Cause of adnexal torsion

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dnexal torsion Rowena Findlay, ppsc (Medical Imaging), GradDipMedUltrasound, Monash Health, Vic Ovarian torsion is an infrequent but important cause of lower abdominal and pelvic pain in girls.

1 dnexal torsion Rowena Findlay, ppsc (Medical Imaging), GradDipMedUltrasound, Monash Health, Vic Ovarian torsion is an infrequent but important cause of lower abdominal and pelvic pain in girls. It is a gynaecological emergency that requires prompt surgical intervention. [1] lka S Karnik 2006 Introduction Ovarian torsion is the 5th most common surgical emergency [2,3] and makes up 2.7 3% of all acute gynaecologic complaints [2,4]. s ovarian torsion coexists with tubal torsion in up to 67% of patients, this paper will consider adnexal torsion rather than just ovarian torsion. Historically, only 50% of adnexal torsion cases are diagnosed using ultrasound [5] and ultrasound has a false positive rate approaching 50% [6]. Most research into adnexal torsion is retrospective and involves low case numbers so conclusive ways of diagnosing and managing adnexal torsion are poorly researched. This paper s the literature that is available on adnexal torsion to identify ways of improving ultrasound detection rates in this clinically and sonographically difficult group of patients. However, by ing the literature, we discovered a few simple ways to improve the ultrasound detection rates. Clinical presentation The clinical presentation of adnexal torsion is wide and varied making the diagnosis difficult for the practitioner [7]. The classical clinical presentation of adnexal torsion is pain, nausea, vomiting, urinary symptoms, fever and increased WC count [8]. The problem is the patient can present with all or some of these symptoms and all of these symptoms overlap with other pathologies, further complicating the diagnosis [9,10]. There is also no sensitive biochemical marker for adnexal torsion [11], although there is some evidence an elevated interleukin-6 may help identify patients that will require surgery [8]. CT and MRI detection rate for adnexal torsion is similar to ultrasound, which until recently was poor [12]. ll of these factors make the role of ultrasound important to give the surgeons some confidence in the diagnosis before surgery. Cause of adnexal torsion In adnexal torsion, we know the ovary twists on its vascular pedicle causing a reduction or complete loss of blood flow; this twisting rarely occurs in isolation [13]. eing aware of the causes of adnexal torsion can help the sonographer identify the torsion. The most common cause of adnexal torsion is a mass greater than 5 cm which has been reported to cause anything from 50 to 81% of adnexal torsions [12]. The most common mass which causes adnexal torsion is a cyst, complex or simple [14]. Malignant masses are more likely to invade the surrounding structure so are less susceptible to movement and therefore to torsion. Roughly 2% of adnexal torsions are caused by malignant masses [10]. Other causes include: ovarian hyperstimulation (OHSS) due to in-vitro fertilisation (IVF) treatment, causing enlargement of the ovary which can cause the ovary to rotate on its axis and cut off the ovarian blood supply. Sixteen per cent of women with OHSS will develop adnexal torsion [7] and it is the cause of 48.5% of all adnexal torsions [15] pregnancy can cause movement of the uterus and ovaries out of the pelvis and into the abdomen in the first trimester, which can in turn cause the adnexa to rotate. This is responsible for 17 20% of torsions [7] pelvic surgery, especially tubal ligation, thought to cause adhesions on the fallopian tube limiting the movement of this portion of the adnexa. The adnexa can twist around the adhered anatomy [13] polycystic ovarian syndrome (PCOS) causing enlargement of the ovaries which can result in movement of the ovary and rotation around its vascular pedicle [15,16]. Torsion in a normal ovary usually occurs in the premenarchal patient [2]. This is thought to be because of elongated pelvic ligaments and mobile fallopian tubes [7]. Torsion in the menarchal patient rarely occurs without one of the pre-mentioned causes. Pathophysiology dnexal torsion is a cascade of changes that results in compromise to ovarian blood flow and ovarian ischaemia. When the adnexa begins to torse, or is mildly 16

dnexal torsion peer some techniques that can help improve the ultrasound diagnosis rate of adnexal torsion. Fig 1. Classical ultrasound appearance of ovarian torsion.

