Chronic Adnexal Torsion

Published Date: 19th July 2016

Publication Authors: Ramachandran N

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Introduction 

Acute adnexal torsion diagnosis is challenging because clinical evaluation and imaging studies are often nonspecific. There are an additional population of women who present with mild, nonspecific symptoms or an incidental finding of an adnexal mass. These cases may represent a failed diagnosis of acute torsion, or perhaps the torsion has occurred over a longer period of time and should be viewed as a separate entity of chronic adnexal torsion.

Cases 

The first case is a 42-year-old woman who presented acutely with right iliac fossa pain, this resolved over 48 hours and she was discharged. Ultrasound imaging 3 weeks after the acute event suggested an endometrioma of the left ovary. Laparoscopy performed 8 months later showed a necrotic right ovary, adherent to the left ovarian fossa.

The second case is a 44-year-old woman who presented with 3 years of pelvic pain, with occasional episodes of exacerbations. Episodes of severe pain were accompanied by vomiting and urinary frequency. An ultrasound scan showed a 9.5 9 9 cm cyst arising from the left ovary, which was perceived to be haemorrhagic in nature. Laparoscopy revealed a 10 9 9 9 9 cm left torted hydrosalpinx which was adherent to small bowel, omentum and the anterior abdominal wall, and accompanied by a normal ovary.

The final case is a 57-year-old woman who presented with post menopausal bleeding. An ultrasound suggested a 5.9 9 4.7 9 2.7 cm complex cystic mass posterior to the uterus. At laparoscopy the left ovary, enlarged with a dermoid cyst, appeared to have auto-amputated and was in the right side of the pouch of Douglas, attached to bowel and the right uterosacral ligament. The left cornua of the uterus extended into a small

remnant of fallopian tube. Histology confirmed a torted mature teratoma, likely with neovascularisation on the right uterosacral ligament. On direct questioning she gave a history of severe pelvic pain for about a week 33 years previously.

Discussion 

Failure to diagnose and treat adnexal torsion during the acute phase may be more common than is thought, and a lower threshold for diagnostic laparoscopy may be warranted. An acceptable percentage of negative laparoscopies in that setting would need to be agreed. Alternatively a slowly developing torsion with subacute symptomatology may need to be considered in patients with spurious imaging findings or chronic pelvic pain.

Goodfellow, L; Anagnostopoulos, A; Ramachandran, N; McCormack, J; Hawe, J. (2013).  Chronic adnexal torsion, fiction or reality? . BJOG: An International Journal of Obstetrics and Gynaecology. 120 (Supplement S1), 386-7

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