Isolated Tubal Torsion in Adolescence: Case Report and Review

Abstract

Background: Isolated torsion of the fallopian tube is a rare cause of lower abdominal pain in adolescence. Lack of specific clinical signs, images, and laboratory data make preoperative diagnoses difficult. This article presents a case of isolated torsion of the fallopian tube in an adolescent girl. Case: A 15-year-old girl presented with right lower abdominal pain for 6 days, and ultrasonography and magnetic resonance imaging (MRI) revealed a cystic mass on the left side of her uterus. Urgent laparoscopy was carried out according to the diagnosis of torsion of the left ovarian cyst. The procedure revealed torsion of the right fallopian tube with necrosis and swelling, so a laparoscopic salpingectomy was performed. Results: She was discharged, uneventfully, on the third day after surgery. Conclusions: During the reproductive period of life, prompt diagnosis and treatment are needed to preserve fertility for women. On MRI, the coiling-up sign described by Park et al. might be useful for diagnosis, while laparoscopy is also helpful for diagnosis and treatment. (J GYNECOL SURG 29:39)

Introduction

Isolated torsion of the fallopian tube is an uncommon occurrence. Moreover, it rarely occurs during adolescence and menopause. In most cases, it is seen during the reproductive period of a woman's lifecycle. While the chief complaint is abdominal pain, it is difficult to diagnose torsion of the fallopian tube preoperatively because of the lack of specific clinical signs and laboratory data. This article presents a case of a 15-year-old girl with isolated torsion of the fallopian tube managed by a laparoscopic operation, explores the preoperative diagnosis, and reviews the literature.

Case

A 15-year-old girl with lower abdominal pain on her third menstruation day consulted her doctor, who prescribed antibiotics for suspected gastroenteritis. This patient had had her menarche when she was 13 years' old and was still a virgin. She usually took psychotropic drugs (etizolam and fluvoxamine maleate) for a maladaptative psychiatric condition and was receiving psychiatric counseling.

After 3 days, her temperature rose to 38°C, and she felt more-severe right lower abdominal pain. She went to a hospital near her home, where she was admitted. She received antibiotic treatment for 6 days, but her pain remained, though she no longer had a fever. She underwent abdominal ultrasonography and computed tomography (CT), which revealed a cystic mass proximal to the uterus. Because torsion of an ovarian cyst was suspected, she was referred to the current authors' hospital for further evaluation and treatment on the seventh day after admission.

When this patient arrived at the new hospital, her abdomen was generally soft and flat except for mild tenderness and rebound tenderness in the right lower quadrant of the abdomen. Her height and weight were 164 cm and 67 kg, respectively, and she had a temperature of 36.9°C. Her blood pressure was 125/80 mm Hg with a pulse rate of 115 beats per minute. Her laboratory data, including a complete blood count were as follows: white blood cells, 5800/μL; red blood cells, 3.73×10⁶/μL; hemoglobin, 9.1 g/dL; hematocrit, 29.8%; platelets, 35.1×10⁴/μL; aspartate aminotransferase, 13 international units (IU)/L; alanine aminotransferase, 11 IU/L; lactate dehydrogenase, 23 IU/L; blood–urea–nitrogen, 5 mg/dL; creatinine 0.5 mg/dL; total bilirubin, 0.2 mg/dL; C-reactive protein, 1.60 mg/dL; cancer antigen (CA) 125, 83.4 U/mL; CA 19-9, 5.1 U/mL; α-fetoprotein, <1.0 ng/mL; and Chlamydia antibodies, immunoglobulin (Ig)A (–), IgG (–).

Transabdominal ultrasonography showed a normal uterus and a cystic structure measuring 85×66 mm in the left side of the uterus (Fig. 1). On magnetic resonance imaging (MRI), the cystic tumor was noted to contain blood that was hyperintense on T1-weighted imaging (Fig. 2A) and hypointense on T2-weighted imaging (Fig. 2B).

FIG. 1.

Ultrasonography. Abdominal sonography shows a cystic mass that contains a solid tumor, measuring 85×66 mm in the left side of the uterus.

FIG 2.

Magnetic resonance imaging (MRI). Axial T1-weighted MRI (A) and axial T2-weighted MRI (B) show a cystic tumor, which is shown as hypointense on T1-weighted MRI and hyperintense on T2-weighted MRI, respectively. The wall of this cyst is shown as hyperintense on T1-weighted MRI. The solid part is not shown. From these findings, it was suspected that the mass contained blood.

