adnexal torsion

1. Management of
Adnexal
Torsion
SOGC CLINICAL
PRACTICE GUIDELINE,
2017
Prof.
Aboubakr
Elnashar
Benha University
Hospital, Egypt
ABOUBAKR ELNASHAR

2. CONTENTS
I. INTRODUCTION
II. DIAGNOSIS
III.TREATMENT
ABOUBAKR ELNASHAR

3. I. INTRODUCTION
1. DEFINITION
Partial or complete rotation of the adnexa on its
vascular pedicle.
It can involve
Ovary
fallopian tube, or
both.
Isolated fallopian tube torsion is uncommon in any age
group.
ABOUBAKR ELNASHAR

4. 2. EPIDEMIOLOGY
Adnexal torsion
most likely to occur in
Children
adolescents
reproductive age women (average age 26)
: detrimental effects on ovarian function and
fertility
important to
make an early diagnosis
 management in a timely fashion.
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5. 3. PATHOPHSIOLOGY
Venous blood flow is the first to be impaired, followed
by compromised arterial flow:
Congestion
adnexal Edema,
Ischemia, and
ultimately Necrosis.
The duration of ischemia required to cause irreversible
damage:
unknown.
Torsion involves the right adnexa slightly more often
(66%) than the left adnexa.
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6. Adenxal torsionABOUBAKR ELNASHAR

7. 4. AETIOLOGY
An adnexal mass
found in most adult cases
No mass:
8% to 18%
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8. Adenxal mass
The majority:
benign ovarian masses
tubal or
paraovarian cysts
functional ovarian cysts: 25%
benign teratomas: 30%
Cystic teratomas: 60%
Cystadenomas: 30%
make up the majority of benign ovarian
neoplasms in adults.
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9. Malignant lesions:
Uncommon
Adult: 3%
Paediatric:0%to 6%
Postmenopausal: 22%
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10. Aetiology
The risk of malignancy at the time of torsion, in both
the paediatric and adolescent population and adult
population
very low (II-2).
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11. II. DIAGNOSIS
1. HISTORY & EXAMINATION
Diagnosis:
Challenging
Maintain a high index of suspicion.
1.Pain
Acute
unilateral lower abdominal
Stabbing: 70%
Sharp: 60%
±intermittent
{partial torsion with spontaneous reversal}
For several months prior to the adnexal torsion is
common.
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12. 2. Nausea and vomiting
common and reported in 60% to 70%
3. Fever
may be present in up to 10%
usually a late finding
{presence of necrotic tissue}
4. A palpable mass
60% to 90% of adults
20% to 36% of children
5. Peritoneal signs
3% to 27%
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13. 2. DIFFERENTIAL DIAGNOSIS
1. Non-torsed pelvic cyst or tumour,
2. PID
3. Ectopic pregnancy,
4. Appendicitis,
5. Diverticulitis, and
6. Urolithiasis.
{clinical characteristics lack sensitivity and
specificity} the diagnosis of adnexal torsion should be
considered in all females presenting with acute
abdominal pain.
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14. 3. LABORATORY STUDIES
No specific blood test
1. An elevated WBC (>12109)
 20% to 56% of cases
 very nonspecific
 may not be present on initial presentation
2. CRP level
 if necrosis is present
 nonspecific marker
 more likely to be elevated if the diagnosis is
appendicitis rather than adnexal torsion.
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15. 3. The inflammatory marker IL-6
more promising marker
significantly higher levels
could be used to differentiate
surgical cause of right lower quadrant pain
(appendicitis or ovarian torsion)
non-surgical cause.
4. The infection marker CD64
significantly higher in patients with appendicitis
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16. 5. Elevation of D-dimers
found in animal studies.
may also become a valuable parameter in the early
diagnosis of ovarian torsion.
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17. 4. IMAGING
1. B-mode ultrasound
 imaging modality of choice for patients with
suspected adnexal torsion
{most sensitive and specific examination}
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18. Findings
1. Ovarian enlargement
2. Absence of Doppler flow.
consistent with torsion
normal flow may be seen if the
ovary has transiently detorsed
only partially torsed
early in the torsion process when arterial perfusion is
still preserved and only venous and lymphatic drainage
are obstructed.
3. Congestion of the ovary:
transudation of fluid into the follicles: solid mass with
multiple peripheral cysts 8 to 12 mm in diameter.
moderately sensitive
highly specific for the diagnosis of ovarian torsion.
ABOUBAKR ELNASHAR

19. TVS: Adnexal torsion.
an enlarged ovary (maximal diameter, >5 cm) with
prominent peripheral nonovulatory follicles and a small
amount of free fluid (arrow) around the inferior margin.ABOUBAKR ELNASHAR

20. Transabdominal CDU
PPV: 19% to 34%
NPV: 96.3% to 99.5%
False-positive rate: high: high rate of negative
surgical explorations for ovarian torsion.
Transvaginal ultrasound
higher PPV, in the range of 94%
Not feasible in the paediatric and adolescent
populations.
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21. The size of the adnexa
Predictive of the absence or presence of adnexal
torsion.
Significant asymmetry: specific but not sensitive
An adnexal volume ratio
volume of affected ovary/volume of unaffected
ovary
 > 20
very high PPV in menarchal females
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22. The presence of flow
1. Predict viability of the adnexal structures
arterial and venous flow:
no evidence of embolism or necrosis on final
pathology
either arterial flow only or no flow:
evidence of embolism or necrosis on final
pathology.
venous flow:
ovarian tissue viability.
2. Blood flow was present
in 28.5%of surgically proven torsion
ABOUBAKR ELNASHAR

