A 27-year-old woman presents to the emergency department with severe sharp left lower abdominal pain. She is nauseous and has vomited twice. She has no diarrhea or blood in her stool and no dysuria. She is not currently sexually active. The episode of pain began after a weightlifting session earlier on the day of presentation, though she routinely lifts weights 3-4 times per week and has never experienced similar symptoms before. She has a history of a left follicular ovarian cyst that is being managed with surveillance. The patient has no other significant past medical history and takes no medication. Temperature is 37 ºC (98.6 ºF), pulse is 120/min, respiratory rate is 20/min, blood pressure is 135/86 mmHg, and SpO 2 is 100% on room air. On physical examination, the patient appears to be in pain. There is moderate tenderness to palpation in the left lower abdomen with guarding but without rebound. Beta HCG urine pregnancy test is negative. A transvaginal ultrasound is ordered. Which of the following additional historical elements would be most consistent with the likely underlying condition?

Adnexal torsion occurs when the ovary and fallopian tube twist, either completely or partially, on their ligamentous support, causing obstruction of their blood supply.

You may also see this process referred to as ovarian torsion, which occurs when the ovary twists on its supporting ligaments without involvement of the fallopian tube.

On the other hand, the tube itself rarely rotates alone and instead often twists alongside the ovary.As a little reminder, the ovary is suspended to the pelvic sidewall by the infundibulopelvic, or IP, ligament and to the uterus by the utero-ovarian ligament.

Blood is supplied to the ovary from both the ovarian and uterine arteries. Now, if the ovary is enlarged, such as in the presence of a cyst, it may rotate on the axis of the two ligaments.

Often, this occurs in ovaries measuring between 5 to 10 centimeters and occurs more frequently in the right adnexa, as the left adnexa has less space due to the presence of the sigmoid colon.

Adnexal torsion can cause edema, venous congestion, and compression of blood vessels. The venous supply is compromised first, and with time, the arterial supply might be affected too.

Adnexal torsion is a surgical emergency and requires urgent reversal of the torsion to prevent necrosis and loss of the ovary.

When assessing a patient with a chief concern suggesting adnexal torsion, your first step is to perform a focused history and physical examination and obtain an hCG.

History & Physical1:33–2:30

The patient may report fever, nausea, and vomiting, as well as abdominal or pelvic pain. If pain is present, it is usually sudden, non-radiating, and intermittent in nature.

On physical exam, you may note abdominal or pelvic tenderness, rebound pain or guarding, and possibly the presence of a pelvic mass.

Lastly, hCG is typically negative.Here’s a clinical pearl! While extremely rare, adnexal torsion can occur in a pregnant patient.

The enlargement of the ovary due to the presence of the corpus luteum cyst and increased laxity of ligaments may contribute to the development of this rare condition.

Pelvic Ultrasound2:30–3:25

Okay, back to our patient; after completing your focused history and physical, your next step is to order a pelvic ultrasound.

Now, if the ultrasound shows symmetrical ovaries with normal adnexal position and size, you will consider an alternative diagnosis.

With a negative hCG, ectopic pregnancy is already ruled out. However, the patient may have a ruptured ovarian cyst, a tubo-ovarian abscess, or appendicitis.On the flip side, the ultrasound may reveal an asymmetrically enlarged ovary; with absent Doppler flow, where you might see the presence of twisted pedicle, or the whirlpool sign, which is significant for a thickened vascular pedicle of an enlarged ovary.

If you see these findings, you should suspect adnexal torsion. Now that you suspect adnexal torsion, your next step is to proceed with a diagnostic laparoscopy.

Diagnostic Laparoscopy3:25–6:48

Remember, this is a surgical emergency and every minute of compromised blood flow can impact the viability of the ovary!

So, upon entry into the abdominal cavity, assess the adnexa for evidence of torsion. You may see no evidence of torsion with the adnexa appearing to be in a normal anatomical position.

This indicates either the adnexa spontaneously detorsed or that you should consider an alternative diagnosis.Alternatively, you might see the ovary or fallopian have twisted on the IP or utero-ovarian ligaments.

This visually confirms the diagnosis of adnexal torsion. The next step is to perform laparoscopic detorsion by untwisting the adnexa.

At this point, assess for ovarian viability and pathology. Often, the ovary will have a blue or black appearance and there might be a cyst present.Here’s a clinical pearl!

The blue or black appearance does not mean the ovary is no longer functional. In fact, the ovary is quite resilient when vascular injury occurs due to its dual blood supply.

Rarely, the ovary might be grossly ischemic with a black, gelatinous appearance indicating that it has become necrotic and is no longer viable.Okay, as you’re assessing ovarian viability, you might see that your patient has viable adnexa without adnexal pathology.

Remember, you have already detorsed the adnexa, so at this time you can consider oophoropexy. This procedure involves affixing the affected ovary to the pelvic sidewall or round ligament to limit its range of motion with the hope that repeat adnexal torsion will not occur.

It is indicated if the contralateral ovary is absent or in cases of repeat adnexal torsion. In the absence of these two indications, oophoropexy is not needed, as repeat adnexal torsion is unlikely.

Alright, your patient might have viable adnexa with adnexal pathology present. Commonly, you may see a simple or dermoid cyst on the affected ovary.

If a cyst is present, perform a cystectomy. If the adnexal pathology appears malignant, the patient is postmenopausal, or the cyst has obliterated the normal appearing ovarian tissue, perform an oophorectomy.

You may also consider a salpingectomy if the fallopian tube is adherent to the ovary, if the patient is postmenopausal, or if they have completed childbearing.

If you do not remove the ovary, you can again consider oophoropexy if indicated.Finally, let’s see what to do if you encounter a non-viable adnexa with or without adnexal pathology present.

Again, remember that every effort should be made to save the ovary. However, if the ovary is overtly necrotic and gelatinous indicating it is no longer viable, perform an oophorectomy and possible salpingectomy.

Review6:48–7:33

Alright, as a quick recap… Adnexal torsion refers to the twisting of the fallopian tube and ovary on their supporting ligaments, which compromises blood supply to the ovary.

It is a surgical emergency. While ultrasound aids in the diagnosis of adnexal torsion, it can only be confirmed by visualization on diagnostic laparoscopy.

Every effort should be made to salvage the ovary during surgical detorsion. Any pathology noted should be removed, including cysts or malignant appearance.

Thanks to the ovary’s dual blood supply, it is quite resilient in the event of vascular injury and often regains most of its function after surgical detorsion.

Rarely, the ovary might be necrotic and it

Adnexal torsion: Clinical sciences

Transcript

Introduction0:00–1:33

History & Physical1:33–2:30

Pelvic Ultrasound2:30–3:25

Diagnostic Laparoscopy3:25–6:48

Review6:48–7:33

Decision-Making Tree

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