Because she continued to experience pain, it was decided to perform an urgent laparoscopy according to the indication for the diagnosis of torsion of the left tumorous ovary. Laparoscopy revealed torsion of the right fallopian tube with necrosis and swelling. The fallopian tube was twisted three complete turns clockwise (Fig 3A).

FIG 3.

Findings during laparoscopy. (A) Adhesion of the greater omentum was seen around the uterus and both adnexa (arrows). (B) A double balloon catheter was used to aspirate the contents of the cyst. (C) Laparoscopy revealed torsion of right fallopian tube with necrosis and swelling at the Douglas pouch. The fallopian tube was twisted three complete turns clockwise (arrow). The uterus, bilateral ovaries, and left fallopian tube were normal.

The uterus, bilateral ovaries, and left fallopian tube were normal. Adhesion of the greater omentum was prominent around the uterus and both adnexa (Fig. 3B). The cyst was punctured, using a double balloon catheter (Hakko Medical Inc., Tokyo, Japan), and the cyst contained 120 mL of hemorrhagic liquid (Fig 3C). As it was difficult to preserve the fallopian tube, laparoscopic right salpingectomy was performed. The excised right tube looked like a cyst with edematous and necrotic changes of ampulla of the fallopian tube (Fig 4). Pathologic examination revealed marked necrosis and hemorrhagic changes without any evidence of malignancy.

FIG. 4.

Specimen. The right isthmus of the fallopian tube is extended like a cyst. Edematous and necrotic changes were seen in the ampulla of the fallopian tube.

Results

The patient was discharged uneventfully on the third day after surgery.

Discussion

While the common cause of gynecologic acute abdomen may be ovarian tumor torsion mostly of the fallopian tube, isolated torsion of the fallopian tube is very rare, as the reported incidence is 1 in 1,500,000 women.¹ Gynecologists usually encounter this condition in women of reproductive age but rarely in adolescent and menopausal women.

Expected factors for torsion of the fallopian tube are anatomical abnormalities (congenital abnormalities of the mesosalpinx or fallopian tube, hydrosalpinx, hematosalpinx, and ovarian or paraovarian tumors), local physiologic abnormalities (hypermotion of the tube or spasm of the tube caused by drugs), hemodynamic abnormalities (venous congestion in mesosalpinx), trauma, sudden body movement, previous operation (such as tubal ligation), previous disease (pelvic inflammatory disease [PID]), and pregnancy.^2,3

In another study by Tirso et al., fallopian-tube torsion was caused by genital tuberculosis in woman with no history of sexual intercourse.⁴ In most cases, it is difficult to discover a definite cause for fallopian-tube torsion. Milki and Jacobson. reported that torsion of the right fallopian tube is more commonly described than that of the left fallopian tube.⁵ It could be that mobility of the left fallopian tube is limited by the sigmoid colon or that there is slow venous flow on the left side, which results in congestion.⁵

When patients present with symptoms of abdominal pain, nausea, and vomiting, differential diagnosis includes torsion and rupture of the ovary, appendicitis, PID (such as an adnexitis), urinary-tube infection, and urinary calculus.

In adolescence, the common course of acute lower abdominal pain is appendicitis. Because fallopian-tube torsion has no pathognomonic, specific symptoms nor any laboratory data, it is difficult to diagnose preoperatively.

Sonography, CT, and MRI are useful for diagnoses of this disease. Sonography is convenient and could provide useful information about ovarian blood flow via color Doppler imaging to estimate the viability of the target organ. CT and MRI findings of fallopian-tube torsion include a normal ipsilateral ovary, thickness of the tubal wall, an adnexal cyst with a dilated fallopian tube, deviation of uterus to the torsional side, and a “beak sign”—a term that is applied when the mass that deforms the edge of an adjacent organ has a beaklike shape, suggesting that the mass arises from the organ.⁶

Park et al. reported that CT and MRI scanning depict the coiling-up sign of the torsioned fallopian tube, which is helpful for diagnosing isolated tubal torsion.⁷ In the present case, the appearance of the coiling-up sign was shown next to a cystic lesion (Figs. 5 A and B).

FIG. 5.

A coiling-up sign on magnetic resonance imaging (MRI). (A) T1-weighted sagittal MRI shows a coiling-up sign (arrow) on the anterior side of the uterus. (B) T1-weighted coronal MRI shows a coiling-up-like sign (arrow) on the right side of the cyst, and shows that the the uterus has been moved to the right side.

