Adexal torsion

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124 AJR:189, July 2007

AJR2007; 189:124129

0361803X/07/1891124

American Roentgen Ray Society

r et al.

f Adnexal Torsion

G e ni t ou r in a r y I m ag i ng C l in i ca l O b s er v at i on s

CT Features of Adnexal Torsion

Nurith Hiller1

Liat Appelbaum1

Natalia Simanovsky1

Ahinoam Lev-Sagi2

Dvora Aharoni3

Tamar Sella1

Hiller N, Appelbaum L, Simanovsky N, Lev-

Sagi A, Aharoni D, Sella T

Keywords: adnexa, adnexal torsion, CT, pelvic imaging,

womens imaging

DOI:10.2214/AJR.06.0073

Received January 15, 2006; accepted after revision

October 31, 2006.

1Department of Radiology, Hadassah-Hebrew University

Medical Center, PO Box 12227, Jerusalem, Israel, 91121.

Address correspondence to T. Sella

([email protected]).

2Department of Gynecology, Hadassah-Hebrew University

Medical Center, Jerusalem, Israel.

3Department of Radiology, Shaare Zedek Medical Center,

Jerusalem, Israel.

OBJECTIVE. Adnexal torsion is most commonly a clinical diagnosis, often aided by sono-

graphic findings. At times, the clinical presentation can mimic nongynecologic causes of acute

lower abdominal pain. In these cases, CT may be the initial imaging study. The purpose of this

study was to define the CT features associated with adnexal torsion.

CONCLUSION. On CT, a well-defined adnexal mass abnormally located in the pelvis with

ipsilateral deviation of the uterus in a woman or girl with lower abdominal pain should raise the

suspicion of adnexal torsion. Inflammatory signs on CT suggest the presence of necrosis.

dnexal torsion is a gynecologic

emergency caused by partial or

complete twisting of the mesovar-

ium. Early surgical intervention is

needed to save the ovary. The diagnosis is

most commonly a clinical one aided by

sonography. However, because the clinical

presentation of adnexal torsion can mimic

other causes of acute abdominal pain, CT

sometimes is performed in equivocal cases. In

addition, if the clinical presentation is un-

clear, CT may be the initial diagnostic imag-

ing examination performed. Thus familiaritywith the spectrum of CT characteristics of ad-

nexal torsion is essential for prompt recogni-

tion of this potentially serious condition. Our

review of the literature revealed descriptions

of the CT characteristics of adnexal torsion in

only a few small series of patients [13]. The

goal of our study was to define the CT fea-

tures associated with adnexal torsion and to

correlate these features with the clinical,

sonographic, surgical, and pathologic find-

ings. To our knowledge, our series is the larg-

est described in the literature.

Materials and MethodsA search of two university hospital registries for

the years 19952005 identified the records of 328

patients with surgically proven adnexal torsion.

Thirty-five (10.7%)of these patients underwent CTas part of a preoperative evaluation. CT examina-

tions were performed with one of the following

scanners: 2400 Elite scanner (Elscint), helical Twin

Flash scanner (Philips Medical Systems), 4-MDCT

MX 8000 scanner (Philips Medical Systems). The

standard parameters for abdominal CT for each ma-

chine were used, that is, 5-mm slice thickness with

a table increment of 5 mm and a pitch of 11.5.

Tube current and kilovoltage were adjusted to the

type of machine and size of the patient. Oral con-

trast material (1,000 mL meglumine ioxithalamate,

Telebrix 3%, Guerbet) was administered to all pa-

tients 90 minutes before CT. Intravenous contrast

material (100 mL meglumine ioxithalamate, Te-

lebrix 30, Guerbet) was administered to all but four

patients according to a standard injection protocol

at an injection rate of 2.5 mL/s.

Clinical information obtained from the patientsmedical records included age, medical history, and

clinical signs and symptoms at presentation. Fever

was defined as body temperature exceeding 37.5C.

Abdominal pain was defined as lower abdominal

pain, flank pain, or both. The onset of abdominal pain

was defined as acute when occurring up to 24 hours

before admission, subacute if it had lasted up to 1

week, and chronic if it had persisted for more than 1

week before admission. Laboratory values were re-

viewed with emphasis on inflammatory markers. An

elevated WBC count was defined as greater than

10,000/mm3. Sonographic findings were extracted

from the charts, and images were reviewed when

available. Hospital institutional review board ap-proval was obtained for this retrospective study.

