Our patient is a 34-year-old G0P0 white female who presented with complaints of right lower quadrant pain. The pain began suddenly the morning of admission upon stepping out of the shower. She described it as sharp, constant, nonradiating, and graded it as 10 out of 10 in intensity. Although her pain persisted, she did note episodes of improvement, followed by exacerbation. Her pain was improved with sitting and aggravated with walking and lying supine. She noted associated anorexia, nausea and emesis, and several episodes of watery diarrhea. She denied fever, vaginal discharge, or bleeding from the vagina, bladder, or rectum. Our patient did not recall a similar pain in the past. She was sexually active, but not currently contracepting, and denied prior pelvic infection.
During physical examination, vital signs included a temperature of 37.3°C, blood pressure of 140/79, pulse of 92 bpm, and respirations of 16/min. She was an obese white female in moderate discomfort. Remarkable findings included marked right lower quadrant tenderness with associated guarding and rebound tenderness. The remainder of her abdomen had generally mild tenderness with palpation. Bowel sounds were present and normal. No gross distension or fluid wave was appreciated.
Laboratory evaluation included a β-hCG assay with negative results, hemoglobin level of 14.8, and white blood cell count of 15,300. Liver function tests and electrolytes levels were within normal range. Her urine contained trace ketones, but no blood, leukocytes, or nitrites were noted. A vaginal smear was obtained and revealed no pathogens or increased leukocytes. Swabs of the endocervix for Neisseria gonorrhoeae and Chlamydia trachomatis were taken.
Radiologic evaluation included a sonogram, which showed an anteverted uterus of normal dimensions with normal myometrium and endometrium. Her right ovary was not seen and her left ovary contained a 3-cm simple cyst.
Based on her examination, the General Surgery service was consulted to evaluate her for possible appendicitis. During their evaluation, a computed tomography scan was obtained. It showed a 10 x 8 x 7 cm cystic structure with septations, either contiguous with or adjacent to the right ovary. The left ovarian simple cyst persisted, and the appendix was deemed normal.
With these findings, our patient was consented for diagnostic laparoscopy to evaluate a probably torsed adnexa. Upon placement of the laparoscope, a large purple cystic mass was seen. Due to its large size, laparotomy was planned to further evaluate the mass.
Upon reaching the pelvis, the enlarged, cyanotic, cystic mass was elevated (See Figure 1). It was identified as the right tube and ovary. Hemorrhage into the fallopian tube had created a cyanotic cyst with fimbria stretched across the cyst surface (Figure 2). Investigation of the vascular supply to these organs revealed torsion (Figure 3). The vascular pedicle was untwisted, but failed to show signs of reperfusion. Right salpingoophorectomy was performed, and the specimen was sent to pathology for further examination (Figure 4).
Discussion:
As noted in Chapter 9, adnexal torsion is more common in the reproductive years, and 70 percent of cases are in women aged 20 to 39 years. In cases of torsion, the tube and ovary are typically involved, although isolated torsion of the tube or ovary may be less commonly found. Classically, pathologic enlargement of an ovary serves to increase ovarian dimension and increase the risk for torsion. Indeed, most cases involve ovarian masses measuring 6 to 10 cm. However, the genesis of torsion in our patient is unclear, as our patient’s involved ovary appeared normal size.
Our patient was classical in her clinical presentation. Her pain waxed and waned, localized to one side, and was associated with nausea and vomiting. In many cases, low-grade fever may point to adnexal necrosis, although our patient was afebrile. However, her elevated WBC of 15,000 resulted from her necrotic tube and ovary.
During surgery, detorsion of the adnexa is reasonable. Previous concerns that untwisting would lead to pulmonary embolism have been refuted. Thus, detorsion of the adnexa is generally recommended to evaluate organ reperfusion and viability. If the adnexa fails to perfuse following untwisting of the vascular pedicle, then removal of the involved structures is recommended.
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