23. Whirlpool sign of ovarian torsion
seen with transvaginal
sonography.
Conventional transabdominal
sonography. White arrows point to
torsion of ovarian vessels. A
portion of large ovarian cyst
(CYST) involved with the torsion is
seen to the right of the twisted
ovarian vessels. BL = bladder.
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24. Transvaginal color Doppler
shows twisting of the
vessels.
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25. Color Doppler:
Red arrowheads shows absence of blood flow demonstrating
ovarian torsion.
diagnosis rests on ovarian enlargement with normal ovarian
volume being up to approximately 15 cc. Other suggestive
findings are multiple peripherally based follicles.
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26. Longitudinal sonogram
shows an enlarged 7-cm
ovary) with peripheral cysts.
Power Doppler
complete absence of blood
flow in the ovary. The
pinpoint foci of color in the
center of the ovary are
secondary to motion artifact.
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27. Intraperitoneal fluid
{leakage of interstitial fluid from the twisted ovary}.
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28. 2. CT scans
well-visualized, normal appearing ovaries may rule
out ovarian torsion.
Findings:
uterine tube thickening (74%),
eccentric or concentric wall thickening (54%)
 eccentric septal thickening (50%).
 low overall sensitivity:
not recommended for the workup of suspected
adnexal torsion.
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29. 3. MRI
Findings:
hemorrhagic infarction of adnexal torsion
non-specific
Indication:
MRI and CT may prove useful in ruling out other
causes of lower abdominal pain.
ultrasound
•modality of choice for suspected torsion
1. CT and MRI don’t evaluate the blood flow to the
ovary
2. more costly than CDU,.
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30. Ovarian torsion in a 32-year-old woman.
(a) Transverse sonogram of the left ovary shows a central hemorrhagic cyst (cursors)
with the classic “fishnet” appearance.
(b) Longitudinal sonogram shows peripheral cystic structures. A hemorrhagic cyst can
act as a lead point, weighing down the ovary and predisposing it to torsion.
(c) On a duplex US image, spectral Doppler waveforms show only peripheral venous
flow; no arterial flow could be detected. There is also a small amount of pelvic free fluid.
(d) Correlative CT image shows the large, septated cystic lesion in the pelvic midline
with minimum enhancement and possible peripheral cysts (arrows). A necrotic-
appearing ovary was removed at surgery.
ABOUBAKR ELNASHAR

31. Diagnosis
1. The diagnosis of adnexal torsion should be
considered in females presenting with:
acute abdominal pain (II-2B).
2. Ultrasound with and without colour flow Doppler :
the imaging modality of choice for any suspected
adnexal torsion (II-2).
ABOUBAKR ELNASHAR

32. 3. suggestive of adnexal torsion
Decreased or absent colour Doppler flow
increased total ovarian volume
abnormal adnexal volume ratios
4. decision to operate should not be based exclusively
on sonographic findings (II-2B).
5. A prompt diagnosis and referral to a surgeon:
minimizes trauma and ischemia to the ovary when
torsion is suspected
6. surgery should be performed as soon as possible (II-
2B).
ABOUBAKR ELNASHAR

33. ABOUBAKR ELNASHAR

34. III. TREATEMENT
 modified significantly over the last decade.
Detorsion with or without cystectomy despite the
necrotic appearance of the ovary.
Several issues that surround this approach include
whether a blue-black ovary implies functional loss?,
whether there is a risk of malignancy in previously twisted
ovaries left in situ?
whether there is any way to predict which ovary will do
better?
whether there is a role of oophoropexy to prevent recurrence?
ABOUBAKR ELNASHAR

35. The practice by many gynaecologists
oophorectomy in 30% to 86% of patients.
{untwisting of the ovarian pedicle would result in a
thromboembolic event}
 1. pulmonary embolism 0.2% were following
adnexectomy
(McGovern et al, )
2. No thromboembolic cases after detorsion only
treatment.
3. documenting ovarian function following detorsion
with CDU, additional surgery, or even successful in
IVF
ABOUBAKR ELNASHAR

36. TREATMENT
1. The theoretical risk of a thromboembolic event
following detorsion
Unfounded
should not preclude conservative management (II-
2B).
2. Laparoscopy
preferred surgical approach for adnexal torsion (II-
2).
3. Ovarian function following detorsion, even in cases
of
the blue-black ovary, has been consistently
documented
with colour flow Doppler (II-2).
ABOUBAKR ELNASHAR

37. 4. Conservative surgical treatment of ovarian torsion,
including detorsion with or without cystectomy,
should be performed if torsion is confirmed, even in
cases of a blue-black ovary (II-2B).
5. Delaying the cystectomy
should be considered to avoid further insult to the
edematous ovary (II-2B).
ABOUBAKR ELNASHAR

38. 6. An oophorectomy rather than a cystectomy should be
considered in the postmenopausal female population
with ovarian torsion, due to the increased risk of
malignancy (II-2B).
7. Oophoropexy
can be considered in situations where
1. ovarian ligament is congenitally long,
2. patients with repeat torsion, or
3. when no obvious cause for the torsion can be
found (III-C).
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39. ABOUBAKR ELNASHAR
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