Torsion of the hematosalpinx was detected via laparoscopy. The hematosalpinx might have caused the tubal torsion or could have been a result of that torsion. Therefore, it is difficult to determine definitively which was the initial event. However, in addition to the definite identification of the hematosalpinx, or the torsion as an initial event, it could be speculated that both events create a vicious cycle.

Twenty-four case reports of fallopian-tube torsion in teenagers were published in the 29 years from 1981 to 2009 (Table 1).^8–30 There were 8 premenarchal and 9 unknown cases. Most likely, all cases were of girls with no history of sexual intercourse. In most cases, preoperative ultrasonography was carried out, when 3 cases were preoperatively diagnosed correctly as fallopian-tube torsion. Other preoperative diagnoses were torsion of an ovarian cyst (n=4), appendicitis (n=3), torsion of a paraovarian cyst (n=2), a cystic ovarian follicle with ovulatory pain (n=1), and an adnexal tumor (n=1). In other cases there was no diagnosis (n=10).

Table 1.

Case Reports of Fallopian-Tube Torsion in Teenagers from 1981 to 2009

Case #	Age	Menarche	Ex of inter	Symptom	Imaging	Preoperative dx	Side	Time interval	Technique	Reference
1	13	11	No	RtLAP, Vo	S	Rt ovarian cyct torsion	Rt	1month	Lap rt salpingectomy	8
2	14	n/d	n/d	LAP	S	n/d	Rt	n/d	Lap rt salpingectomy	9
3	19	n/d	No	LtLAP	S	Lt ovarian cyst torsion	Lt	1 year	Lap lt salpingectomy	10
4	11	11	No	RtLAP, Vo	S	Rt tubal torsion	Rt	2 days	Lap rt salpingectomy	11
5	15	13	n/d	LAP	S, M	Lt adnexal tumor	Lt	18 months	Lap lt salpingectomy	12
6	16	11	No	LAP, scalding	S, C, M	Paraovarian cyst torsion	Rt	8 days	Lap rt salpingectomy	13
7	15	13	No	LtLAP	S, M	Lt ovarian cyst torsion	Lt	6 days	Lap lt salpingectomy	14
8	12	Not yet	n/d	LAP	S	n/d	Lt	2 days	Lap lt salpingectomy	15
9	12	n/d	n/d	LAP	S, M	Lt tubal torsion	Lt	4 days	Lap lt salpingectomy	16
10	12	Not yet	No	RtLAP, Vo	S, C	n/d	Rt	2 days	Laparoscopy→Abd rt adnexectomy	17
11	14	11	No	RtLAP	S	n/d	Rt	n/d	Lap rt salpingectomy	18
12	14	n/d	n/d	LtLAP	C	Lt ovarian cyst torsion	Lt	2 days	Lap lt detorsion	19
									Lap lt paraovarian cyst resection
13	12	not yet	n/d	LAP	S, C, M	Lt paraovarian cyst torsion	Lt	1 month	Lap lt salpingectomy	20
						Torsion of Lt hydrosalpinx
14	15	n/d	n/d	LAP	S	n/d	n/d	n/d	Lap salpingectomy	21
15	17	n/d	n/d	RtLAP, Vo	S	Ovulation ache	Rt	n/d	Abd rt salpingectomy	22
16	14	n/d	n/d	LAP	n/d	n/d	Rt	n/d	n/d	23
17	15	Already	n/d	LtLAP	S	n/d	Lt	3 days	Lap lt salpingectomy	24
18	11	Not yet	n/d	RtLAP, Vo	S	n/d	Rt	1 day	Lap rt salpingectomy	25
19	11	Not yet	n/d		S, M	n/d	Rt	n/d	Lap rt salpingectomy	26
20	18	already	n/d	RtLAP, Vo	S	Rec of rt tubal torsion	Rt	1 day	Lap rt detorsion	27
21	13	Not yet	n/d	RtLAP	X-ray	Acute appendicitis	Rt	n/d	Abd rt salpingectomy, appendectomy	28
22	4	Not yet		RtLAP, Vo	X-ray	Acute appendicitis	Rt	1 day	Abd rt detorsion, appendectomy	28
23	13	n/d	No	LAP	n/d	n/d	Rt	n/d	Lap lt salpingectomy	29
24	13	Not yet	No	RtLAP	n/d	Acute appendicitis	Rt	4 days	Abd rt salpingectomy, appendectomy	30

Ex of inter, experience of intercourse; Preoperative dx, preoperative diagnosis; Time interval, time interaval between onset of pain to surgery; LAP, lower abdominal pain; Vo, vomiting; S, sonography; C, computed tomography; M, magnetic resonance imaging; X-ray, abdominal X-ray; Lt, left; Rt, right; Rec, recurrence; Lap, laparascopic; Abd, abdominal; n/d, not described.

