Ovarian/Tubal Torsion

Published on 10/03/2015 by admin

Filed under Obstetrics & Gynecology

Last modified 22/04/2025

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Ovarian/Tubal Torsion

Synonyms/Description

Adnexal torsion

Etiology

Torsion is defined as the twisting by at least one complete turn of the adnexa, ovary, or (rarely) the tube only around the infundibulo-pelvic and tubo-ovarian ligament, resulting in ischemia. It occurs more frequently on the right side (70%), perhaps because of a longer tubo-ovarian ligament on the right. Approximately 15% of ovarian torsions occur in children. An increase in weight of the adnexa is the primary risk factor for torsion, particularly with dermoid cysts and other mobile ovarian masses. Ovarian cancer or endometriomas seldom cause torsion because of lack of mobility of these lesions. The incidence of ovarian torsion increases during pregnancy, and ovarian stimulation is an additional risk factor.
Up to 26% of cases of torsion occur in patients who have an apparently normal adnexa; therefore a leading ovarian mass is not always present.
Paratubal cysts weighing down the tube can cause isolated torsion of the tube, although this is rare compared with ovarian torsion. Occasionally a torsed fallopian tube is associated with a hydrosalpinx.

Ultrasound Findings

An adnexal mass in a patient with pain should prompt consideration of adnexal torsion as a diagnosis. The typical appearance of a torsed ovary is a large, edematous ovary with multiple, small, peripherally placed follicles and heterogeneous texture of the ovarian stroma. The ovary may be very large and tender during the scan. If color Doppler reveals no blood flow in the ovary, then the diagnosis of torsion can be made confidently. The presence of flow, however, cannot be used to rule out adnexal torsion. Blood flow to the ovary may be intermittent or diminished because venous flow may be obliterated, but arterial flow may still be present. The ovary also has a dual blood supply, which may confound the Doppler findings. Doppler interrogation of the twisted vascular pedicle may reveal a spiral appearance of the vessels, referred to as the “whirlpool” sign. A positive whirlpool sign has a high positive predictive value for diagnosing torsion and should be part of the evaluation in a symptomatic patient.
The detection rate of torsion is reportedly only between 46% and 74%, likely because of the nonspecific findings associated with this entity and lack of expertise in recognizing them.
Isolated tubal torsion is rare, and it typically mimics a hydrosalpinx such that differentiation between an uncomplicated hydrosalpinx and tubal torsion is difficult. The whirlpool sign can be very helpful when considering tubal torsion.

Differential Diagnosis

A patient with ovarian or tubal torsion typically presents with fairly acute, worsening pelvic pain. This is often, although not always, accompanied by nausea, vomiting, and fever. The clinical differential diagnosis includes appendicitis, ureteral calculi, diverticulitis, colitis, ectopic pregnancy, pelvic inflammatory disease, and ruptured or hemorrhagic ovarian cyst. The presence of an adnexal mass narrows the differential diagnosis to a tubo-ovarian abscess (TOA), an ectopic pregnancy, a hemorrhagic cyst, or torsion. Color Doppler may help because a TOA is associated with excessive blood flow caused by inflammation, and an ectopic pregnancy can be excluded by a negative pregnancy test. An inflamed appendix can occasionally be confused with an adnexal mass; however, the tubular configuration of the appendix should help to exclude ovarian torsion, and a normal ovary usually can be visualized transvaginally.

Clinical Aspects and Recommendations

Adnexal or ovarian torsion is a gynecologic surgical emergency, and quick diagnosis is essential. If the diagnosis is made early and normal blood flow is restored, the adnexa may be saved. If the diagnosis is missed or delayed, ischemia will eventually result in necrosis of the ovary and/or fallopian tube. The longer surgical treatment is delayed, the more severe the sequelae because of increasing release of cytokines, which can result in sepsis and more severe systemic sequelae.

Figures

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Figure O3-1 Adolescent girl with a 1-month history of pelvic pain. Endometriosis was the diagnosis initially given before referral. A shows a large pelvic mass seen anterior to the uterus on a transabdominal scan (calipers). B to D show various transvaginal views of the mass, which has both cystic and solid components. Note that there is complete absence of blood flow to the ovary. The diagnosis of torsion was made based on these findings, and the patient was taken to surgery.

 

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Figure O3-2 Young, reproductive-age woman with a 2-day history of acute pelvic pain. Local diagnosis of ovarian tumor was made. A shows the huge edematous ovary with a few peripheral follicles. B shows the edematous twisted pedicle. C shows color Doppler of the whirlpool sign of the twisted pedicle.

 

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Figure O3-3 A, Transvaginal view of a huge pelvic mass with no blood flow. Note the severely edematous ovary with a few peripheral follicles. B and C show the twisted vascular pedicle or positive whirlpool sign in 2-D and 3-D.

 

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Figure O3-4 Torsed fallopian tube. A shows a hydrosalpinx with a very thickened wall and debris within the tube. B and C show 3-D of the tube, demonstrating the complex-appearing fluid and debris within the swollen tube. The diagnosis of torsion was made at surgery.

 

Videos

Video 1 on ovarian/tubal torsion is available online.

Suggested Reading

Boukaidi S.A., Delotte J., Steyaert H., Valla J.S., Sattonet C., Bouaziz J., Bongain A. Thirteen cases of isolated tubal torsions associated with hydrosalpinx in children and adolescents, proposal for conservative management: retrospective review and literature survey. J Pediatr Surg. 2011;46:1425–1431.

Huchon C., Fauconnier A. Adnexal torsion: a literature review. Eur J Obstet Gynecol Reprod Biol.. 2010:1508–1512.

Servaes S., Zurakowski D., Laufer M.R., Feins N., Chow J.S. Sonographic findings of ovarian torsion in children. Pediatr Radiol. 2007;37(5):446–451.

Valsky D.V., Esh-Broder E., Cohen S.M., Lipschuetz M., Yagel S. Added value of the gray-scale whirlpool sign in the diagnosis of adnexal torsion. Ultrasound Obstet Gynecol. 2010;36:630–634.

Vijayaraghavan S.B., Senthil S. Isolated torsion of the fallopian tube: the sonographic whirlpool sign. Ultrasound Med. 2009;28:657–662.

Wilkinson C., Sanderson A. Adnexal torsion—a multimodality imaging review. Clin Radiol. 2012;67:476–483.

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