Adnexal torsion is twisting of the ovary and sometimes the fallopian tube, interrupting the arterial supply and causing ischemia. Symptoms include severe pelvic pain, often with nausea and vomiting. Diagnosis is clinical and with transvaginal ultrasonography. Treatment is usually laparoscopic surgery.
Adnexal torsion is one of the most common gynecologic emergencies, occurring most often during reproductive years. It usually occurs when the ovary is enlarged because of a mass or other problem. Prolonged ischemia can cause loss of ovarian function or damage to the fallopian tube.
Risk factors for adnexal torsion include the following:
Ovarian enlargement to > 4 cm (particularly by benign tumors)
Pregnancy (if a large corpus luteal cyst is present)
Induction of ovulation
Prior history of adnexal torsion
Benign tumors are more likely to cause torsion than malignant ones. Torsion of normal adnexa, which is rare, is more common among children and adolescents than adults (1).
Typically, one ovary is involved, but sometimes the fallopian tube is also involved. Adnexal torsion can cause peritonitis.
General reference
1. American College of Obstetricians and Gynecologists (ACOG): Adnexal torsion in adolescents: ACOG Committee Opinion No, 783. Obstet Gynecol. 134 (2):e56–e63, 2019. doi:10.1097/AOG.0000000000003373
Symptoms and Signs of Adnexal Torsion
Adnexal torsion causes sudden, severe pelvic pain and usually nausea and vomiting. For days or occasionally weeks before the sudden pain, some women have intermittent, colicky pain, presumably resulting from intermittent torsion that spontaneously resolves. The pain may be localized to the side with the torsion or may be diffuse.
Tachycardia, fever, abdominal tenderness, and peritoneal signs may be present. During pelvic examination, cervical motion tenderness and a unilateral tender adnexal mass are typically present. Pain may be out proportion to examination findings. Peritoneal signs, if present, typically develop later in the course.
Diagnosis of Adnexal Torsion
History and pelvic examination
Transvaginal ultrasonography
Exploratory surgery to confirm
Adnexal torsion is suspected based on typical symptoms (ie, intermittent, severe pelvic pain, usually with nausea and vomiting) and unexplained peritoneal signs plus severe cervical motion tenderness or an adnexal mass. Other common causes of pelvic pain (eg, appendicitis, ectopic pregnancy, pelvic inflammatory disease, tubo-ovarian abscess) should be ruled out.
Clinical diagnosis of adnexal torsion is supported by imaging with transvaginal ultrasonography that shows an enlarged ovary or an ovarian mass. Color Doppler ultrasonography that shows decreased or absent blood flow in the ovary provides further support for the diagnosis.
If adnexal torsion is suspected, exploratory surgery is done immediately. The presence of a twisted ovary confirms the diagnosis.
Treatment of Adnexal Torsion
Surgery to salvage the ovary
If adnexal torsion is suspected, laparoscopy (or rarely laparotomy) is done immediately to confirm the diagnosis and to attempt to salvage the ovary and fallopian tube by detorsing (untwisting) them, especially in a woman of reproductive age, and restoring perfusion. Salpingo-oophorectomy is required for nonviable or necrotic tissue.
If an ovarian cyst or mass is present and the ovary can be salvaged, cystectomy is done. Otherwise, oophorectomy is required.
Key Points
Adnexal torsion of the ovary and/or fallopian tube is a common gynecologic emergency; it usually occurs when the ovary is enlarged because of a mass or other problem.
Torsion causes sudden, severe pelvic pain and sometimes nausea and vomiting; it may be preceded by days or occasionally weeks of intermittent, colicky pain, presumably resulting from intermittent torsion.
Suspect adnexal torsion based on symptoms, pelvic tenderness during examination, and Doppler transvaginal ultrasonography with decreased or absent blood flow; follow immediately with exploratory surgery to confirm the diagnosis and treat it.
If adnexal torsion is diagnosed, immediately attempt to salvage the ovary and fallopian tube by untwisting them via laparoscopy or laparotomy; if nonviable or necrotic tissue or an ovarian cyst or mass is present, surgical removal (salpingo-oophorectomy, cystectomy) is required.