2 dnexal torsion peer some techniques that can help improve the ultrasound diagnosis rate of adnexal torsion. Fig 1. Classical ultrasound appearance of ovarian torsion. 30-year-old presents with sudden right-sided pelvic pain. Ultrasound demonstrated an enlarged, avascular right ovary with an echogenic central area and multiple peripheral cysts. t surgery, the ovary was found to be torsed and it had to be removed as adequate blood supply could not be restored twisted, the first thing that occurs is the venous flow is reduced and then blocked. The continued arterial flow engorges the ovary and causes it to enlarge [11]. This can be referred to as incomplete adnexal torsion [17]. This enlargement continues to compress the blood vessels and will eventually compress the arterial supply causing loss of blood flow in the ovary resulting in necrosis [18]. The ovary has a dual blood supply, one laterally and one medially [19], therefore it is possible to tort off the arterial supply medially and still be obtaining blood flow laterally. While the dual blood supply can sustain the ovary in the short term, it can also be a source of potential confusion and misdiagnosis [5,18]. Classic ultrasound appearance This pathogenesis causes a classic ultrasound appearance we should all be familiar with (fig 1). It includes: focally tender ovary [7] the vascular engorgement of the ovary and the eventual ischemia will cause the ovary to be probe tender unilateral enlargement of the ovary [7,12,16,17,20 22] again, the vascular engorgement of the ovary caused by reduced or no vascular outflow will cause the ovary to enlarge multiple small peripheral cysts [7,17, 20 22] these are actually follicles that are displaced peripherally by the vascular engorgement of the ovary central echogenic stroma [17] this is the visualisation of the vascular engorgement of the ovary no or reduced internal vascularity [2,11, 12,16 19,21] the degree of pedicle torsion will affect the vascular appearance of the ovary, with the venous flow affected before the arterial flow. Unfortunately, when we use this classical criterion we know only 50% of torsion cases are diagnosed using ultrasound [5] and ultrasound has a false positive rate approaching 50% [12]. It is also thought once these ultrasound criteria are found, the viability of the ovary at surgery is low [18], possibly because once these signs are present, the ovary has been without blood supply for too long a period. Strategies for improving ultrasound diagnosis y ing the current literature on adnexal torsion it is possible to find Clinical presentation The first step the sonographer can take is to obtain a thorough clinical history [15]. The classical clinical presentation of adnexal torsion is a sudden onset of pain, nausea, vomiting, urinary symptoms and fever [8]. e aware that all of these symptoms or none of them can occur. When a female patient is having any discomfort in the iliac fossa or adnexal areas, it is essential that you look at the patient s ovaries. Even from a transabdominal scan you can usually determine if there is enlargement of an ovary or tenderness over the area and determine if an endovaginal scan may be necessary, if possible. Look for a cause dnexal torsion rarely occurs in isolation [5]. Searching for a cause of the torsion can help you build a case for torsion being present. mass greater than 5 cm is the most common cause of adnexal torsion (fig 2), having a sensitivity of 50 81% [5]. s discussed previously, the mass within the ovary causes the ovary to move within the pelvic cavity as it seeks room to exist within the pelvis. This movement can be a rotating motion which rotates the ovarian pedicle and compromises the ovarian blood supply [23]. OHSS, pregnancy [most common in first trimester), previous pelvic surgery and PCOS are other causes of adnexal torsion that the sonographer can look for. Vascularity e aware the vascularity of adnexal torsion evolves over time and with the degree of torsion [11]. The venous flow will be the first to be affected [24]; it will lose the continuous forward flow first (fig 3) and eventually progress to complete loss of flow. Secondly, the arterial flow is affected. The ovary will lose arterial flow centrally first (fig 4) ISSUE

was able to demonstrate the whirlpool sign (D).

cyst; (D) Whirlpool sign in left adnexa.

(E) Surgical photo of the normal left ovary (arrow) and the torsed fallopian tube

23-year-old presented with mild RIF pain that worsened when she played netball.