Two radiologists, each with more than 10 years

of experience in body imaging, retrospectively re-

viewed all CT scans. For each adnexal mass found

on CT scans, the size, nature (cystic, solid, or com-

bined), borders, and location within the pelvis were

assessed. For adnexal findings with a cystic compo-

nent, mural thickness was measured and defined as

abnormal when greater than 3 mm. Uterine loca-

A


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CT of Adnexal Torsion

AJR:189, July 2007 125

tion, visualization of the contralateral ovary, and

changes in the adjacent pelvic fat and blood vessels

also were assessed. Surgical and pathologic find-

ings were recorded separately, and the radiologists

evaluating the CT scans were blinded to these find-

ings. Data were collected and analyzed with de-

scriptive statistics.

ResultsClinical Presentation

The age range of the patients was 585

years (mean, 38.5 years). Three (9%) of the

35 patients (ages 5, 9, and 12 years) were

premenarchal, and 10 (29%) were post-

menopausal. Abdominal pain was clinically

present in all patients. Pain was located in

the lower abdomen in 29 (83%), in the flank

in three (8.5%),and in both the lower abdo-men and the flank in another three (8.5%) of

the patients. The pain was ipsilateral to the

involved adnexa in 26 (74%) of the patients.

The onset of pain was acute in 21 (60%),

subacute in nine (26%), and chronic in five(14%) of the patients. Additional clinical

signs and symptoms included nausea or

vomiting in 16 (46%), elevated WBC count

in 15 (43%), peritoneal signs in 12 (34%),

and fever in seven (20%) of the patients.

Peritoneal signs correlated invariably with

the presence of adnexal necrosis at patho-

logic examination. All other signs and symp-

toms showed no such correlation.

Sonographic Findings

Sonography was performed on 33 (94%)

of the 35 patients, revealing an adnexal mass

in 31 patients. The size range of the lesions

was 320 cm (mean, 9.5 cm). Findings were

solid on sonography in seven (23%), simple

cyst in three (10%), multiloculated cystic in

10 (32%), and mixed solid and cystic in 11

(35%) of the 31 cases. In 25 patients, thesonographic study preceded CT. Torsion was

not diagnosed in 16 of these 25 patients. The

sonographic findings were interpreted as

hemorrhagic corpus luteum cyst in three pa-

tients, pedunculated necrotic myoma in two

patients, uncomplicated dermoid cyst in two

patients, benign cyst in two patients, pelvic

mass unrelated to the adnexa in one patient,

and endometrioma in one patient. In the

other five patients, the adnexa appeared ab-

normal on sonography, but a specific diagno-

sis was not made, and patients were referred

for CT for further evaluation. The correct di-

agnosis of adnexal torsion was made onsonography before CT in nine cases and was

later confirmed on CT. Doppler sonography

was performed on only 11 (33%) of 33 pa-

tients, revealing abnormal adnexal vascular

flow in six (55%) and normal flow in five

(45%) of the patients. On the basis of clinical

and sonographic findings, the diagnosis of

adnexal torsion was made before CT in only

nine (26%) of 35 cases.

Fig. 126-year-oldwoman with torsion ofright ovarian dermoid.Unenhanced CT scanshows well-defined fat-containing mass (M) toleft of uterus (U). Uterusis deviated to right.

Infiltration of fat (arrow)anterior to twisted massis evident. Pathologicexamination revealednecrosis.

Surgery

Twenty-five (71%) of the 35 patients un-

derwent laparotomy, and 10 (29%) underwent

laparoscopic surgery. The surgical finding

was full torsion (at least 360o) in 29 (83%)

and partial torsion (90270o) in six (17%) of

the patients. Torsion of the ovary and fallo-pian tube was found in 21 (60%), torsion of

the ovary alone in 13 (37%), and isolated tu-

bal torsion in only one (3%) of the patients.

The surgical procedure included total abdom-

inal hysterectomy and bilateral salpingo-

oophorectomy in 11 (31.5%), unilateral salp-

ingo-oophorectomy in 13 (37%), removal of a

benign ovarian tumor with preservation of the

ovary in three (8.5%), adnexal detorsion and

cyst aspiration in four (11.5%), and adnexal

detorsion with no further intervention in four

(11.5%) of the patients.

