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Sequential Torsion of the Uterine Adnexa
Case Report Sequential Torsion of the Uterine Adnexa
JAMES G. BUSS, M.D., Department of Obstetrics and Gynecology; RAYMOND A. LEE, M.D., Section of Gynecologic Surgery Sequential bilateral torsion of the uterine adnexa in a young girl led to right and, subsequently, left salpingo-oophorectomy. Acute lower abdominal pain in a young female patient, especially one who has had previous similar episodes, should alert the physician to the possible presence of adnexal torsion. If possible, surgical management of this condition should be conservative—that is, the blood supply should be restored to the adnexa and a viable tube or ovary should be preserved. Contralateral adnexal suspension should always be done, in an effort to prevent bilateral adnexal torsion and to preserve the reproductive potential in these young patients.
Uterine adnexal torsion is an uncommon yet important cause of acute abdominal pain in the female patient. 1 Although the condition is most frequently unilateral, bilateral adnexal torsion can occur. Concomitant bilateral torsion of the uterine adnexal structures has been described in most reported cases; rarely, sequential torsion has occurred.2 In this report, we describe a case of sequential bilateral adnexal torsion in a young girl. Our purpose is to emphasize the need for prompt surgical intervention and, when possible, a conservative operation that includes measures to prevent a future recurrence. R E P O R T O F CASE A 7-year-old girl was brought to the emergency room because of right-lower-quadrant abdominal pain of 36 hours' duration. The pain was inter mittent, cramping, nonradiating, and gradually progressive. No precipitating event could be iden tified. During the past year, the child had had several similar episodes of lower abdominal pain, Address reprint requests to Dr. R. A. Lee, Section of Gyne cologic Surgery, Mayo Clinic, Rochester, MN 55905. Mayo Clin Proc 62:623-625,1987
which had occurred approximately once every 2 months. An appendectomy had been performed in 1980 at another institution. On examination, the patient's temperature was 37.4°C. The abdomen was nondistended, and bowel sounds were normoactive. Moderately severe right-lower-quadrant abdominal tender ness caused voluntary guarding; no masses were detected. Rectal examination confirmed these findings. Urinalysis revealed microscopic pyuria and hematuria; Gram stain of a urine specimen was negative. The hemoglobin value was 13.5 g/dl, and the leukocyte count was 15,800/mm 3 , with 78% segmented neutrophils and 10% band forms present. Abdominal flat and upright roentgenograms disclosed unremarkable findings except for considerable fecal material in the colon. On the following day, the patient's pain had not changed appreciably and her temperature was 37.8°C. Results of an excretory urogram were normal. Pelvic sonography demonstrated a com plex multicystic mass (6 by 4.5 by 4 cm) in the midline posterior to the uterus. Because of these findings, exploratory laparotomy was performed. The right ovary was en larged, swollen, and dark blue and, along with
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the right tube, had undergone torsion. The uterus and left adnexa appeared normal. The right adnexa was untwisted but appeared to be nonviable. A right salpingo-oophorectomy was per formed. Examination of the specimen confirmed massive edema and hemorrhage (7 by 5 by 3.5 cm), and an associated simple ovarian cyst (2.5 cm) was identified. The patient's postoperative course was un eventful, and she was dismissed on the fourth postoperative day. Almost 2 years later, the patient again came to the emergency room with lower abdominal pain. It was similar to the pain she had expe rienced with her previous adnexal torsion. Objec tive findings, however, were minimal. Abdominal flat and upright roentgenograms showed unre markable findings, with the exception again of substantial colonic fecal material. The mother wanted to take the child home and return in the afternoon. Two enemas administered at home produced little effect. The patient returned to the emergency room 2 hours later; the pain had in creased, and she appeared to be in considerable distress, sitting upright and rocking from side to side. She had vomited twice. On examination, her temperature was 37.0°C. The abdomen appeared nondistended, and bowel sounds were normoactive. Direct and rebound left-lower-quadrant tenderness were noted. A left adnexal mass (5 by 4 cm) was palpated on rectal examination. Preoperatively, the hemoglobin concentration was 13.7 g/dl and the leukocyte count was 9,500/ mm 3 , with 70% neutrophils and 0 band forms. Results of urinalysis were normal. At laparotomy, the left tube and ovary were found to be wound many times around their base and appeared black, necrotic, and nonviable. A left salpingo-oophorectomy was performed. Ex amination of the specimen demonstrated hemorrhagic infarction (7 by 5 by 5 cm) without other abnormalities. The patient's postoperative course was un eventful, and she was dismissed on the fifth postoperative day. Hormonal replacement ther apy will be initiated when the child reaches 11 years of age.
