Adnexal Torsion: Review of the Literature

doi:10.1016/j.jmig.2013.09.010

Journal of Minimally Invasive Gynecology

Volume 21, Issue 2, March–April 2014, Pages 196-202

https://doi.org/10.1016/j.jmig.2013.09.010 Get rights and content

Abstract

Adnexal torsion is one of a few gynecologic surgical emergencies. Misdiagnosis or delay in treatment can have permanent sequelae including loss of an ovary with effect on future fertility, peritonitis, and even death. A PubMed search was performed between 1985 and 2012 for reviews, comparative studies, and case reports to provide a review of the epidemiology, risk factors, clinical presentation, common laboratory and imaging findings, and treatments of adnexal torsion. Common symptoms of torsion include pain, nausea, and vomiting, with associated abdominal or pelvic tenderness, and may differ in premenarchal and pregnant patients. Laboratory and imaging findings including ultrasound with Doppler analysis, computed tomography, and magnetic resonance imaging can assist in making the diagnosis but should not trump clinical judgment; normal Doppler flow can be observed in up to 60% of adnexal torsion cases. Treatment depends on the individual patient but commonly includes detorsion, even if the adnexae initially seem necrotic, with removal of any associated cysts or salpingo-oophorectomy, because recurrence rates are higher with detorsion alone or detorsion with only cyst aspiration.

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.

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Review ArticleAdnexal Torsion: Review of the Literature

Abstract

Section snippets

Risk Factors

Clinical Presentation

Physical Examination

Laboratory Tests

Imaging

Treatment

Premenarchal Patients

Conclusion

Acknowledgments

J Pediatr Adolesc Gynecol

J Pediatr Surg

Eur J Obstet Gynecol Reprod Biol

J Pediatr Surg

Fertil Steril

Fertil Steril

Am J Obstet Gynecol

J Am Assoc Gynecol Laparosc

Fertil Steril

Ann Emerg Med

Fertil Steril

Ultrasound Clin

Fertil Steril

Eur J Obstet Gynecol Reprod Biol

Eur J Obstet Gynecol Reprod Biol

Eur J Obstet Gynecol Reprod Biol

Eur J Obstet Gynecol Biol

J Pediatr Adolesc Gynecol

Fertil Steril

Fertil Steril

Obstet Gynecol

J Pediatr Surg

J Pediatr Surg

Am J Surg

J Adolesc Health

J Pediatr Surg

BJOG

Obstet Gynecol

Fertil Steril

The value of laparoscopy in acute pelvic pain

Ann Surg

Comprehensive Gynecology

Review Article
Adnexal Torsion: Review of the Literature