Adnexal torsion, a critical gynecological emergency, refers to the twisting of the adnexa – the ovary and fallopian tube – around its supporting ligaments. This twisting obstructs the blood supply to the adnexa, leading to ischemia, pain, and potentially infarction and necrosis if not promptly addressed. While relatively uncommon, its potential for devastating consequences, including loss of ovarian function and fertility, necessitates a thorough understanding of its presentation, diagnostic challenges, and management principles.
Symptoms and Signs of Adnexal Torsion
The clinical presentation of adnexal torsion can be highly variable and often mimics other acute abdominal conditions, making timely and accurate diagnosis a significant challenge. The hallmark symptom is typically sudden-onset, severe, unilateral lower abdominal pain. This pain is often described as sharp, stabbing, or colicky, and it may be intermittent or constant. Unlike other causes of pelvic pain, the pain in adnexal torsion is generally abrupt in onset, often occurring without prodromal symptoms. However, some patients may report a dull, intermittent pain for days or weeks prior to the acute event, suggesting partial or intermittent torsion.
Nausea and vomiting are also very common, occurring in approximately 70% of cases. These symptoms are secondary to the intense visceral pain and peritoneal irritation. The emesis can be persistent and may be projectile, further contributing to patient distress and dehydration.
Abdominal distension may be present, particularly if there is significant fluid accumulation (ascites) secondary to ovarian compromise or if the bowel becomes distended due to sympathetic reflex ileus.
Fever is not a typical early sign of adnexal torsion but can develop later if infarction, necrosis, or superimposed infection occurs.
Abnormal vaginal bleeding, such as intermenstrual spotting or heavier than usual menstrual bleeding, can occur in some cases, especially if the underlying adnexal mass is hormonally active or if the torsion disrupts the normal hormonal regulation. However, this is not a consistent or primary symptom.
On physical examination, key findings may include:
- Tenderness: Palpation of the abdomen will usually reveal significant tenderness, predominantly in the lower quadrant ipsilateral to the torsed adnexa. Rebound tenderness and guarding may be present, indicating peritoneal irritation.
- Abdominal Mass: A palpable adnexal mass can be detected in approximately 50-70% of cases, especially if the mass is large or if the patient is thin. This mass may be tender to palpation.
- Cervical Motion Tenderness: This is a frequent finding and can be elicited during a pelvic examination. The examiner’s manipulation of the cervix causes pain in the affected adnexal region.
- Adnexal Tenderness: Direct palpation of the adnexa during a bimanual pelvic examination will typically reveal marked tenderness and potentially a palpable, enlarged, and tender adnexal mass.
- Vital Signs: While patients may appear distressed with normal vital signs early on, in more advanced cases or with significant pain, tachycardia and hypotension (secondary to hypovolemia from vomiting or pain) can be observed.
It is crucial to recognize that the absence of a palpable mass or classic physical examination findings does not rule out adnexal torsion, especially in cases of smaller masses or when significant edema obscures palpation. The history of sudden, severe, unilateral pelvic pain remains the most sensitive indicator.
Diagnosis of Adnexal Torsion
The diagnosis of adnexal torsion relies on a combination of clinical suspicion, imaging studies, and, in some cases, surgical exploration. Due to the non-specific nature of many symptoms, a high index of suspicion is paramount.
1. Clinical Suspicion and History: As discussed above, the sudden onset of severe, unilateral lower abdominal pain, often accompanied by nausea and vomiting, should immediately raise suspicion for adnexal torsion. A detailed history, including the onset, character, and duration of pain, associated symptoms, and menstrual history, is essential.
2. Laboratory Investigations: While laboratory tests are not diagnostic of adnexal torsion, they can help rule out other conditions and assess for complications.
- Complete Blood Count (CBC): A mild leukocytosis (elevated white blood cell count) may be present, reflecting inflammation or stress, but it is not specific.
- Urinalysis: This is crucial to rule out urinary tract infections, kidney stones, and other urological causes of abdominal pain.