PathologyPathologic examination revealed an ovarian

cyst or mass in 25 (71%) of the 35 patients. The

mean age of patients with an underlying

ovarian lesion was 44 years (median, 45

years); the mean age of patients with no under-

lying lesion was 25 years (median, 19 years).

Two patients with an ovarian mass were pre-

menarchal, and both had a mature teratoma.

The most common histologic diagnosis was

mature teratoma (Fig. 1), found in eight (32%)

of the 25 patients. Additional histologic diag-

noses included benign cystadenoma in six

(24%), simple cyst in three (12%), cystade-

nofibroma in three (12%), fibroma in three(12%), fibrothecoma in one (4%), and Brenner

tumor in one (4%) of the patients. Necrosis of

the torsed adnexa was encountered at patho-

logic examination in 20 (57%) of the 35 cases.

CT Findings

For 32 patients, CT was performed up to 1

week after admission, the interval ranging

from less than 24 hours to 1 week (mean, 1.7

days; median, 1.5 days). Three patients un-

derwent CT before admission to the hospital

for further evaluation of the CT finding. Ad-

nexal enlargement was found on CT of all pa-

tients, the maximal diameter ranging from 4to 20 cm (mean, 9.5 cm; median, 10 cm). Ab-

normalities were found equally on the right

and left sides (on the right in 18 and on the left

in 17 patients). All of the torsed adnexa had

well-defined smooth margins on CT. In 28

(80%) of the cases, the torsed adnexa had at

least a partially cystic component on CT

(Fig. 2), and in one half of these cases mural

thickening was present. The adnexal structure


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Hiller et al.

126 AJR:189, July 2007

A B

Fig. 258-year-old woman with torsion of left adnexa manifesting as left flank pain.A and B, Contrast-enhanced CT scan (A) and transabdominal sonogram (B) show large midline well-defined cystic mass with thickening of posterior wall (straight arrow, A)and internal septations (curved arrows). Pathologic examination revealed necrotic adnexa with no underlying tumor.

Fig. 341-year-old woman with left adnexal torsion. Contrast-enhanced CT scanshows abnormally located left ovary (LO) on contralateral side of pelvis in farposterior location. Ipsilateral fallopian tube (arrow) is distended. Right ovary(asterisk) is in normal position. Uterus (U) is deviated anteriorly. At surgery, ovary andfallopian tube were found to be torsed, and underlying mass was found. Pathologicexamination revealed necrotic cystadenofibroma of ovary.

Fig. 442-year-old woman with torsion of right ovary manifesting as chronic rightlower abdominal pain that gradually increased in severity. Contrast-enhanced CTscan shows enlarged right cystic ovary (RO) crossing midline of pelvis anterior touterus (U). Spiral appearance of adnexal vascular pedicle (arrow) is whirl sign.Pathologic examination revealed serous cystadenoma without necrosis.

involved was found in an abnormal location

in the pelvis in 22 (63%) of the patients. One

half of these abnormalities were on the con-

tralateral side of the pelvis (Fig. 3), and the

other half were found in a midline position.

Five of the 11 midline lesions were in a far

posterior location, in the pouch of Douglas,

and three were in a far anterior position, abut-

ting the anterior pelvic fascia (Fig. 4). The


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AJR:189, July 2007 127

uterus was deviated to the side of the involved

adnexa in 16 (46%) of the 35 patients (Fig. 5).

Thickening of the fallopian tube manifested

on CT as greater than 3 mm wall thickness andtubular distention. Thickening resulted in a tu-

bular masslike lesion or a target lesion, de-

pending on the configuration of the adnexa

(Fig. 5). This finding was present in six (17%)

of the 35 patients. Infiltration of periadnexal fat

was seen in 10 (29%) of the patients. All cases

of infiltration were associated with the patho-

logic finding of necrosis (Fig. 6). In one case a

plasmaerythrocyte level was clearly seen,

suggesting internal hemorrhage (Fig. 7).

The aforementioned and additional CT find-

ings are summarized in Table 1. The correct

preoperative diagnosis of adnexal torsion

based on CT findings was made for 12 (34%)of the 35 patients. Overall, 14 cases of adnexal

torsion were diagnosed on the basis of preop-

erative imaging findings. The CT diagnosis

agreed with the sonographic diagnosis of ad-

nexal torsion in seven (50%) of the 14 cases.