Mayo Clin Proc, July 1987, Vol 62
Often a nonadherent, mobile, destabilizing mass of the ovary, tube, or paratubal structures is identified or suspected to be causally related to the torsion. Nevertheless, evidence exists in the literature for torsion of normal adnexal struc tures. Torsion of otherwise normal tubes and ovaries seems to occur most frequently in chil dren or young adults. 3 In such patients, the ideal approach is a conservative operation—that is, one that restores the blood supply to the ischemic adnexa and preserves a viable tube or ovary; thus, the patient's maximal reproductive poten tial and endocrine function are maintained. Be cause the affected tube and ovary are often severely compromised, however, a conservative approach is frequently not possible and salpingooophorectomy commonly becomes necessary. Hibbard 1 emphasized the difficulties involved in salvaging the ovary in a patient with uterine adnexal torsion. Perhaps a major factor is the delay in diagnosis and definitive treatment that often occurs. Several authors have described the constellation of signs and symptoms found in this disorder, yet the range in severity and initial manifestations is broad. 4 In a recent series, Hib bard 1 reported that the preoperative diagnosis had been accurate in only 85 of 225 patients (38%). Palpation of an adnexal mass is often crucial in recognizing this disorder, but this means of detection is frequently not possible in a young child, because of the high position of the ovaries at this age. 5 Ultrasound examination may be useful in such a situation and may reveal a unilaterally enlarged ovary with cystic dilata tion of follicles.6 In general, however, extensive preoperative studies only waste time when early abdominal exploration is indicated. Laparoscopy sometimes will prove useful in those cases in which the diagnosis remains in doubt and the need for laparotomy is uncertain. At laparotomy, distinguishing edematous, con gested, yet viable tissues from those that have undergone irreversible infarction and necrosis is often difficult by inspection alone. Way,7 among other proponents, advocated untwisting of the pedicle followed by a brief period of observation for signs of improved perfusion that might ensue. Others 1 have been reluctant to untwist the pedicle because of the concerns of embolization of blood clot or, in some cases, malignant cells. When DISCUSSION Uterine adnexal torsion can occur at any age but necrosis and destruction of the adnexa are ob is most common in women of reproductive age. vious, nothing is gained by untwisting the ped-
Mayo Clin Proc, July 1987, Vol 62
SEQUENTIAL TORSION OF THE UTERINE ADNEXA
icle. Perhaps in those patients with partial com promise, the pedicle can be unwound and the possibility of ovarian or tubal preservation can be further assessed. This approach may be ap plicable in a young patient in whom a malignant process is not suspected, necrosis is not obvious, the pedicle is only loosely twisted, and the ovar ian vein is minimally distended at the base of the torsion. As our case illustrates, torsion of the contralateral, apparently normal adnexa can occur. We agree with those who.have recommended fixation of the remaining ovary by permanent suture to the pelvic sidewall at the time of oophorectomy for torsion. Excessive tension on the suspended adnexa should be avoided because it may inter fere with the adnexal blood supply or the depo sition of ova in the uterine tube. Alternatively, an unusually long utero-ovarian ligament might
be plicated. Although no definitive data are avail able to support these measures, they should help to prevent another adnexal torsion. REFERENCES
625
1. Hibbard LT: Adnexal torsion. Am J Obstet Gynecol 152:456-461, 1985 2. Dunnihoo DR, Wolff J: Bilateral torsion of the adnexa: a case report and a review of the world literature. Obstet Gynecol 64 (Suppl 3):55S-59S, 1984 3. Berger RL, Robbins G: Torsion of the normal ovary. Am J Surg 102:716-719,1961 4. Lee RA, Welch JS: Torsion of the uterine adnexa. Am J Obstet Gynecol 97:974-977,1967 5. James DF, Barber HRK, Graber EA: Torsion of normal uterine adnexa in children: report of three cases. Obstet Gynecol 35:226-230, 1970 6. Graif M, Shalev J, Strauss S, Engelberg S, Mashiach S, Itzchak Y: Torsion of the ovary: sonographic features. AJR 143:1331-1334, 1984 7. Way S: Ovarian cystectomy of twisted cysts. Lancet 2:4748, 1946
BACK COPY/MISSING COPY POLICY Orders for back issues of the Mayo Clinic Proceedings must be prepaid. Single copies are $4.00 each. Missing copies (issues that were not received) will be provided free of charge if we are notified no later than two months after the issue date. After this deadline, we must ask our subscribers to pay the price of $4.00 per issue. All orders must be prepaid. Please send your check and your order to: Mayo Clinic Proceedings Circulation Office Room 1035, Plummer Bldg. Mayo Clinic Rochester, M N 55905
JAMES G. BUSS, M.D., Department of Obstetrics and Gynecology; RAYMOND A. LEE, M.D., Section of Gynecologic Surgery Sequential bilateral torsion of the uterine adnexa in a young girl led to right and, subsequently, left salpingo-oophorectomy. Acute lower abdominal pain in a young female patient, especially one who has had previous similar episodes, should alert the physician to the possible presence of adnexal torsion. If possible, surgical management of this condition should be conservative—that is, the blood supply should be restored to the adnexa and a viable tube or ovary should be preserved. Contralateral adnexal suspension should always be done, in an effort to prevent bilateral adnexal torsion and to preserve the reproductive potential in these young patients.