3 dnexal torsion C D E Fig 2 (above). 32-year-old presented with a sudden onset of LIF pain. She had a known ovarian cyst. The ultrasound demonstrated a normal left ovary with good arterial () and continuous venous flow (). The left adnexa had a large adnexal simple cyst (C) (> 5 cm) and the sonographer was able to demonstrate the whirlpool sign (D). The patient went to surgery and was found to have a normal left ovary with a torted fallopian tube (E). The tube was odematous and arterial supply could not be returned to it, so it was removed. () rterial flow in ovary; () Continuous venous flow in ovary; (C) Left adnexal cyst; (D) Whirlpool sign in left adnexa. etween the uterus and ovary the tissue is visualised forming a circular pattern; (E) Surgical photo of the normal left ovary (arrow) and the torsed fallopian tube (arrowhead) Fig 3 (left, right and below). 23-year-old presented with mild RIF pain that worsened when she played netball. Ultrasound showed a tender enlarged right ovary with good arterial flow () but intermittent venous flow (). The whirlpool sign was shown in the right adnexa (C). The patient was managed conservatively and returned to the department once symptoms had resolved. The second ultrasound demonstrated a normal -mode ovary with good arterial flow (D), constant venous flow and resolution of the whirlpool sign. () Normal arterial flow; () Intermittent venous flow; (C) Whirlpool sign in right adnexa; (D) Right ovary once symptoms resolved C D 18

dnexal torsion peer Fig 4. 14-year-old with two days of right pelvic pain.

The surgeons detorted the ovary and the ovary returned to its normal colour and was left in situ.

4 dnexal torsion peer Fig year-old with two days of right pelvic pain. The ultrasound demonstrated an enlarged tender right ovary with a central echogenic area and arterial flow peripherally, but no flow centrally (). t surgery it was found to be torsed. The surgeons detorted the ovary and the ovary returned to its normal colour and was left in situ. repeat ultrasound post-surgery demonstrated the ovary had returned to a normal size and had good vascularity in the ovary (). () Peripheral arterial flow; () Post surgical appearance and then progress to complete lack of arterial flow [7]. Despite some early statements in the literature that suggest non viable ovaries can be determined by the observation of loss of vascularity [7,21,25], this has largely been discredited [11,17,26 28]. It is possible the degree of torsion and the period of time the ovary has been torsed tends to determine the level of ovarian vascularity, although there is not clear evidence to support this [19,24]. However, there has been evidence that the period of time the patient has had the symptoms affects the salvation rate of the ovary at surgery [29]. Whirlpool sign This can also be referred to as coiling [30]. The whirlpool sign is the visualisation of the twisted ovarian blood vessels that form loops in the shape of a whirlpool (figs 3,4). It has a very similar appearance to volvulus, where there is malrotation of the midgut, and testicular torsion where the testicular vessels twist within the testicular canal. To demonstrate this you need to move the probe back and forth along the axis of the fallopian tube or ovarian ligament. You will see a hypoechoic hetrogenous circular area that will appear lateral to the fundus of the uterus and extend towards the ovary. If the vascular supply to the ovary has not been completely cut off when you apply a low-scale colour Doppler, you will see the ovarian vessels travelling through this lesion in a circular fashion. Recent literature has come to identify that this may be our best way of identifying adnexal torsion [3,6]. Vijaraghaven et al. [3] in 2004 performed a small study of 21 patients of which 20 had surgically confirmed torsion and one patient was treated conservatively. ll of their patients had the whirlpool sign on ultrasound examination. Valsky et al. [6] in 2010 performed a respective study of their surgically confirmed ovarian torsions. They discovered that before they introduced their department to the whirlpool sign, 55.2% (of a total of 58 patients) of their patients were correctly diagnosed with ovarian torsion. Once the department was educated on the whirlpool sign, their positive confirmation of ovarian torsion increased to 90% (This study group included 22 patients). uslender et al. [11] in 2009 found that the whirlpool sign is present before there is increase in ovarian size and loss of vascularity. Since it is thought that the duration of adnexal torsion predicts the salvable rates of the ovary at surgery [29], and the whirlpool sign is the first ultrasound sign of adnexal torsion [11], this is a great way to improve ovary salvation rates from ultrasound diagnosis. We also have to be aware that when the ovarian vascularity is not compromised and the ovary shows no signs of torsion, but the whirlpool sign is identified, clinicians may choose to manage the patient conservatively [30] (fig 3). Conclusion dnexal torsion is a difficult but important diagnosis for the clinician to make. Ultrasound is still the best imaging modality for helping with this diagnosis. The sonographer needs to be aware the adnexal torsion is a dynamic condition, so the appearance on ultrasound is wide and varied. ll sonographers should already be aware of the classical presentation of adnexal torsion, which is the demonstration of unilateral ovarian enlargement, focal tenderness of the ovary, peripheral cysts, echogenic central stroma and intermittent or complete absence of venous flow and absent arterial flow. When considering the vascularity of the ovary, we know the ovary loses central flow first and arterial flow is the last to be absent. Intermittent venous flow is the first indication of vascular disruption to the ovary when there is adnexal torsion. dnexal torsion rarely occurs in isolation, so we should be trying to demonstrate causative factors such as a mass greater than 5 cm, OHSS, PCOS and pregnancy in the first trimester. It is also more common in patients with a history of pelvic surgery and premenarchal patients. ISSUE

