Adnexal Torsion

Adnexal torsion is twisting of the ovary, fallopian tube or both on their pedicle, with obstruction of venous and arterial supply. It includes isolated tubal torsion.

Lead points include ovarian cysts, paratubal cysts, hydrosalpinx, tumours and a long mesosalpinx.

It is a gynaecological emergency in all ages.

Early surgery preserves the ovary and tube in most women.

Sudden severe pelvic pain with nausea and vomiting, sometimes intermittent pain over days.

Adnexal tenderness, a palpable mass and peritonism with necrosis.

Differential diagnosis: ectopic pregnancy, ruptured cyst, appendicitis, tubo-ovarian abscess, renal colic, pelvic inflammatory disease, degenerating fibroid.

Complications: ovarian or tubal necrosis, peritonitis, adhesions, loss of the adnexa and reduced fertility.

Diagnosis is clinical, supported by ultrasound, and normal Doppler flow does not exclude torsion.

• Pregnancy test; full blood count; C-reactive protein.
• Transvaginal ultrasound: adnexal mass or enlarged ovary, free fluid, thickened twisted tube, whirlpool sign; normal Doppler flow does not exclude torsion.
• MRI or CT scan if the findings are unclear and the woman is stable.
• Diagnostic laparoscopy for high suspicion.

Operate urgently to untwist the adnexa, remove any lead point, and conserve the ovary and tube.

• Supportive: nil by mouth; IV access and fluids; analgesia; urgent theatre.
• Pharmacological: morphine 2.5 to 5 mg IV titrated every 5 minutes (child 0.05 to 0.1 mg/kg IV); paracetamol 1 g IV 6-hourly (maximum 4 g in 24 hours; child 15 mg/kg); ondansetron 4 mg IV 8-hourly. Ceftriaxone 1 g IV daily plus metronidazole 500 mg IV 8-hourly for infected or necrotic tissue.
• Procedures: laparoscopic detorsion and removal of the lead point (cystectomy, paratubal cyst excision, or salpingostomy for hydrosalpinx); salpingectomy only if the tube is necrotic or hydrosalpinx is unsalvageable and fertility is not planned or the woman will have in vitro fertilisation; oophoropexy for recurrence; oophorectomy only for necrotic ovary or suspected cancer.
• Special groups: in children and adolescents conserve the tube and ovary; in pregnancy operate by laparoscopy in the first or second trimester, give progesterone 200 mg vaginal at night if the corpus luteum is removed before 10 weeks.
• Red flags: persistent pain, fever, peritonism, shock, suspicion of malignancy.
• Follow-up: review at 1 and 6 weeks; ultrasound at 6 to 8 weeks; fertility counselling.