
Jain KA (1995) Magnetic resonance imaging findings in ovarian torsion. Magn Reson Imaging 13(1):111–113
Kalstone CE, Jaffe RB, Abell MR (1969) Massive edema of the ovary simulating fibroma. Obstet Gynecol 34:564–571
Tavassoli FA, Devilee P. World Health Organization Classification of Tumours. Pathology and genetics. Tumours of the breast and female genital organs. Lyon: IARC Press; 2003 .p190.
Hall BP, Printz DA, Roth J (1993 May–Jun) Massive ovarian edema: ultrasound and MR characteristics. J Comput Assist Tomogr 17(3):477–479
Harmon JC, Binkovitz LA, Binkovitz LE (2008) Isolated fallopian tube torsion: sonographic and CT features. Pediatr Radiol 38(2):175–179
Kisku S, Thomas RJ (2013) An uncommon twist: isolated fallopian tube torsion in an adolescent. Case Rep Surg 2013:509424
Kousari YM, Pollock AN (2016) Isolated fallopian tube torsion with paraovarian cyst. Pediatr Emerg Care 32(11):817–819
Sun LT, Ning CP, Guo XJ, Li XY, Liu W, Tian JW (2014) Role of ultrasound in diagnosing isolated torsion of fallopian tube. J Obstet Gynaecol Res 40(1):208–214
Athanasias P, Doumouchtsis SK, Malick R, Croucher C (2013) Isolated fallopian tube torsion: a rare variant of a common entity with successful laparoscopic detorsion. J Obstet Gynaecol 33(3):318–319
Smith AL, Bieber EJ (2008) The diagnostic challenge of identifying isolated fallopian tube torsion: a case report of laparoscopic management. J Minim Invasive Gynecol 15(4):514–516
Kawahara Y, Fukuda T, Futagawa S et al (1996) Intravascular gas within an ovarian tumor: a CT sign of ovarian torsion. J Comput Assist Tomogr 20(1):154–156
Fujii S, Mukuda N, Nosaka K, Fukunaga T, Inoue C, Ogawa T (2016. Dec 22) The mechanism causing high-signal intensity on diffusion-weighted imaging in adnexal torsion: two case reports. Magn Reson Med Sci. https://doi.org/10.2463/mrms.cr.2016-0105.
Kilickesmez O, Tasdelen N, Yetimoglu B, Kayhan A, Cihangiroglu M, Gurmen N (2009) Diffusion-weighted imaging of adnexal torsion. Emerg Radiol 16(5):399–401
Fujii S, Kaneda S, Kakite S et al (2011) Diffusion-weighted imaging findings of adnexal torsion: initial results. Eur J Radiol 77(2):330–334
Kato H, Kanematsu M, Uchiyama M, Yano R, Furui T, Morishige K (2014) Diffusion-weighted imaging of ovarian torsion: usefulness of apparent diffusion coefficient (ADC) values for the detection of hemorrhagic infarction. Magn Reson Med Sci 13(1):39–44
Petkovska I, Duke E, Martin DR et al (2016) MRI of ovarian torsion: correlation of imaging features with the presence of perifollicular hemorrhage and ovarian viability. Eur J Radiol 85(11):2064–2071
Koonings PP, Grimes DA (1989) Adnexal torsion in postmenopausal women. Obstet Gynecol 73(1):11–12
Kim HS, Yoo SY, Cha MJ, Kim JH, Jeon TY, Kim WK (2016) Diagnosis of neonatal ovarian torsion: emphasis on prenatal and postnatal sonographic findings. J Clin Ultrasound 44(5):290–297
Hasiakos D, Papakonstantinou K, Kontoravdis A, Gogas L, Aravantinos L, Vitoratos N (2008) Adnexal torsion during pregnancy: report of four cases and review of the literature. J Obstet Gynaecol Res 34(4 Pt 2):683–687
Yilmaz E, Usal C, Kovanlikaya A, Karabay N (2001) Sonographic and MRI findings in prepubertal adnexal hemorrhagic cyst with torsion. J Clin Ultrasound 29(3):200–202
Swenson DW, Lourenco AP, Beaudoin FL, Grand DJ, Killelea AG, McGregor AJ (2014) Ovarian torsion: case-control study comparing the sensitivity and specificity of ultrasonography and computed tomography for diagnosis in the emergency department. Eur J Radiol 83(4):733–738
Mancuso A, Broccio G, Angio LG, Pirri V (1997) Adnexal torsion in pregnancy. Acta Obstet Gynecol Scand 76(1):83–84
Takeda A, Hayashi S, Teranishi Y, Imoto S, Nakamura H (2016) Chronic adnexal torsion: an under-recognized disease entity. Eur J Obstet Gynecol Reprod Biol 210:45–53
Neinstein LS, Braud BJ (1984) Coincident acute appendicitis and hemorrhagic corpus luteal cyst. J Adolesc Health Care 5(2):137–138
Dewhurst C, Beddy P, Pedrosa IMRI (2013) Evaluation of acute appendicitis in pregnancy. J Magn Reson Imaging 37(3):566–575
Jain KA (2002) Sonographic spectrum of hemorrhagic ovarian cysts. J Ultrasound Med 21(8):879–886
Levine D, Brown DL, Andreotti RF et al (2010) Management of asymptomatic ovarian and other adnexal cysts imaged at US Society of Radiologists in Ultrasound consensus conference statement. Ultrasound Q 26(3):121–131
Baltarowich OH, Kurtz AB, Pasto ME, Rifkin MD, Needleman L, Goldberg BB (1987) The spectrum of sonographic findings in hemorrhagic ovarian cysts. AJR Am J Roentgenol 148(5):901–905
Lamazou F, Legouez A, Letouzey V et al (2011) Ovarian hyperstimulation syndrome: pathophysiology, risk factors, prevention, diagnosis and treatment. J Gynecol Obstet Biol Reprod 40(7):593–611
Li W, Zhang Y, Cui Y, Zhang P, Pelvic WX (2013) Inflammatory disease: evaluation of diagnostic accuracy with conventional MR with added diffusion-weighted imaging. Abdom Imaging 38(1):193–200
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Conflict of interest
The authors declare that they have no conflict of interest.
Ethical statement
The authors declare that they comply with the mentioned ethical guidelines.
Financial disclosure statements
The authors report no financial interests.
Rights and permissions
About this article
Cite this article
Ssi-Yan-Kai, G., Rivain, AL., Trichot, C. et al. What every radiologist should know about adnexal torsion. Emerg Radiol 25, 51–59 (2018). https://doi.org/10.1007/s10140-017-1549-8
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s10140-017-1549-8