Adnexal torsion is an infrequent but serious cause of acute (sudden onset) abdominal pain. Studies have shown that adnexal torsion accounts for 2.5% of all gynecologic surgical emergencies in the United States. Although it can occur at any age, adnexal torsion is typically seen in younger patients with average age being 25.
Q. What is adnexal torsion?
A. Adnexal torsion is twisting of the ovary and/or fallopian tube (the adnexa) that results in obstruction of the normal blood flow to the ovary. Lack of blood flow initially causes pain and eventually can result in necrosis (death of the cells) of the ovary. Adnexal torsion may be caused by spasm of the muscle, congestion and enlargement of veins, or excessively long fallopian tubes. A mobile tumor may be more likely to twist on itself because of increased weight. The most common type of tumor to undergo torsion is a dermoid cyst. Adnexal torsion rarely occurs in malignant (cancerous) ovaries since they usually have associated adhesions (scar tissue). About 20% of adnexal torsion presents in patients who are pregnant.
Q. How is adnexal torsion diagnosed?
A. A woman typically presents either to her physician or to the emergency room with sudden onset of lower abdominal pain. Pain often coincides with heavy lifting, exercise, or intercourse. The pain is usually located on the same side as the adnexal torsion. The woman may have nausea, vomiting, and gastrointestinal complaints. Often she may describe an intermittent nature to the pain.
A physical exam usually reveals a decrease in the bowel sounds (sounds that indicate movement in the small bowel), an adnexal mass, fever, and elevated heart rate. Severe abdominal tenderness with rebound tenderness (pain that is worse when the pressure is relieved) is often noted.
The physician may order laboratory tests, including a pregnancy test (to be certain that pain is not from a complication of pregnancy), and a complete blood count (elevation in white blood cell count is often seen with torsion). He or she may also order an ultrasound to examine your ovaries. Quite often the affected ovary shows up as a mass on ultrasound. Doppler sonography, which shows flow of blood through blood vessels, may be used to determine if there is adequate blood flow to the ovary.
Q. What is the treatment for adnexal torsion?
A. Treatment of adnexal torsion is emergency surgery. Your physician may recommend diagnostic and operative laparoscopy as the first line treatment. This involves placing a tiny camera into your abdomen through a small incision under your umbilicus (navel). This will allow your physician to look at your adnexa and see if it has undergone torsion. If the diagnosis is adnexal torsion, your physician will look to see if the ovary and fallopian tube look viable. As long as there does not appear to be necrosis (cell death) of these tissues, your physician may just untwist the adnexa and remove any cyst that is present. If it looks like necrosis of the tissues has taken place, your physician may need to remove the entire tube and ovary. He or she may be able to do this laparoscopically, by placing a few more small incisions over your lower abdomen and inserting instruments that allow manipulation of the adnexa. If the ovary is too large, a laparotomy, which involves a larger incision on your abdomen, may be required to remove the tube and ovary. If you have a laparoscopy you may be asked to stay overnight, or may be allowed to go home the same day after observation. If you have a laparotomy, your recovery time will be longer and you will need to stay in the hospital for 2 to 3 days.
Prevention of Adnexal Torsion
There is no way to predict who will have an adnexal torsion. The most important point is to recognize the signs and symptoms early, and to have surgery as soon as the diagnosis is suspected. If a conservative procedure is performed at the time of surgery, then measures to prevent a future torsion can be undertaken. Your physician may perform an oophoropexy, which involves suturing your ovary to another structure to stabilize it, with the hope that it will not retorse in the future.
Thomas G. Stovall, M.D.
Dr. Stovall is a Clinical Professor of Obstetrics and Gynecology at the University of Tennessee Health Science Center in Memphis, Tennessee and Partner of Women’s Health Specialists, Inc.