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Pelvis » Female Pelvis (Gynecology)
Right tubal and ovarian torsion
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Presentation A young woman with acute onset right adnexal pain. A pelvic ultrasound was performed.
Caption: Transverse image of the right adnexa
Description: There is a complex mass seen in the right adnexa. The right ovary is not seen separate from the mass.
Caption: Transverse image of the right adnexa
Description: The complex heterogeneous mass is again noted in the right adnexa. It is predominantly hypoechoic with a few cystic areas within the mass.
Caption: Sagittal image of the contralateral ovary
Description: The contralateral left ovary appears normal and shows prominent follicles within.
Caption: Sagittal image of the right adnexa
Description: This is the peripheral component of the complex mass that was seen in the right adnexa. It appears to be an enlarged and heterogeneous right ovary with peripherally displaced follicles - this is classical for torsion.
Caption: Spectral Doppler image of the right adnexal mass
Description: Spectral analysis demonstrates a normal arterial waveform. The venous waveform however, could not be obtained, implying that the venous supply is probably compromised.
Differential Diagnosis Right complex ovarian cyst, right tubal and ovarian torsion, right ovarian mass, ectopic pregnancy
Final Diagnosis Right tubal and ovarian torsion
Discussion Adnexal torsion can present as a surgical emergency and requires a prompt and definitive diagnosis to prevent permanent damage to the adnexal structures.  Adnexal torsion can either involve only the ovaries, only the fallopian tubes or possibly both. The torsion can be complete or partial and intermittent.

Ovarian torsion may occur in a normal ovary [30% cases]; however, cysts and tumors are the leading causes of excessive rotation of the ovary, leading to torsion. Prior abdominal surgeries and ovarian hyperstimulation syndromes are also known causes. According to literature reports, right sided torsion is more common than left. The torsion initially causes edema of the ovary, reducing the venous return from the ovary.  If persistent, the arterial flow is also compromised. Eventually hemorrhagic necrosis may occur. 

Spontaneous isolated tubal torsion, although reported, is not very common. The torsed tube distends with blood and may undergo necrosis. 

Two distinct age groups are identified, the prepubertal or the adolescent age group, where it is mainly idiopathic in nature and in the postmenopausal group due to adnexal masses. The patients present with acute onset lower abdominal pain, nausea and vomiting. Clinically it mimics a number of conditions, the closest differential being appendicitis. 

Transabdominal and transvaginal [wherever possible] gray-scale ultrasound with color Doppler is the diagnostic imaging modality in most cases. CT and MRI may be performed in non-diagnostic cases.

Gray-scale ultrasound features: Comparison with the normal contralateral ovary is always advisable.
1. The completely torsed ovary is enlarged and appears edematous.
2. The affected ovary may show a heterogeneous echotexture and may be seen as a complex adnexal mass with septations and debris, as a cystic mass or as a solid mass with peripheral cysts.
3. The affected ovary may show small spherical cystic areas towards the periphery. These peripheral cysts represent immature follicles and this is quite a specific finding for the diagnosis of torsion in the appropriate clinical scenario.
4. Associated intraperitoneal fluid may be seen due to weeping of the interstitial fluid from the affected ovary.
5. In cases of partial torsion, the ovary may be normal in size and show normal intra-ovarian flow, but the echotexture is usually heterogeneous.
6. In cases of isolated tubal torsion, the affected fallopian tube is distended and appears as a cystic pelvic mass with normal ovarian flow.

Color Doppler features: 90% of the affected ovaries have abnormal color Doppler findings.
1. There is absent intra-ovarian venous flow.
2. Subsequently, the intra-arterial flow is reduced, followed by complete lack of flow. The complete absence of flow should be confirmed by power Doppler to prevent erroneous interpretation.
3. In cases of partial/incomplete torsion, intra-ovarian flow may be demonstrated. So, the presence of flow does not necessarily rule out torsion and in which case, the gray scale findings are diagnostic enough.
4. Flow within the adnexal vessels may be preserved, which predicts viability of the ovaries. Absent adnexal flow in a visible twisted vascular pedicle is usually associated with necrotic ovaries.
5. With tubal torsion, the distended tube may show a lack of flow or has reversed flow during diastole.

A study by Brown, et al found that color Doppler studies performed after the injection of contrast media produced much stronger signals in the ischemic ovaries, thereby allowing a more definitive diagnosis.

CT and MRI scans may complement the ultrasound features and help in reaching a diagnosis in cases of doubt.

Most of the cases need to undergo immediate surgical evaluation. Laparoscopic or open surgical detorsion with preservation of viable functional ovarian tissue, oophorectomy or salpingectomy with contralateral oopheropexy if torsion is idiopathic in nature are the surgical procedures offered. Depending on the clinical scenario, conservative management has also proven effective.
Case References 1. Albayram F, et al. Ovarian and adnexal torsion. JUM. 2001 Oct; 20(10):1083.
2. Fleischer A. Ovarian torsion – eMedicine. www.emedicine.com/radio/topic509.htm
3. Hurh PJ, et al. Ultrasound of a torsed ovary. Ped Rad. 2002 Aug; 32(8):586.
4. Milki A, et al. Isolated torsion of the fallopian tube. J Repr Med. 1998 Sep; 43(9):836.
5. Rizk DE, et al. Torsion of the fallopian tube in an adolescent female. J Ped Adol Gyn. 2002 Jun; 15(3):159.
6. Ben-Ami M, et al. Eur J Obs Gyn Reprod Biol. 2002 Aug 5: 104(1):64.
7.S halev J, et al. Subtorsion of the ovary. JUM. 2001 Aug; 20(8):849.
8. Lee EJ, et al. Diagnosis of ovarian torsion with color Doppler sonography. JUM. 1998 Feb; 17(2):83. 
9. Stark JE, et al. Ovarian torsion in prepubertal and pubertal girls. AJR. 1994 Dec; 163(6):1479.
10. Brown JM, et al. Contrast-enhanced ultrasonographic visualization of gonadal torsion. JUM 1997 May; 16(5):309.
Follow Up Surgery confirmed right tubal and ovarian torsion.
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