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Case Report
Rare, Isolated Fallopian
Tube Torsion
Roberto P. Harris, MD; Larry Barmat, MD
Isolated fallopian tube torsion is an uncommon cause of acute, lower abdominal
pain. The diagnosis is difficult and often delayed due to the lack of pathognomonic
symptoms, characteristic physical signs, and specific imaging and laboratory
studies. Ultrasonography and computed tomography (CT) can demonstrate changes
suggesting tubal torsion, but definitive diagnosis requires surgical exploration.
The exact etiology of fallopian tube torsion is unknown. Torsion has been reported more frequently in association with cysts, tumors, surgical sterilization, primary carcinoma of the fallopian tube, hematosalpinx, hydrosalpinx, labor, and endometriosis in premenarchal girls.1
The most common symptom of fallopian tube torsion is pelvic pain projecting to the side of the torsion. It is often accompanied by gastrointestinal (GI) symptoms (eg, nausea, vomiting). A sensitive adnexal mass may be found on vaginal examination, or cervical-motion tenderness mimicking pelvic inflammatory disease. The authors report two cases of isolated fallopian tube torsion seen in a short period of time.
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CASE REPORT
Case 1
A 17-year-old virginal girl was transferred from her local hospital
to the authors’ emergency department secondary to a 3-day
history of left lower-quadrant pain and a large adnexal mass viewed
on ultrasonography. The pain was associated with nau-sea but no
emesis or bowel/urinary symptoms. The patient had experienced a
similar episode with less intense pain 3 months earlier, with ultrasonographic
findings demonstrating a 5-cm left adnexal mass. She had been discharged
following resolution of the pain with analgesics, and had remained
asymptomatic on follow-up.
The patient’s vital signs were stable on arrival at the
emergency department, and she was afebrile. Physical findings were
significant for tenderness in the left lower quadrant, with voluntary
guarding and rebound. Bowel sounds were normal and active. Manual
pelvic examination was deferred due to an intact hymen. The patient
was in extreme discomfort and could not tolerate rectal examination.
Laboratory findings included
a negative serum pregnancy
test, normal white blood cell (WBC) count, hemoglobin level of
15.6 g/dL, and a normal urine analysis. Transabdominal ultrasonography showed
a large, left cystic adnexal mass
of 7.5-cm maximal diameter containing a mildly thickened septum
on posterior acoustic enhancement. There was also an 8-mm focal mural nodule
in the posterior aspect of the mass. No free fluid was seen. Left ovarian
flow could not be adequately assessed secondary to the patient’s body
habitus and because transvaginal examination was contraindicated in the
presence of an intact hymen.
The acute onset of pain, physical findings consistent with a “surgical” abdomen,
and detection of an adnexal mass on ultrasonography raised suspicion
for torsion of the left adnexal structures. However, other possible
sources of pain could not be excluded (eg, hemorrhagic cyst, tubo-ovarian
abscess, leaking cyst). Therefore, it was decided that the patient
should undergo diagnostic laparoscopy.
Under anesthesia, rectal examination confirmed the ultrasonographic
findings of a left adnexal mass. Laparoscopic evaluation revealed three
twists in the left fallopian tube, which contained a 5 x 6-cm paratubal
cyst. The left fallopian tube was necrotic, and clots were noted at the
fimbriated end (Figure). A mild hemoperitoneum with approximately 50 mL
of blood was found in the cul-de-sac. The left ovary, right adnexa, and
appendix were normal. The tube was detorsed, but there was no evidence
of return of blood flow after careful observation. Given the signs of
necrosis, it was deemed necessary to perform a left salpingectomy; this
was accomplished without complication.
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Figure not available online
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Necrotic fallopian
tube with clotting at the fimbriated end.
Courtesy of Roberto P. Harris, MD; Larry Barmat, MD. |
Gross pathologic examination demonstrated a paratubal cyst, and fragments of pink/red hemorrhagic, membranous soft tissue. Several of the inner surfaces had focal red/tan fibrous papillations measuring up to 0.5 cm in diameter. Findings for the left fallopian tube were consistent with hemorrhagic infarction. Microscopic examination showed a para-
tubal cystadenofibroma.
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Case 2
A 15-year-old virginal girl was evaluated in the authors’ emergency
department with a 2-day history of intermittent left lower-quadrant pain.
The pain became severe and was accompanied by nausea; no GI symptoms
were noted. The patient had been examined at her local hospital the day
before with milder complaints, and a 3-cm ovarian cyst was noted on CT.
On physical examination, the patient was in moderate distress, but
her vital signs were within normal limits. Abdominal assessment demonstrated
left lower-quadrant tenderness, with guarding and rebound. Manual pelvic
examination was deferred due to an intact hymen. Rectal evaluation showed
a tender left adnexal mass. Laboratory findings included a negative urine
pregnancy test, a normal WBC count, and a normal hemoglobin level.
Transabdominal pelvic ultrasonography showed a dilated, anechoic
tubular structure on the left side measuring approximately 7.4
x 2.4 cm. The left adnexa was ill-defined, with areas of cystic change
and hyperechogenicity.
Results for Doppler color-flow imaging were normal within the
echogenic portion of the left adnexa, which was thought to be the left
ovary. The
right ovary yielded normal color flow and wave forms. A small
amount of free pelvic fluid was also identified.
The differential diagnosis
included ruptured corpus luteum, adnexal abscess, or torsion of
adnexal structures. The index of suspicion for torsion was raised due
to the acute, severe, unilateral lower abdominal pain in association
with a dilated left adnexa and different echo levels
on ultrasonography. In addition, normal Doppler color-flow imaging
was confined to the echogenic portion of the adnexa. It was therefore
decided to perform diagnostic laparoscopy.
