OVERVIEW

What is adnexal torsion?

Ovarian torsion refers to the complete or partial twisting of the ovary on its supporting ligaments, often leading to obstruction of its blood supply. It is one of the most common gynecological emergencies and can occur in women of all ages.

The fallopian tube often twists along with the ovary, a condition known as adnexal torsion. Adnexal torsion is uncommon and most frequently occurs in women of reproductive age. Laparoscopic surgery is typically required to untwist the affected ovary.

Is adnexal torsion common?

Adnexal torsion is one of the common gynecological acute abdominal conditions.

Who is most at risk for adnexal torsion?

• Individuals with cysts or tumors in the adnexal region;
• Those with congenital elongated ovarian ligaments or abnormally relaxed pelvic ligaments;
• Pregnant women, especially during early pregnancy or those with a history of ovulation induction.

SYMPTOMS

What are the manifestations after adnexal torsion?

• Acute abdominal symptoms: Sudden, unilateral lower abdominal pain, which may be intermittent or persistent. In cases of incomplete torsion, the pain may be mild or intermittent, sometimes resolving after spontaneous reduction. Frequent, intermittent abdominal pain may occur months before diagnosis.
• Gastrointestinal symptoms such as nausea and vomiting.
• Fever: Occurs later due to tissue ischemia and necrosis, usually low-grade.
• In severe cases, shock may develop, manifesting as lethargy, cold extremities, thready pulse, and hypotension.
• A palpable mass in the adnexal region with marked tenderness, high tension, and most pronounced at the pedicle, rarely accompanied by peritoneal irritation.

What complications can adnexal torsion cause?

• Adnexal necrosis, affecting ovarian function and fertility.
• Thromboembolic diseases.
• Risk of malignant transformation.

CAUSES

What Causes Adnexal Torsion?

• Adnexal Mass: Most torsion cases involve identifiable masses, often benign ovarian tumors or cysts of the fallopian tubes or accessory ovaries. These typically occur in tumors with long stalks, moderate size, good mobility, and a center of gravity偏向一侧 (e.g., cystic teratomas, cystadenomas). Malignant lesions are rare but may occur in postmenopausal women.

• Anatomical Abnormalities: Excessive length of the fallopian tube or ovarian mesentery, congenital genital anomalies (e.g., asymmetric unicornuate uterus), or松弛 pelvic ligaments.

• Pregnancy or Puerperium: Particularly common in early pregnancy or women with a history of ovulation induction (55% in early pregnancy, 34% in mid-pregnancy, 11% in late pregnancy). As the uterus enlarges, tumors may shift into the abdominal cavity with increased mobility. Postpartum uterine shrinkage, abdominal laxity, or uterine traction may also contribute.

DIAGNOSIS

Which aspects of a patient's medical history are important for doctors' diagnosis?

Previous self-palpation of a movable lower abdominal mass, past gynecological examinations indicating adnexal masses, and a history of similar episodes of pain.

Severe lower abdominal pain occurring after sudden changes in body position, or intense pain in a pre-existing adnexal mass following positional changes, should raise suspicion for ovarian torsion.

What tests are needed for adnexal torsion?

• Ultrasound: The most commonly used imaging modality. Findings include ovarian enlargement and reduced or absent Doppler blood flow. Generally, the degree of ischemia correlates with the severity of torsion. Transabdominal color Doppler ultrasound has a positive predictive value of 19%–34% and a negative predictive value of 96.3%–99.5%, while transvaginal ultrasound has a positive predictive value of up to 94%. Combined use of both methods offers high diagnostic value, though transvaginal ultrasound is unsuitable for children and adolescents.

• MRI and CT: These can also aid in identifying adnexal torsion in adolescents and adults. However, since neither CT nor MRI can assess ovarian blood perfusion and are more expensive than transabdominal color Doppler ultrasound, they are not preferred as initial diagnostic tools for suspected torsion. Nonetheless, MRI and CT may help rule out other causes of lower abdominal pain.

• There are no definitive laboratory tests to confirm adnexal torsion. Serum human chorionic gonadotropin (hCG), hematocrit, white blood cell count, and electrolyte panels should be checked to exclude alternative diagnoses.

Which conditions is adnexal torsion easily confused with?

Torsion of pelvic cysts or tumors, acute pelvic inflammatory disease, ruptured ectopic pregnancy, ruptured ovarian corpus luteum cysts, ruptured ovarian endometriotic cysts, acute appendicitis, diverticulitis, and urolithiasis.

Due to the lack of sensitive and specific clinical features, adnexal torsion should be considered in all female patients presenting with acute abdominal pain.

TREATMENT

Which department should I go to for adnexal torsion?

Gynecology (or obstetrics and gynecology), emergency department.

Is surgery necessary for adnexal torsion? What are the treatment options?

Surgery is required for adnexal torsion. The specific approach—laparoscopic or open surgery—depends on the patient's condition. Surgical options include:

• For most premenopausal patients, detorsion with ovarian preservation is recommended over salpingo-oophorectomy, even if the ovary appears dark and congested.
• If a benign adnexal mass is present, ovarian cystectomy is typically performed.
• Salpingo-oophorectomy is necessary if the ovary shows obvious necrosis or if malignancy is suspected.
• Oophoropexy may be considered for congenital ovarian ligament elongation, recurrent torsion, or cases without a clear cause.

Why is ovarian preservation recommended even if the ovary appears dark and congested during torsion?

This conservative approach retains the ovary and fallopian tube.

Studies confirm that conservative management does not increase thromboembolic risks. Current evidence suggests detorsion should be performed even with ovarian necrosis, followed by cystectomy after reperfusion.

For adnexal torsion surgery, should laparoscopic or open surgery be chosen?

Guidelines recommend laparoscopy as the preferred approach due to advantages like lower postoperative fever rates and shorter hospital stays.

However, laparoscopy is not advised for masses >10 cm or suspected malignancy. If the surgeon lacks expertise, the safest method (e.g., open surgery) should be chosen.

Does adnexal torsion increase cancer risk?

The malignancy risk from torsion is extremely low. However, postmenopausal patients have higher cancer risks, so oophorectomy is prioritized over cystectomy in this group.

Can adnexal torsion be completely cured?

Most patients recover well post-surgery, as associated tumors are often benign. Severe/prolonged torsion may lead to secondary peritonitis if infection or rupture occurs.

DIET & LIFESTYLE

What should be noted in diet after the cure of adnexal torsion?

No special dietary precautions are needed. Just maintain a healthy eating habit.

What should be noted in daily life after the cure of adnexal torsion?

Avoid strenuous exercise.

Does adnexal torsion affect fertility?

Prolonged torsion can cause severe ovarian tissue ischemia, leading to irreversible damage, which may reduce or even eliminate the function of the affected ovary, resulting in decreased fertility.

PREVENTION

How to Prevent Adnexal Torsion and Its Complications

• Regular gynecological examinations to achieve early detection, diagnosis, and treatment of ovarian cysts or tumors.
• Individuals with high-risk factors such as a history of adnexal cysts or torsion should avoid strenuous exercise or sudden changes in body position.
• For girls with abdominal pain, pelvic examinations combined with ultrasound should not be neglected to ensure early diagnosis and treatment, preventing permanent loss of function in one ovary due to delayed treatment.
• Elderly women should be educated to seek timely medical treatment to reduce surgical complications.
• Women with a history of ovarian cysts should seek immediate medical attention if they experience abdominal pain.