ADNEXAL TORSION
Adnexal torsion is the twisting of part or all of the adnexa on its mesentery, resulting in tissue ischemia and frank infarction. This usually involves the ovary but may include the fallopian tube as well. Although this accounts for only 2% to 3% of all gynecologic operative emergencies, it is nonetheless a significant event that often results in the loss of the ovary. Torsion of the adnexa is usually associated with the presence of an ovarian, tubal, or a paratubal mass (50% to 60% have an ovarian tumor or cyst). The risk of torsion is higher during pregnancy (20% of cases) or after ovulation induction. The average age of patients suffering adnexal torsion is in the mid-20s.
Torsion in prepubertal females may be caused by a pelvic mass or due to
mechanical factors unique to children. In early puberty the ovaries drop from
their prepubertal position at the pelvic brim into the pelvis. This is driven
by the pubertal surge of gonadotropins. Some young women may have longer
supportive ligaments, predisposing them to torsion at this time. Approximately
60% of the time ovarian torsion occurs on the right side and is often confused
with appendicitis. The sigmoid colon in the left lower quadrant helps prevent
the left ovary from twisting.
The first indication of torsion is generally abrupt, intense, and
unilateral abdominal pain. This occurs with swelling and inflammation due to
venous obstruction, which generally occurs before arterial obstruction. The
pain of adnexal torsion is generally intermittent, with a periodicity that
varies from hours to days or longer; this is in contrast to the variable pain
caused by obstruction of the bowel, ureter, or common bile duct, which is more
regular and frequent. The pain is often accompanied by nausea and vomiting (60%
to 70% of cases), and physical examination most often can demonstrate a
unilateral tender mass (90% of cases). Because these symptoms and findings can
be nonspecific, the possibility of other causes such as an ectopic pregnancy,
rupture or bleeding into a cyst, abscesses, or small bowel obstruction must all
be considered.
Ultrasonography may demonstrate a cystic adnexal mass, but the acute
character and intensity of symptoms usually encountered means that the
diagnosis is most often made at the time of surgery. Doppler-flow studies to
demonstrate the presence or absence of blood flow to the ovary may be helpful
but the absence of flow is not diagnostic of an adnexal torsion: the presence of
blood flow does, however, rule out complete obstruction and complete ischemia of
the ovary.
Patients with confirmed adnexal torsion (and those with a high degree of
suspicion) are generally treated by surgical exploration. Conservative
operative management may be possible in more than 75% of patients.
It is thought that irreversible ischemia may not occur for as long as 72 hours
after the initial obstruction. This allows the ovary to be conserved by
“detorsion” of the ovary. Most authors suggest removing an ovarian or tubal
mass following “detorsion” to reduce the risk of recurrence. Part or the entire
ovary may thus be salvaged if intervention takes place early enough in the
process. Unfortunately, when significant ischemia or underlying pathology is
present, removal of part or all of the ovary may be required. There is
insufficient data to resolve the value or need for oophoropexy following
detorsion.
Concerns about the possibility of freeing a thrombus from the obstructed venous supply of the adnexa have been raised. If such a thrombus were present, the possibility that this could embolize to the heart and lungs would militate against untwisting the adnexa. Although a theoretical risk, this has not been demonstrated to occur clinically, making conservative management of these cases more acceptable.