Laparoscopy was performed in 19 cases, and laparotomy was chosen in 4 cases. There was 1 case for which the treatment procedure was not described. In the last 5 years, laparoscopy was performed in all of cases from that point onward. Therefore, it should be noted that laparoscopy currently plays an important role in diagnosis and treatment.

The surgical technique for addressing this disease is release or resection of the torsional salpinx. The current authors usually tend to determine the necessity for salpingectomy intraoperatively when gross inspection of the twisted fallopian tube is possible. However, in fact, there is no established rule for resection of the affected tube at present.

In the literature that was reviewed, 19 cases were treated by salpingectomy, 1 case by adnexectomy, and 3 cases by detorsion. Because this disease usually occurs during the reproductive period of the lifecyle, preserving fertility is important. Therefore, further consideration is warranted to establish a standard for preserving the fallopian tube. As time passes from the onset of this condition, blood circulation became worse because of the torsion. As a result, the range of necrosis will spread. In literatured reviewed, the range of time between the onset of pain to the operation was 1 day to 1 year. For preserving fertility, it is necessary to have prompt diagnosis and surgical intervention. Especially in adolescence, as in the present case, the diagnosis of this disease is often likely to be delayed. Because there are no characteristic symptoms, patients often have to undergo prolonged investigations to rule out the more common causes of the abdominal pain. In adolescence, patients first usually consult a pediatrician and then, if deemed necessary, they consult a gynecologist. It is necessary, therefore, to be in close communication with other physicians to enable prompt diagnosis and treatment. Laparoscopic treatment is less invasive and especially useful for diagnosis and treatment in these cases.

Conclusions

The current authors reported torsion of the fallopian tube in adolescence. It was difficult to make a preoperative diagnosis in this disease. Laparoscopy was effective for diagnosis and treatment. Park et al. have described a coiling-up sign that shows on MRI imaging that is a specific sign of fallopian-tube torsion.⁷ In the current case, this sign was discovered retrospectively on the MRI. This sign aids in making preoperative diagnoses. In cases of fallopian-tube torsion, prompt diagnosis and treatment is required to preserve fertility. Although fallopian-tube torsion is a rare disease in adolescent girls, it should be considered as part of the differential diagnosis of acute lower abdominal pain.

Footnotes

Acknowledgments

The authors would like to express great gratitude to Eiko Yamashita, MD, in the department of radiology, at the Tokai University School of Medicine, for her helpful comments on MRI.

Disclosure Statement

No author has any conflict of interest in connection with this article.

References

Hansen

. Isolated torsion of the fallopian tube. Acta Obstet Gynecol Scand, 1970; 49:3.

, Liang

, Su

, Chang

, Hsu

, Ling

. Isolated torsion of the fallopian tube: A rare diagnosis in an adolescent without sexual experience. Taiwan J Obstet Gynecol, 2008; 47:235.

Goktolga

, Ceyhan

, Ozturk

et al. Isolated torsion of fallopian tube in a premenarcheal 12-year-old girl. J Obstet Gynaecol Res, 2007; 33:215.

Perez-Medina

, Bueno

, Redondo

, Gallego

, Bajo-Arenas

. Torsion of the fallopian tube and acute pelvic pain: an unusual presentation of genital tuberculosis. Fertil Steril, 2008; 89:1810.

Milki

, Jacobson

. Isolated torsion of the fallopian tube: A case report. J Reprod Med, 1998; 43:836.

Gross

, Blumstein

, Chow

. Isolated fallopian tube torsion: A rare twist on a common theme. AJR Am J Roentgenol, 2005; 185:1590.

Park

, Kim

. Isolated tubal torsion: Specific signs on preoperative computed tomography and magnetic resonance imaging. Acta Radiol, 2008; 49:233.

Dadhwal

, Gupta

, Deka

, Mittal

. Laparoscopic management of isolated fallopian tube torsion in a premenarchal 13-year-old adolescent girl. Arch Gynecol Obstet, 2009; 279:909.

Sorensen

. Torsion of a hydrosalpinx in a 14-year-old. Ugeskr Laeger, 2008; 170:3251.

10.