5 dnexal torsion e aware of and actively search for the whirlpool sign which actually demonstrates the twisted adnexa and can be visualised before any other ultrasound signs are present. The whirlpool sign is a visualisation of the actual condition rather than looking for the resulting pathology of the condition. Initial research into the whirlpool sign suggests this sign may be the most effective way for ultrasound to improve its positive diagnostic rates. y applying the classic ultrasound appearance of adnexal torsion with a few more modern techniques, we can improve our ultrasound diagnosis rate of this condition. References 1. Karnik S, Sainani Md NI, Kamat Md NN. Sequential bilateral torsion of normal ovaries in a prepubertal child. J Clin Ultrasound. 2006;34(1):33 7. Epub 2005/12/ Hibbard LT. dnexal torsion. m J Obstet Gynecol. 1985;152(4): Epub 1985/06/ Vijayaraghavan S. Sonographic whirlpool sign in ovarian torsion. J Ultrasound Med. 2004;23(12):1643 9; quiz Epub 2004/11/ Willms, Schlund JF, Meyer WR. Endovaginal Doppler ultrasound in ovarian torsion: a case series. Ultrasound Obstet Gynecol. 1995;5(2): Epub 1995/02/ Lo LM, Chang SD, Horng SG, Yang TY, Lee CL, Liang CC. Laparoscopy versus laparotomy for surgical intervention of ovarian torsion. J Obstet Gynaecol Res. 2008;34(6): Epub 2008/11/ Valsky DV, Esh-roder E, Cohen SM, Lipschuetz M, Yagel S. dded value of the gray-scale whirlpool sign in the diagnosis of adnexal torsion. Ultrasound Obstet Gynecol. 2010;36(5): Epub 2010/06/ Chang HC, hatt S, Dogra VS. Pearls and pitfalls in diagnosis of ovarian torsion. Radiographics. 2008;28(5): Epub 2008/09/ Reed JL, Strait RT, Kachelmeyer M, yczkowski TL, Ho ML, Huppert JS. iomarkers to distinguish surgical etiologies in females with lower quadrant abdominal pain. cad Emerg Med. 2011;18(7): Epub 2011/07/ White M, Stella J. Ovarian torsion: 10- year perspective. Emerg Med ustralas. 2005;17(3): Epub 2005/06/ Martin C, Magee K. Ovarian torsion in a 20-year-old patient. CJEM. 2006;8(2): Epub 2006/12/ uslender R, Shen O, Kaufman Y, Goldberg Y, ardicef M, Lissak et al. Doppler and gray-scale sonographic classification of adnexal torsion. Ultrasound Obstet Gynecol. 2009;34(2): Epub 2009/07/ Rha SE, yun JY, Jung SE, Jung JI, Choi G, Kim S et al. CT and MR imaging features of adnexal torsion. Radiographics. 2002;22(2): Epub 2002/03/ Lo LM, Chang SD, Lee CL, Liang CC. Clinical manifestations in women with isolated fallopian tubal torsion; a rare but important entity. ust NZ J Obstet Gynaecol. 2011;51(3): Epub 2011/06/ Stark JE, Siegel MJ. Ovarian torsion in prepubertal and pubertal girls: sonographic findings. m J Roentgenol. 1994;163(6): Epub 1994/12/ Dagmois EJ, Jemma Ross, Jackie. n update on the diagnosis and management of ovarian torsion. The Obstetrician & Gynaecologist. 