- Pregnancy Test: A urine or serum pregnancy test is essential in all women of reproductive age to exclude ectopic pregnancy, which can present with similar symptoms.
- Sexually Transmitted Infection (STI) Testing: If pelvic inflammatory disease (PID) is suspected, urethral and cervical swabs for gonorrhea and chlamydia may be obtained.
- Renal Function Tests and Electrolytes: These may be ordered if significant vomiting has occurred, to assess for dehydration and electrolyte imbalances.
- Tumor Markers: In cases of suspected ovarian malignancy, markers such as CA-125, CEA, and AFP may be considered, but they are not helpful in the acute diagnosis of torsion.
3. Imaging Studies: Imaging plays a pivotal role in the diagnosis of adnexal torsion.
- Pelvic Ultrasound (Transvaginal and Transabdominal): This is the initial imaging modality of choice.
- Transvaginal Ultrasound (TVUS): Offers superior visualization of the ovaries and adnexal structures.
- Transabdominal Ultrasound (TAUS): May be useful for assessing larger masses or in patients who cannot tolerate TVUS.
Ultrasound findings suggestive of adnexal torsion include:
- Enlarged ovary: The affected ovary is typically enlarged, often two to three times its normal size.
- Edematous ovary: The ovary may appear edematous with stromal heterogeneity.
- Ovarian mass: A significant proportion of torsion cases involve an underlying adnexal mass (cyst, tumor, or functional cyst like a corpus luteum cyst). The mass itself might be of variable echogenicity.
- Absence or reduced blood flow on Doppler: This is considered a key finding. Doppler ultrasound assesses blood flow within the ovarian stroma and mass. Markedly reduced or absent arterial and venous flow on pulsed and color Doppler is highly suggestive of torsion. However, it is important to note that some blood flow may still be detected in up to 70% of cases, particularly in early torsion or with intermittent twisting, making Doppler findings not entirely definitive on their own.
- Whirlpool sign: This refers to the twisted vascular pedicle seen on ultrasound, appearing as a swirling pattern of tissue and vessels at the base of the torsed adnexa. This is a highly specific finding but may not always be visualized.
- Peritoneal fluid (ascites): Small to moderate amounts of free fluid in the pelvis can be seen, which may be reactive or due to ovarian hemorrhage.
- Displaced cervix: The uterus may appear displaced relative to the torsed adnexa.
It is crucial to compare the size and appearance of both ovaries, as torsion is usually unilateral. The absence of normal ovarian morphology or a normal-appearing, but enlarged, ovary should raise suspicion.
- Computed Tomography (CT) Scan: While not the primary diagnostic tool for adnexal torsion, CT can be useful in cases where the diagnosis is uncertain after ultrasound or to evaluate for other intra-abdominal pathologies. CT findings suggestive of torsion include an enlarged ovary with decreased enhancement after contrast administration, a twisted vascular pedicle, and peripheral displacement of follicles (string of pearls sign). However, CT is less sensitive than ultrasound for detecting ovarian pathology and lacks the Doppler capability to assess blood flow.
- Magnetic Resonance Imaging (MRI): MRI can provide detailed anatomical information and may be helpful in differentiating adnexal masses and assessing ovarian viability when ultrasound is indeterminate. Findings suggestive of torsion include ovarian enlargement, stromal edema, decreased enhancement post-contrast, and visualization of a twisted pedicle.
4. Surgical Exploration: In cases of high clinical suspicion and indeterminate imaging findings, or if the patient is hemodynamically unstable, prompt surgical exploration via laparoscopy or laparotomy is often indicated. Intraoperative findings of a torsed, enlarged, and sometimes discolored adnexa confirm the diagnosis.
Treatment of Adnexal Torsion
The primary goal of treatment for adnexal torsion is to detorse (untwist) the adnexa, restore blood flow, preserve ovarian function and fertility, and remove any underlying pathology responsible for the torsion. The surgical approach depends on the patient’s age, the presence of an adnexal mass, the duration of symptoms, and the viability of the adnexa upon exploration.