Discussion

Twisting of the adnexal vascular pedicle re-

sults in venous compromise followed by arte-

rial occlusion and ischemia of the adnexa with

subsequent necrosis. Although this condition

is a surgical emergency, the diagnosis is often

missed [4]. The clinical presentation is nonspe-cific and can mimic other abdominal condi-

tions, such as tuboovarian abscess, acute

appendicitis, torsion of epiploic appendix,

diverticulitis, and rupture of a corpus luteum.

Findings at physical examination are nonspe-

cific, and the examination is often limited by

pain. Although it is generally considered an

acute condition, adnexal torsion occasionally

takes a subacute or intermittent chronic course,

further complicating the diagnosis [5].

In our study, the clinical presentation of

adnexal torsion was not acute in 40% of the

patients. The pain was nonspecific, rarely

manifesting as flank pain, which is a symp-tom of renal colic. Gastrointestinal symp-

toms such as nausea and vomiting were quite

common (46%). No correlation was found

between these symptoms and the presence of

adnexal necrosis. Peritoneal signs were

present in 34% of the patients, all of whom

had complete torsion and pathologically

confirmed necrosis of the adnexa. Labora-

tory tests are usually not helpful in the diag-

nosis of adnexal torsion. Imaging therefore

plays a central diagnostic role.

Sonography is usually the initial imaging

technique performed when adnexal torsion oranother gynecologic pathologic condition is

suspected. The sonographic findings of ad-

nexal torsion are nonspecific and include the

presence of a cystic, solid, or complex pelvic

mass with or without mural thickening or the

presence of pelvic ascites [6]. A more specific

sonographic sign of torsion of a normal ovary

is evidence of multiple small homogeneous

cysts in the periphery of an enlarged ovary

[7]. However, such an appearance in a young

fertile women is not sufficient for a diagnosis

because a normal ovary with prominent folli-

cles has a similar appearance.

The added value of color Doppler sonogra-phy in the diagnosis of adnexal torsion has not

been fully established. In several studies with

small numbers of patients, investigators [69]

have concluded that the diagnosis or exclu-

sion of adnexal torsion cannot be reliably

based on the absence or presence of flow on

color Doppler sonography. Those authors re-

marked that normal blood flow commonly is

seen in torsed adnexa. The identification of a

Fig. 550-year-old woman with torsion of left adnexa manifesting as acute leftabdominal pain. Contrast-enhanced CT scan shows left ovarian mass (LO) crossingmidline to right side. Twisted vascular pedicle and dilated fallopian tube (arrow) areevident to left of mass. Uterus (U) is deviated to side of torsed adnexa. Right ovary,which contains small simple cyst (asterisk), is in normal location. At surgery, ovaryand fallopian tube were found to be torsed, and underlying mass was found.Pathologic examination revealed necrosis of left ovary and fallopian tube withovarian mucinous cystadenoma.

Fig. 620-year-old woman with acute lower abdominal pain. Contrast-enhanced CTscan shows torsion of left ovary (LO) in right side of pelvis. Right ovary (RO) is innormal location, and uterus (U) is markedly deviated to involved left side. Mild fatstranding (arrow) anterior to torsed ovary is evident. Pathologic examinationrevealed necrotic adnexa with no underlying mass. B = bladder.


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AJR:189, July 2007 129

United States [12], and most of the patients do

not undergo CT. It therefore is difficult to col-

lect a larger series of cases. Our observations

were subject to selection bias because only pa-

tients referred for CT were included, and these

patients usually posed a complicated diagnos-

tic challenge. The retrospective nature of thisstudy also was a limiting factor, especially in

view of the major technical advancements in

CT and sonography over the long study period.

Further examination of this topic with a large

prospective study based on modern imaging

technology may be warranted.

Evaluation of adnexal torsion with CT is in-

frequent; however, recognition of the CT find-

ings of this potentially serious condition is ex-

tremely important. In cases of lower abdominal

pain in a woman or girl, the CT finding of a

smooth adnexal mass abnormally located in the

pelvis with ipsilateral deviation of the uterus

should raise suspicion of adnexal torsion.

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Adexal torsion