Laparoscopic evaluation showed minimal free fluid and a swollen,
7-cm left fallopian tube with a distal, necrotic paratubal cyst that was
causing a triple twist in the tube. The left ovary was normal, as were
the right fallopian tube, ovary, and the uterus. There was no evidence
of endometriosis. Attempts at detorsion failed. The left fallopian tube
was extremely friable, with an extensive area of destruction at the fimbriated
end. Salpingectomy was performed using bipolar cautery, but the
left ovary was preserved.
The fallopian tube and cyst were submitted for pathologic evaluation. The specimen showed fragments of fallopian tube with no malignant transformation and a necrotic paratubal cyst.
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DISCUSSION
Determining the etiology of acute pelvic pain can be very challenging
due to the diversity of presentations and variety of possible causes. The diagnosis of isolated
torsion of a fallopian tube is particularly difficult and is often
delayed because of its rarity. Despite this infrequency, the authors
treated the two cases described here in a 3-month period.
The presumptive diagnosis of fallopian tube torsion relies on
both clinical suspicion and noninvasive imaging findings. Clinically,
the patient presents with acute, unilateral pelvic pain and the
classical peritoneal signs of rebound and cervical-motion tenderness
on pelvic examination. These patients’ clinical symptoms
of pelvic pain and nausea are
consistent with previous reports.1,2 Both
patients experienced intermittent episodes of pain prior to hospital
admission. The
history of pain with resolution of symptoms followed by acute exacerbation
has likewise been described elsewhere,2 and
may be secondary to twisting and untwisting of the fallopian tube.
The ultrasonographic
findings described in the first case showed a cystic left adnexal
mass with a thickened septum, as well as a mural nodule on posterior
acoustic enhancement similar to those in the literature.3 In the
second case, ultrasonography showed dilation of the tube with no
echoes. The presence of free fluid was an inconsistent finding
in both cases, as well as those reported in the literature.2,3
The normal fallopian tube is rarely visible on ultrasonography
because of its narrow diameter and lack of clear echogenic features.
Occasionally, a fallopian tube can be seen if it is surrounded
by fluid, but a tube that is visible on ultrasonography is probably
abnormal. Ultrasonographic features of selective torsion of the
fallopian tube include tubal wall thickening, hematosalpinx, and
an adnexal mass with a wide range of echogenicities.3 The spectrum
of ultrasonographic findings varies depending on the adnexal pathology,
the degree of severity, and the duration of adnexal torsion.
One retrospective study analyzed 20 patients who underwent preoperative
ultrasonographic examination with adnexal torsion confirmed at
surgery.4 Gray-scale
imaging demonstrated cystic lesions in 80% (16/20), solid masses
in 5% (1/20), and normal adnexae in 15%;
cul-de-sac fluid was present in 55% (11/20).
If arterial and venous blood flow is present, the likelihood of
adnexal torsion is decreased. However, another retrospective study5 found
that Doppler color flow was normal in 60% of surgically confirmed
ovarian torsions. Although Doppler assessment was highly specific—all
cases with abnormal findings were surgically confirmed as ovarian
torsion—it was not very sensitive, missing the diagnosis 60%
of the time. Thus, the diagnosis of ovarian or adnexal torsion
cannot
be based solely on Doppler findings, as the presence of arterial
or venous flow does not exclude this possibility.6
The exact cause of fallopian tube torsion is unknown. It is very
unlikely in normal, intact adnexa and has been associated with
ovarian cysts and tumors.7,8 It
has also been described during pregnancy and after surgical sterilization.
The proposed mechanism
is a sequential, mechanical event. The process is thought to begin
with blockage of the adnexal veins and lymphatic vessels by an
ovarian tumor, pregnancy,
hydrosalpinx, postinfection adhesions, or pelvic surgery. Such
obstruction leads to pelvic congestion and local edema, with subsequent
enlargement of the adnexa. This in turn predisposes the tube to
partial or complete torsion.
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CONCLUSION
These two unique cases occurring in a short period of time have raised
the authors’ awareness of isolated tubal torsion as a possible cause
for acute pelvic pain. Furthermore, it is noteworthy that both cases involved
virginal adolescents in whom sexually transmitted infections, pregnancy,
and sterilization were not considerations. These cases emphasize the need
to include tubal torsion in the differential diagnosis even in patients
with an unremarkable gynecologic/obstetric history.
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Roberto P. Harris, MD, is resident in obstetrics and gynecology, Albert Einstein Medical Center, Philadelphia, Penn. Larry
Barmat, MD, is attending physician in reproductive endocrinology and infertility, Abington Memorial Hospital, Pennsylvania; director of Coculture and the Donor Egg Program, Abington Reproductive Medicine, Pennsylvania; and director, Division of Reproductive Endocrinology and Infertility, Albert Einstein Hospital, Philadelphia, Penn.
References
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OB/GYN. 2004;49:76-81.
- Varras M, Tsikini A, Polyzos D, Samara CH, Hadjopoulos G, Akrivis CH. Uterine adnexal torsion: pathologic and gray-scale ultra-
sonographic findings. Clin Exp Obstet Gynecol. 2004;31(1):34-38.
- Pena JE, Ufberg D, Cooney N, Denis AL. Usefulness of Doppler sonography in the diagnosis of ovarian torsion. Fertil
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- Albayram F, Hamper UM. Ovarian and adnexal torsion: spectrum of sonographic findings with pathologic correlation. J
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- Shukla R. Isolated torsion of the hydrosalpinx: a rare presentation. Br
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784-786.
- Darwish AM, Amin AF, Mohammad SA. Laparoscopic management of paratubal and paraovarian cysts. JSLS. 2003;7(2):101-106.
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