Review ArticleAdnexal Torsion: Review of the Literature
Section snippets
Risk Factors
Ovulation induction, ovarian hyperstimulation syndrome, history of adnexal torsion, polycystic ovarian syndrome, previous tubal ligation, and pregnancy have all been cited as risk factors for adnexal torsion [11]. The risk of torsion with ovarian hyperstimulation syndrome further increased with a successful pregnancy, from 2.3% to 16% in a retrospective study by Mashiach et al [12] of 201 hyperstimulated cycles. Pansky et al [5] demonstrated in a retrospective study that women who experienced a
Clinical Presentation
A thorough patient history and physical examination are key to making the diagnosis of adnexal torsion. The most common symptom in women with adnexal torsion is acute onset of abdominal pain (90% to 100%), usually isolated to one side 2, 6. This pain may be described as constant or intermittent because the ovary may torse and untorse over time and may have an onset with sudden change in position or activity. Sometimes these episodes of pain can occur for several days to months before admission,
Physical Examination
Adnexal torsion is a clinical diagnosis that can be supported with laboratory and imaging findings. The signs and symptoms can mimic those of several other diagnoses. Multiple studies have demonstrated the difficulty of correctly diagnosing adnexal torsion preoperatively, as the diagnosis is confirmed at laparoscopy in approximately only 10% to 44% of patients 1, 17, 18, 19.
Findings at physical examination include normal temperature to low-grade fever (18%) [6], slight tachycardia, and elevated
Laboratory Tests
A pregnancy test should be performed to rule out ectopic pregnancy, and a complete blood cell count and electrolyte values are usually determined. Most laboratory findings are normal, although a slight leukocytosis may be observed in 27% to 50% of patients 5, 6. The white blood cell count and C-reactive protein value are generally lower than in acute appendicitis [22]. Several serum markers have been studied to determine whether they can assist in making a preoperative diagnosis of adnexal
Imaging
Pelvic ultrasonography, with or without Doppler analysis, is the most commonly used imaging study to aid in the diagnosis of adnexal torsion. Ultrasonography is relatively inexpensive, free of ionizing radiation exposure, and widely available, but it is also user dependent. A transvaginal approach is most commonly used; in pregnant, young, or virginal patients, a transabdominal approach is acceptable, but it may limit visualization of the ovarian vessels [24]. Common findings include an ovarian
Treatment
Adnexal torsion is a surgical emergency, and the most common method of treatment is laparoscopy (Figs. 3 and 4). After placement of appropriate laparoscopic ports, the first general rule is to detorse the adnexa. It was previously thought that untwisting the torsed adnexa could cause showering of vascular emboli, and thus most torsion was managed by removing the adnexa [15] without untwisting it. This has been proved untrue. McGovern et al [34] demonstrated a pulmonary emboli risk of 0.2% in
Premenarchal Patients
Torsion in women of reproductive age generally involves an ovary enlarged because of a cyst; however, in premenarchal girls it includes a normal ovary 10, 36 in up to 50% of cases. Premenarchal girls will report the same symptoms as postmenarchal patients; however, imaging findings may not demonstrate an abnormal ovary. The incidence of adnexal torsion in children is approximately 2% [47], and, as in adults, the diagnosis is often difficult to make. One retrospective study of 49 cases found
Conclusion
Adnexal torsion is not uncommonly seen in the emergency department; however, for it to be correctly and efficiently diagnosed, it must remain in the differential diagnosis for all female patients with abdominal or pelvic pain. Acute onset of pain, nausea, and vomiting are the most common symptoms and signs. Ultrasound will often demonstrate a unilaterally enlarged ovary with a cyst, but this is not always the case, in particular in premenarchal girls. A high index of suspicion with a low
Acknowledgments
Dr. Miller has received grants and/or other support from Covidien; Femasys, Inc; Olympus Corp.; Novartis AG; AbbVie; Intuitive Surgical, Inc.; Ferring Pharmaceuticals; Ethicon, Inc.; Boston Scientific Corp; CareFusion Corp.; Hologic Corp.; Halt Medical, Inc.; OmniGuide, Inc.; Smith & Nephew plc; and Merck & Co., Inc.
We thank Dr. Aarathi Cholkeri-Singh for her invaluable assistance in the editing of this manuscript.
References (62)
- et al.
Adnexal torsion leading to death of an infant
J Pediatr Adolesc Gynecol
(2008) - et al.
Torsion of uterine adnexa in neonates and children: a report of 20 cases
J Pediatr Surg
(1991) - et al.
Adnexal torsion: a literature review
Eur J Obstet Gynecol Reprod Biol
(2010) - et al.
Cannot exclude torsion: a 15-year review
J Pediatr Surg
(2009) - et al.
Recurrence of ovarian torsion in a multiple pregnancy: conservative management via transabdominal ultrasound-guided ovarian cyst aspiration
Fertil Steril
(2010) - et al.
Adnexal torsion of hyperstimulated ovaries in pregnancies after gonadotropin therapy
Fertil Steril
(1990) - et al.
Comparison of adnexal torsion between pregnant and nonpregnant women
Am J Obstet Gynecol
(2010) - et al.
Accuracy of the preoperative diagnosis in 100 emergency laparoscopies performed due to acute abdomen in nonpregnant women
J Am Assoc Gynecol Laparosc
(2001) - et al.
Emergency laparoscopy for suspected ovarian torsion: are we too hasty to operate?
Fertil Steril
(2010) - et al.
Ovarian torsion: a fifteen-year review
Ann Emerg Med
(2001)
Novel serum inflammatory markers in patients with adnexal mass who had surgery for ovarian torsion
Fertil Steril
Adnexal torsion
Ultrasound Clin
Usefulness of Doppler sonography in the diagnosis of ovarian torsion
Fertil Steril
Adnexal torsion: cystectomy and ovarian fixation are equally important in preventing recurrence
Eur J Obstet Gynecol Reprod Biol
The effectiveness of spectral and color Doppler in predicting ovarian torsion
Eur J Obstet Gynecol Reprod Biol
Adnexal torsion: a report on forty-five cases
Eur J Obstet Gynecol Reprod Biol
Adnexal torsion in very young girls: diagnostic pitfalls
Eur J Obstet Gynecol Biol
Ovarian torsion: to pex or not to pex? Case report and review of the literature
J Pediatr Adolesc Gynecol
Prevention of recurrent adnexal torsion
Fertil Steril
Laparoscopic oophoropexy for the treatment of recurrent torsion of the adnexa in pregnancy: case report and review
Fertil Steril
Management of intermittent ovarian torsion by laparoscopic oophoropexy
Obstet Gynecol
Ovarian torsion diagnosis of inclusion mandates earlier intervention
J Pediatr Surg
Ovarian torsion: clinical imaging and presentation in children
J Pediatr Surg
Acute ovarian torsion in children
Am J Surg
Impact of surgeon specialty on ovarian-conserving surgery in females with an adnexal mass
J Adolesc Health
Maximizing ovarian salvage when treating idiopathic adnexal torsion
J Pediatr Surg
A prospective study of the role of ultrasound in the management of adnexal masses in pregnancy
BJOG
Predictors of persistence of adnexal masses in pregnancy
Obstet Gynecol
Risk analysis of torsion and malignancy for adnexal masses during pregnancy
Fertil Steril
The value of laparoscopy in acute pelvic pain
Ann Surg
Comprehensive Gynecology
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The authors report no conflicts of interest.