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 sympton 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.
CASE REPORTS
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 nausea 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 5cmleft adnexal mass. She has 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 –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
the left salpingectomy; this was accomplished without complication.
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 paratubal cystadenofibroma.
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 sever 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 include 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 illdefined, with areas of cystic change and hyperechogenicity. Results for Doppler colorflow 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 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.
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 relied 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 repots.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,ii 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 varied 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 study 5 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.
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.
1
Krissi H, Shalev J, Bar-Hava I, Langer R, Herman A, Kaplan B. Fallopian tube torsion: laparoscopic
evaluation and treatment of a rare gynecological entity. J Am Board Fam Pract. 2001;14(4):274-277
2
Adekanmi OA Barrington JW, Edwards G, Farrell D. Isolated torsion and haemorrhagic infarction of a
normal fallopian tube in an eleven year old girl . BJOG. 2000;107(8):1047-1048.
3
Monteagudo A, Margulies R, Berg R. Ultrasound clinics. Gynecologic emergency: torsion of the right
fallopian tube pregnancy. Contemp OB/GYN. 2004;49:76-81.
4
Varras M, Tsikini A, Polyzos D, Samara CH Hadjopoulos G, Akrivis CH, Hadjopoulos G, Akrivis CH.
Uterine adnexal torsion: pathologic and gray-scale ultrasonographic findings. Clin Exp Obstet Gynecol.
2004;31(1):34-38.
5
Pena JE, Ufberg D, Cooney N, Denis AL, Usefulness of Doppler sonography in the diagnosis of ovarian
torsion. Fertil Steril. 2000;73(5):1047-1050.
6
Albayram F, Hamper UM. Ovarian and adnexal torsion: spectrum of sonographic findings with pathologic
correlation. J Ultrasound Med. 20001;20(10):1038-1089.
7
Shukla R. Isolated torsion of the hydrosalpinx: a rare presentation. Br J Radiol. 2004;77(921):784-786
8
Darwish AM, Amin AF, Mohammad SA. Laparoscopic management of paratubal and paraovarian cysts.
JSLS. 2003;7(2):101-106.