Uterine adnexal torsion is an uncommon yet important cause of acute abdominal pain in the female patient. 1 Although the condition is most frequently unilateral, bilateral adnexal torsion can occur. Concomitant bilateral torsion of the uterine adnexal structures has been described in most reported cases; rarely, sequential torsion has occurred.2 In this report, we describe a case of sequential bilateral adnexal torsion in a young girl. Our purpose is to emphasize the need for prompt surgical intervention and, when possible, a conservative operation that includes measures to prevent a future recurrence. R E P O R T O F CASE A 7-year-old girl was brought to the emergency room because of right-lower-quadrant abdominal pain of 36 hours' duration. The pain was inter mittent, cramping, nonradiating, and gradually progressive. No precipitating event could be iden tified. During the past year, the child had had several similar episodes of lower abdominal pain, Address reprint requests to Dr. R. A. Lee, Section of Gyne cologic Surgery, Mayo Clinic, Rochester, MN 55905. Mayo Clin Proc 62:623-625,1987
which had occurred approximately once every 2 months. An appendectomy had been performed in 1980 at another institution. On examination, the patient's temperature was 37.4°C. The abdomen was nondistended, and bowel sounds were normoactive. Moderately severe right-lower-quadrant abdominal tender ness caused voluntary guarding; no masses were detected. Rectal examination confirmed these findings. Urinalysis revealed microscopic pyuria and hematuria; Gram stain of a urine specimen was negative. The hemoglobin value was 13.5 g/dl, and the leukocyte count was 15,800/mm 3 , with 78% segmented neutrophils and 10% band forms present. Abdominal flat and upright roentgenograms disclosed unremarkable findings except for considerable fecal material in the colon. On the following day, the patient's pain had not changed appreciably and her temperature was 37.8°C. Results of an excretory urogram were normal. Pelvic sonography demonstrated a com plex multicystic mass (6 by 4.5 by 4 cm) in the midline posterior to the uterus. Because of these findings, exploratory laparotomy was performed. The right ovary was en larged, swollen, and dark blue and, along with
623
624
SEQUENTIAL TORSION OF THE UTERINE ADNEXA
the right tube, had undergone torsion. The uterus and left adnexa appeared normal. The right adnexa was untwisted but appeared to be nonviable. A right salpingo-oophorectomy was per formed. Examination of the specimen confirmed massive edema and hemorrhage (7 by 5 by 3.5 cm), and an associated simple ovarian cyst (2.5 cm) was identified. The patient's postoperative course was un eventful, and she was dismissed on the fourth postoperative day. Almost 2 years later, the patient again came to the emergency room with lower abdominal pain. It was similar to the pain she had expe rienced with her previous adnexal torsion. Objec tive findings, however, were minimal. Abdominal flat and upright roentgenograms showed unre markable findings, with the exception again of substantial colonic fecal material. The mother wanted to take the child home and return in the afternoon. Two enemas administered at home produced little effect. The patient returned to the emergency room 2 hours later; the pain had in creased, and she appeared to be in considerable distress, sitting upright and rocking from side to side. She had vomited twice. On examination, her temperature was 37.0°C. The abdomen appeared nondistended, and bowel sounds were normoactive. Direct and rebound left-lower-quadrant tenderness were noted. A left adnexal mass (5 by 4 cm) was palpated on rectal examination. Preoperatively, the hemoglobin concentration was 13.7 g/dl and the leukocyte count was 9,500/ mm 3 , with 70% neutrophils and 0 band forms. Results of urinalysis were normal. At laparotomy, the left tube and ovary were found to be wound many times around their base and appeared black, necrotic, and nonviable. A left salpingo-oophorectomy was performed. Ex amination of the specimen demonstrated hemorrhagic infarction (7 by 5 by 5 cm) without other abnormalities. The patient's postoperative course was un eventful, and she was dismissed on the fifth postoperative day. Hormonal replacement ther apy will be initiated when the child reaches 11 years of age.
