Adnexal torsion: a single-center retrospective study of diagnosis and treatment

Abstract

Aims: This study was conducted to review the clinical, laboratory, and ultrasound findings of patients with a confirmed post-operative adnexal torsion diagnosis in a tertiary university hospital and to reflect the management of adnexal torsion. Methods: 44 patients (ages [15,44] with a median of 30 yr) who had an operation at Ankara University Hospital Gynecology and Obstetrics Clinics between October 2013 and February 2021 and in whom the preoperative diagnosis of adnexal torsion was confirmed intraoperatively were included in this retrospective study. Patients’ complaints, existing risk factors, physical examination, laboratory, and radiological findings were evaluated. Results: 26 (65%) of the patients complained about acute abdominal pain isolated on one side. Torsion was observed on the right side in 29 (66%) patients. Risk factors: History of ovarian torsion in 1 patient (2%), in vitro fertilization treatment in 5 (11%) patients, 4 (9%) of which also had ovarian hyperstimulation syndrome and 2 (5%) of them had polycystic ovary syndrome, and finally, 28 (65%) patients had increased ovarian size on ultrasound. Ovarian blood flow was not observed in 25 (81%) of 31 patients who underwent transvaginal Doppler ultrasound. Preoperative blood examination showed anemia (Hb<12 g/dL) in 14 (32%), leukocytosis (>10000/mm³) in 26 (59%), and an increase of neutrophil-lymphocyte ratio (NLR) (>3) in 36 (82%). Laparoscopy was performed in 37 (84%) patients and laparotomy in 7 (16%). Conclusion: There is no objective diagnostic tool that can definitively lead to the diagnosis of adnexal torsion. It may be recommended to use ultrasound, Doppler, and NLR in addition to clinical findings and anamnesis. Considering the consequences of delay in the treatment, the most appropriate approach would be to perform a laparoscopy if torsion is suspected. Additionally, the patient’s age, menopausal status, ovarian pathology, and desire for fertility are factors that should be considered in the treatment decision, and ovarian protection should be the primary goal.

Keywords

• Adnexal torsion
• laparoscopy
• ovary
• ultrasound
• neutrophil-lymphocyte ratio

References

1. Anteby S, Schenker J, Polishuk W. The value of laparoscopy in acute pelvic pain. Ann Surg. 1975;181:484-486.
2. Lentz G, Lobo R, Gershenson D. Comprehensive gynecology. 6th ed. Philadelphia, PA: Mosby, Inc. p.383-432;2012.
3. Sasaki KJ, Miller CE. Adnexal torsion: review of the literature. J Minim Invasive Gynecol. 2014;21:196-202.
4. Oelsner G, Bider D, Goldenberg M, Admon D, Mashiach S. Long-term follow-up of the twisted ischemic adnexa managed by detorsion. Fertil Steril. 1993;60(6):976-979.
5. Huchon C, Fauconnier A. Adnexal torsion: a literature review. Eur J Obstet Gynecol Reprod Biol. 2010;150:8-12.
6. Pansky M, Smorgick N, Herman A, Schneider D, Halperin R. Torsion of normal adnexa in postmenarchal women and risk of recurrence. Obstet Gynecol. 2007;109:355-359.
7. Shadinger LL, Andreotti RF, Kurian RL. Preoperative sonographic and clinical characteristics as predictors of ovarian torsion. J Ultrasound Med. 2008;27(1):7-13.
8. Oltmann SC, Fischer A, Barber R, Huang R, Hicks B, Garcia N. Cannot exclude torsion-a 15-year review. J Pediatr Surg. 2009;44:1212-1217.

9. Boswell K, Silverberg K. Recurrence of ovarian torsion in a multiple pregnancy:conservative management via transabdominal ultrasound-guided ovarian cyst aspiration. Fertil Steril. 2010;94:1-3.
10. Nichols D, Julian P. Torsion of the adnexa. Clin Obstet Gynecol. 1985;28:375-380.
11. Houry D, Abbott JT. Ovarian torsion: a fifteen-year review. Ann Emerg Med. 2001;38(2):156-159.
12. Cohen S, Weisz B, Seidman D, Mashiach S, Lidor A. Accuracy of the preoperative diagnosis in 100 emergency laparoscopies performed due to acute abdomen in nonpregnant women. J Am Assoc Gynecol Laparosc. 2001;8(1):92-94.
13. Haskins T, Shull B. Adnexal torsion:a mind-twisting diagnosis. South Med J. 1986;79(5):576-577.
14. Bar-On S, Mashiach R, Stockheim D, et al. Emergency laparoscopy for suspected ovarian torsion:are we too hasty to operate? Fertil Steril. 2010;93(6):2012-2015.
15. Chang HC, Bhatt S, Dogra VS. Pearls and pitfalls in diagnosis of ovarian torsion. Radiographics. 2008;28(5):1355-1368.
16. Ercan Ö, Köstü B, Bakacak M, Coşkun B, Tohma A, Mavigök E. Neutrophil to Lymphocyte ratio in the diagnosis of adnexal torsion. Int J Clin Exp Med. 2015;8(9):16095-16100.
17. Peña JE, Ufberg D, Cooney N, Denis AL. Usefulness of Doppler sonography in the diagnosis of ovarian torsion. Fertil Steril. 2000;73(5):1047-1050.
18. McGovern PG, Noah R, Koenigsberg R, Little AB. Adnexal torsion and pulmonary embolism: case report and review of the literature. Obstet Gynecol Surv. 1999;54(9):601-608.
19. Djavadian D, Braendle W, Jaenicke F. Laparoscopic oophoropexy for the treatment of recurrent torsion of the adnexa in pregnancy: case report and review. Fertil Steril. 2004;82(4):933-936.
20. Chohan L, Kilpatrick CC. Laparoscopy in pregnancy: a literature review. Clin Obstet Gynecol. 2009;52(4):557-569.