, Liang

, Su

, Chang

, Hsu

, Ling

. Isolated torsion of the fallopian tube: A rare diagnosis in an adolescent without sexual experience. Taiwan J Obstet Gynecol, 2008; 47:235.

11.

Markhardt

, Jones

, Drugas

. Isolated torsion of the fallopian tube in a menarchal 11-year-old girl. Pediatr Emerg Care, 2008; 24:374.

12.

Schollmeyer

, Soyinka

, Mabrouk

, Jonat

, Mettler

, Meinhold-Heerlein

. Chronic isolated torsion of the left fallopian tube: A diagnostic dilemma. Arch Gynecol Obstet, 2008; 277:87.

13.

Date

, Hayashi

, Kamimura

, Fujii

, Nakajima

, Konishi

. A case report of torsion of fallopian tube in an adolescent [in Japanese] Rinshyou Sanfujinka, 2007; 61:856.

14.

Yazawa

, Suganuma

, Sugawara

, Furukawa

, Takahashi

. Two cases of tubal torsion treated with laparoscopic surgery: A case of isolated torsion of hydrosalpinx and a case of tubal torsion with paraovarian cyst [in Japanese] Jpn J Gynecol Obstet Endoscopy, 2007; 23:104.

15.

Goktolga

, Ceyhan

, Ozturk

et al. Isolated torsion of fallopian tube in a premenarcheal 12-year-old girl. J Obstet Gynaecol Res, 2007; 33:215.

16.

Orazi

, Inserra

, Lucchetti

, Schingo

. Isolated tubal torsion: A rare cause of pelvic pain at menarche: Sonographic and MR findings. Pediatr Radiol, 2006; 36:1316.

17.

Sozen

, Nobel

. Partial tubal salvage through neosalpingostomy in a 12-year-old girl with combined ovarian and fallopian tube torsion. J Pediatr Surg, 2006; 41:E17.

18.

Lau

, Huang

, Chan

, Lin

, Chen

. Isolated torsion of the fallopian tube in a 14-year-old adolescent. Taiwan J Obstet Gynecol, 2006; 45:363.

19.

Sasaki

, Nakamura

, Kobayashi

. Paraovarian cyst with torsion of fallopian tube in a 14-year-old girl [in Japanese] J Jpn Soc Pediatr Surg, 2006; 42:832.

20.

Terada

, Murakami

, Nakamura

et al. Isolated torsion of the distal part of the fallopian tube in a premenarcheal 12 year old girl: A case report. Tohoku J Exp Med, 2004; 202:239.

21.

Dedecker

, Graesslin

, Khider

, Fortier

, Quereux

, Gabriel

. Isolated torsion of the fallopian tube in a 15-year old adolescent: About one case. [in French] Gynecol Obstet Fertil, 2003; 31:422.

22.

Rizk

, Lakshminarasimha

, Joshi

. Torsion of the fallopian tube in an adolescent female: A case report. J Pediatr Adolesc Gynecol, 2002; 15:159.

23.

Valbo

, Kotanska-Groholt

. Torsion of the fallopian tube causing acute abdominal pain in a young virgin girl [in Norwegian] Tidsskr Nor Laegeforen, 2000; 120:2124.

24.

Lineberry

, Rodriguez

. Isolated torsion of the fallopian tube in an adolescent: A case report. J Pediatr Adolesc Gynecol, 2000; 13:135.

25.

Adekanmi

, Barrington

, Edwards

, Farrell

. Isolated torsion and haemorrhagic infarction of a normal fallopian tube in an eleven year old girl. BJOG, 2000; 107:1047.

26.

Jamieson

, Soboleski

. Isolated tubal torsion at menarche: A case report. J Pediatr Adolesc Gynecol, 2000; 13:93.

27.

Raziel

, Mordechai

, Friedler

, Schachter

, Pansky

, Ron-El

. Isolated recurrent torsion of the fallopian tube: Case report. Hum Reprod, 1999; 14:3000.

28.

Kurzbart

, Mares

, Cohen

, Mordehai

, Finaly

. Isolated torsion of the fallopian tube in premenarcheal girls. J Pediatr Surg, 1994; 29:1384.

29.

Borup

, Rasmussen

. Isolated torsion of the fallopian tube as differential diagnosis to acute abdominal pain in a thirteen year old girl. Acta Eur Fertil, 1990; 21:229.

30.

Duffty

. Torsion of the fallopian tube in a premenarchal girl. Postgrad Med J, 1981; 57:267.