Mayo Clin Proc, July 1987, Vol 62
Often a nonadherent, mobile, destabilizing mass of the ovary, tube, or paratubal structures is identified or suspected to be causally related to the torsion. Nevertheless, evidence exists in the literature for torsion of normal adnexal struc tures. Torsion of otherwise normal tubes and ovaries seems to occur most frequently in chil dren or young adults. 3 In such patients, the ideal approach is a conservative operation—that is, one that restores the blood supply to the ischemic adnexa and preserves a viable tube or ovary; thus, the patient's maximal reproductive poten tial and endocrine function are maintained. Be cause the affected tube and ovary are often severely compromised, however, a conservative approach is frequently not possible and salpingooophorectomy commonly becomes necessary. Hibbard 1 emphasized the difficulties involved in salvaging the ovary in a patient with uterine adnexal torsion. Perhaps a major factor is the delay in diagnosis and definitive treatment that often occurs. Several authors have described the constellation of signs and symptoms found in this disorder, yet the range in severity and initial manifestations is broad. 4 In a recent series, Hib bard 1 reported that the preoperative diagnosis had been accurate in only 85 of 225 patients (38%). Palpation of an adnexal mass is often crucial in recognizing this disorder, but this means of detection is frequently not possible in a young child, because of the high position of the ovaries at this age. 5 Ultrasound examination may be useful in such a situation and may reveal a unilaterally enlarged ovary with cystic dilata tion of follicles.6 In general, however, extensive preoperative studies only waste time when early abdominal exploration is indicated. Laparoscopy sometimes will prove useful in those cases in which the diagnosis remains in doubt and the need for laparotomy is uncertain. At laparotomy, distinguishing edematous, con gested, yet viable tissues from those that have undergone irreversible infarction and necrosis is often difficult by inspection alone. Way,7 among other proponents, advocated untwisting of the pedicle followed by a brief period of observation for signs of improved perfusion that might ensue. Others 1 have been reluctant to untwist the pedicle because of the concerns of embolization of blood clot or, in some cases, malignant cells. When DISCUSSION Uterine adnexal torsion can occur at any age but necrosis and destruction of the adnexa are ob is most common in women of reproductive age. vious, nothing is gained by untwisting the ped-
Mayo Clin Proc, July 1987, Vol 62
SEQUENTIAL TORSION OF THE UTERINE ADNEXA
icle. Perhaps in those patients with partial com promise, the pedicle can be unwound and the possibility of ovarian or tubal preservation can be further assessed. This approach may be ap plicable in a young patient in whom a malignant process is not suspected, necrosis is not obvious, the pedicle is only loosely twisted, and the ovar ian vein is minimally distended at the base of the torsion. As our case illustrates, torsion of the contralateral, apparently normal adnexa can occur. We agree with those who.have recommended fixation of the remaining ovary by permanent suture to the pelvic sidewall at the time of oophorectomy for torsion. Excessive tension on the suspended adnexa should be avoided because it may inter fere with the adnexal blood supply or the depo sition of ova in the uterine tube. Alternatively, an unusually long utero-ovarian ligament might
be plicated. Although no definitive data are avail able to support these measures, they should help to prevent another adnexal torsion. REFERENCES
625
1. Hibbard LT: Adnexal torsion. Am J Obstet Gynecol 152:456-461, 1985 2. Dunnihoo DR, Wolff J: Bilateral torsion of the adnexa: a case report and a review of the world literature. Obstet Gynecol 64 (Suppl 3):55S-59S, 1984 3. Berger RL, Robbins G: Torsion of the normal ovary. Am J Surg 102:716-719,1961 4. Lee RA, Welch JS: Torsion of the uterine adnexa. Am J Obstet Gynecol 97:974-977,1967 5. James DF, Barber HRK, Graber EA: Torsion of normal uterine adnexa in children: report of three cases. Obstet Gynecol 35:226-230, 1970 6. Graif M, Shalev J, Strauss S, Engelberg S, Mashiach S, Itzchak Y: Torsion of the ovary: sonographic features. AJR 143:1331-1334, 1984 7. Way S: Ovarian cystectomy of twisted cysts. Lancet 2:4748, 1946
BACK COPY/MISSING COPY POLICY Orders for back issues of the Mayo Clinic Proceedings must be prepaid. Single copies are $4.00 each. Missing copies (issues that were not received) will be provided free of charge if we are notified no later than two months after the issue date. After this deadline, we must ask our subscribers to pay the price of $4.00 per issue. All orders must be prepaid. Please send your check and your order to: Mayo Clinic Proceedings Circulation Office Room 1035, Plummer Bldg. Mayo Clinic Rochester, M N 55905