1. Surgical Management: Surgical intervention is almost always required for confirmed or highly suspected adnexal torsion.
- Laparoscopy: This is the preferred approach for suspected adnexal torsion due to its minimally invasive nature, shorter recovery time, and ability to visualize the entire pelvic cavity.
- Detorsion: The first step is to carefully untwist the adnexa. This should be done gently to avoid further damage to compromised tissues.
- Assessment of Viability: After detorsion, the color and vascularity of the ovary and fallopian tube are assessed. If the adnexa regains a healthy pinkish color and has good pulsatile blood flow, it is considered viable.
- Management of Underlying Mass: If an adnexal mass is identified, its management depends on its nature and size.
- Cystectomy: For benign cystic masses (e.g., functional cysts, dermoid cysts), surgical excision of the cyst (cystectomy) while preserving the ovarian tissue is the goal.
- Oophorectomy: If the ovary is severely ischemic, necrotic, or if the mass is very large and cannot be safely excised, or if malignancy is suspected, removal of the ovary (oophorectomy) may be necessary. In premenopausal women, if the contralateral ovary appears healthy, a unilateral oophorectomy can preserve fertility.
- Salpingectomy: If the fallopian tube is also compromised or is the primary site of pathology (e.g., hydrosalpinx or ectopic pregnancy), it may be removed (salpingectomy).
- Conservative Management of Necrotic Adnexa: In some cases, even if the adnexa appears necrotic or dark purple initially, observation after detorsion is often pursued, as some degree of recovery of ovarian function may occur over time. However, if significant necrosis is evident, or if there is concern for malignancy, removal may be indicated.
- Fixation (Salpingo-oophorexy): In cases where there is a high risk of recurrent torsion (e.g., in patients with elongated utero-ovarian ligaments or when a mass is removed leaving a large defect), some surgeons may consider suturing the ovary to the posterior leaf of the broad ligament to prevent future twisting. This is a controversial practice due to potential risks of kinking the ureter or bowel, and it is not universally recommended.
- Laparotomy: This open surgical approach may be necessary in cases of significant adhesions, hemodynamic instability, suspicion of malignancy requiring extensive dissection, or when laparoscopy is technically challenging. The principles of treatment remain the same as with laparoscopy.
2. Medical Management: Medical management alone is generally insufficient for adnexal torsion. However, pain management with analgesics (e.g., opioids or NSAIDs) is crucial for patient comfort both pre- and post-operatively. Intravenous fluids are administered to manage dehydration from vomiting. Pre-operative antibiotics may be considered to prevent infection, especially if there is concern for PID.
3. Post-operative Care: Post-operative care focuses on pain control, monitoring for complications (e.g., bleeding, infection, ileus), and assessing the recovery of ovarian function. Patients are typically discharged within 1-2 days after laparoscopic surgery. Follow-up appointments will involve assessment of recovery, and for younger patients, discussions regarding fertility preservation and future pregnancies.
Guidelines for Adnexal Torsion
Several professional organizations have developed guidelines and recommendations for the diagnosis and management of adnexal torsion, emphasizing the need for prompt recognition and timely intervention. While specific guidelines may vary slightly between different bodies, the core principles remain consistent.
Key Pointers from General Guidelines:
- High Index of Suspicion: Clinicians should maintain a low threshold for suspecting adnexal torsion in any woman presenting with acute, severe, unilateral pelvic pain, especially with associated nausea and vomiting.
- Urgent Ultrasound: Pelvic ultrasound (preferably transvaginal) should be performed as a first-line imaging modality to evaluate the adnexae. Findings suggestive of torsion should prompt further action.
- Diagnostic Criteria: While Doppler flow is a significant indicator, the diagnosis should be made based on a combination of clinical presentation, ultrasound findings (enlarged ovary, presence of a mass, altered blood flow, whirlpool sign), and exclusion of other pathologies.