2012;14: Epub Zamindar DS. Unusual Presentation of cute Ovarian Torsion in PCOD. pollo Medicine. 2012;10(1016):1 7. Epub 2012/06/ lbayram F, Hamper UM. Ovarian and adnexal torsion: spectrum of sonographic findings with pathologic correlation. J Ultrasound Med. 2001;20(10): Epub 2001/10/ Nizar K, Deutsch M, Filmer S, Weizman, eloosesky R, Weiner Z. Doppler studies of the ovarian venous blood flow in the diagnosis of adnexal torsion. J Clin Ultrasound. 2009;37(8): Epub 2009/08/ Sivyer P. Pelvic ultrasound in women. World J Surg. 2000;24(2): Epub 2000/01/ M.D. JTS, M.D. MJS. Imaging of Pediatric Ovarian Masses. Radiographics Jul;11(4): Lee EJ, Kwon HC, Joo HJ, Suh JH, Fleischer C. Diagnosis of ovarian torsion with color Doppler sonography: depiction of twisted vascular pedicle. J Ultrasound Med. 1998;17(2):83 9. Epub 1998/04/ Chiou SY, Lev-Toaff S, Masuda E, Feld RI, ergin D. dnexal Torsion New Clinical and Imaging Observations by Sonography, Computed Tomography, and Magnetic Resonance Imaging. J Ultrasound Med. 2007;26: Sutton CL, McKinney CD, Jones JE, Gay S. Ovarian Masses Revisited: Radiologic and Pathologic Correlation. Radiographics Sept;12(5): Shadinger LL, ndreotti RF, Kurian RL. Preoperative sonographic and clinical characteristics as predictors of ovarian torsion. J Ultrasound Med. 2008;27(1): Epub 2007/12/ en-mi M, Perlitz Y, Haddad S. The effectiveness of spectral and color Doppler in predicting ovarian torsion. prospective study. Eur J Obstet Gynecol Reprod iol. 2002;104(1):64 6. Epub 2002/07/ Hurh PJ, Meyer JS, Shaaban. Ultrasound of a torsed ovary: characteristic grayscale appearance despite normal arterial and venous flow on Doppler. Pediatric Radiology. 2002;32(8): Epub 2002/07/ Pena JE, Ufberg D, Cooney N, Denis L. Usefulness of Doppler sonography in the diagnosis of ovarian torsion. Fertil Steril. 2000;73(5): Epub 2000/04/ Villalba ML, Huynh, So M, Mackenzie JD, Ledbetter S, Rybicki F. n ovary with a twist: a case of interesting sonographic findings of ovarian torsion. J Emerg Med. 2005;29(4): Epub 2005/10/ nders JF, Powell EC. Urgency of evaluation and outcome of acute ovarian torsion in pediatric patients. rch Pediatr dolesc Med. 2005;159(6): Epub 2005/06/ uslender R, Lavie O, Kaufman Y, ardicef M, Lissak, bramovici H. Coiling of the ovarian vessels: a color Doppler sign for adnexal torsion without strangulation. Ultrasound Obstet Gynecol. 2002;20(1): Epub 2002/07/09. 20

Sonographic Whirlpool Sign in Ovarian Torsion

Technical dvance Sonographic Whirlpool Sign in Ovarian Torsion S. oopathy Vijayaraghavan, MD, DMRD Objective. To describe an additional maneuver during sonography for ovarian torsion and to assess its