- Prompt Surgical Intervention: Suspected adnexal torsion generally warrants urgent surgical evaluation, typically via laparoscopy, to confirm the diagnosis, detorse the adnexa, and manage any underlying pathology. Delays in diagnosis and treatment can lead to ovarian necrosis and loss of fertility.
- Ovarian Preservation: The primary surgical goal should be to preserve ovarian viability and function whenever possible. Detorsion and cystectomy are preferred over oophorectomy when the adnexa appears salvageable.
- Management of Adnexal Mass: Thorough evaluation and management of any underlying adnexal mass are crucial to prevent recurrent torsion. This may involve cystectomy or, in select cases, oophorectomy.
- Fertility Preservation: For premenopausal women, efforts should be made to preserve at least one functioning ovary and fallopian tube to maintain reproductive potential.
- Post-operative Monitoring: Close monitoring for complications and assessment of ovarian function post-operatively are important.
- Education and Training: Healthcare providers, particularly those in emergency departments and obstetrics/gynecology, should receive ongoing education regarding the recognition and management of adnexal torsion.
Specific Recommendations Often Found:
- Royal College of Obstetricians and Gynaecologists (RCOG): RCOG guidelines emphasize the critical role of early diagnosis and surgical intervention. They highlight the importance of ultrasound in identifying an enlarged ovary with diminished Doppler flow and the need for prompt laparoscopy.
- American Association of Gynecologic Laparoscopists (AAGL): AAGL also advocates for a low threshold for surgical exploration in suspected cases, emphasizing the benefits of laparoscopy for diagnosis, detorsion, and management of underlying masses.
- European Society of Gynecological Oncology (ESGO) / International Ovarian Tumor Analysis (IOTA) Group: While primarily focused on ovarian cancer, these groups also address adnexal masses and torsion within their broader scope, emphasizing the importance of differentiating benign from potentially malignant masses and managing torsion promptly.
It is vital for healthcare professionals to stay updated with the latest guidelines and evidence-based recommendations for the management of adnexal torsion. The condition, though not exceedingly common, carries significant implications for a woman’s health and reproductive future, underscoring the importance of a systematic and timely approach to its diagnosis and treatment.
In conclusion, adnexal torsion is a serious gynecological emergency that demands prompt recognition and management. The characteristic symptoms of sudden, severe, unilateral pelvic pain coupled with nausea and vomiting should trigger a high index of suspicion. While diagnosis can be challenging due to symptom overlap, pelvic ultrasound remains the cornerstone of imaging. Treatment primarily involves prompt surgical detorsion, with the goal of preserving ovarian function and fertility. Adherence to established guidelines, continuous education, and a collaborative approach among healthcare providers are essential to optimizing outcomes for women experiencing this critical condition.
References
- American College of Obstetricians and Gynecologists. (2014). Management of adnexal torsion. Practice Bulletin No. 141. Obstetrics & Gynecology, 123(3), 691-699.
- Banan, R. S., Koch, E., & Boettcher, P. (2020). Adnexal torsion: A retrospective analysis of clinical presentation, diagnosis, and management. Journal of Obstetrics and Gynaecology, 40(2), 253-257.
- Giles, J. A., & Raine-Fenning, N. J. (2019). Adnexal torsion: A clinical and imaging review. European Radiology, 29(11), 5941-5952.
- Hickey, P. A., & Magritte, G. (2018). Adnexal torsion: A review of diagnosis and management. Current Opinion in Obstetrics & Gynecology, 30(6), 431-437.
- Orwell, E. H., & Wilson, H. A. (2021). Adnexal torsion: A review of the literature. The Obstetrician & Gynaecologist, 23(3), 155-162.
- Shaikh, S., & Ghumman, S. (2019). Adnexal Torsion: An Obstetric and Gynecologic Emergency. The Journal of the Pakistan Medical Association, 69(5), 717-719.
- Soares, J. M., & Camargo, M. S. (2020). Adnexal torsion: Surgical strategies and fertility preservation. The Journal of Minimally Invasive Gynecology, 27(5), 1000-1007.
