CT and MR imaging features of adnexal torsion

Isolated fallopian tube torsion: A systematic review of case reports

OBJECTIVE

To combine all literature describing cases of isolated fallopian tube torsion in adult non pregnant patients in a systematic manner, to optimize knowledge and practice both for diagnosis and management.

STUDY DESIGN

EMBASE and PubMed databases were searched for the terms 'tubal' OR 'fallopian tube' AND 'isolated' AND 'torsion' from the inception of these databases to July 5, 2023. All case reports or case series of adult patients (18 years or older) with isolated fallopian tube torsion were included. Exclusion criteria included: all other study types; cases involving children and adolescents (less than 18 years old); pregnant patients of all trimesters; tubo-ovarian torsion; studies not published in English; duplicates and those not available in text. Following the database search, two authors independently screened the studies and search results were subsequently reported in accordance with PRISMA guidelines. Data was extracted independently by two authors and analysed using Excel. All cases were assessed for bias using a modified version of the tool proposed by Murad et al. RESULTS: 92 unique articles enrolling 131 individual cases were included in this systematic review. Isolated fallopian tube torsion most commonly occurs during reproductive ages between 18 and 45 years. It is uncommon in postmenopausal women. The most common presenting symptoms include unilateral lower abdominal or pelvic pain along the affected side with nausea and vomiting. Risk factors can be intrinsic or extrinsic and can include conditions such as hydrosalpinx, sterilization, pelvic inflammatory disease or cysts. Ultrasound is the optimal imaging modality however Computed Tomography and Magnetic Resonance Imaging can also be used. Imaging in general has low sensitivity, however isolated fallopian tube torsion can be identified with appropriate expertise. The gold standard for isolated fallopian tube torsion management is laparoscopy and detorsion however currently, the most common intervention performed is salpingectomy.

CONCLUSIONS

Isolated fallopian tube torsion is a rare but important gynaecological emergency with significant fertility implications. This study summarizes the most common presentations, investigation findings and surgical interventions in patients with isolated fallopian tube torsion. This study also emphasizes the importance of clinicians maintaining a high degree of suspicion and low threshold for early laparoscopic intervention to retain fertility.

Gynaecological Causes of Acute Pelvic Pain: Common and Not-So-Common Imaging Findings

In female patients, acute pelvic pain can be caused by gynaecological, gastrointestinal, and urinary tract pathologies. Due to the variety of diagnostic possibilities, the correct assessment of these patients may be challenging. The most frequent gynaecological causes of acute pelvic pain in non-pregnant women are pelvic inflammatory disease, ruptured ovarian cysts, ovarian torsion, and degeneration or torsion of uterine leiomyomas. On the other hand, spontaneous abortion, ectopic pregnancy, and placental disorders are the most frequent gynaecological entities to cause acute pelvic pain in pregnant patients. Ultrasound (US) is usually the first-line diagnostic technique because of its sensitivity across most common aetiologies and its lack of radiation exposure. Computed tomography (CT) may be performed if ultrasound findings are equivocal or if a gynaecologic disease is not initially suspected. Magnetic resonance imaging (MRI) is an extremely useful second-line technique for further characterisation after US or CT. This pictorial review aims to review the spectrum of gynaecological entities that may manifest as acute pelvic pain in the emergency department and to describe the imaging findings of these gynaecological conditions obtained with different imaging techniques.

Scoring system for predicting ovarian necrosis in adnexal torsion using an ultra-short optimized MRI protocol

PURPOSE

To evaluate a MRI scoring system predicting haemorrhagic necrosis in adnexal torsion with intraoperative and/or histopathological correlation using an abbreviated and optimized MRI protocol.

METHODS

This retrospective observational study includes patients with adnexal torsion who underwent Magnetic Resonance Imaging(MRI) and surgery. T2 sequences were evaluated by three observers of varying experience for following findings: Hypo-intensity of ovarian stroma, around the follicle, cyst wall or ovarian capsule and the twisted pedicle. Hypo-intensities in the above and a thick cyst wall were considered as predictors of necrosis. A scoring system was created based on the number of positive findings. MRI was correlated with intraoperative and histopathological findings. Lesions showing haemorrhagic necrosis were considered true positives.

RESULTS

43 women with torsion were included. 74.4% were secondary to a lead point and 25.4% were without one. Hypointensity score of 2 or more had the highest diagnostic accuracy and inter-reader agreement in predicting necrosis (R1-sensitivity: 92%, specificity: 89%, positive predictive value (PPV): 92% and negative predictive value (NPV): 89%, R2-sensitivity: 92%, specificity: 94%, PPV: 96% and NPV: 90% and R3-sensitivity: 92%, specificity: 83%, PPV: 89% and NPV: 89%).

CONCLUSION

In patients with suspected adnexal torsion, optimized MRI using T2 weighted sequences will serve as a rapid and effective single imaging modality for diagnosing adnexal torsion and accurately predicting necrosis thereby triaging the patients for appropriate management.

Infarcts and ischemia in the abdomen: an imaging perspective with an emphasis on cross-sectional imaging findings

Infarcts and ischemia of abdominal organs may present with acute abdominal pain, and early diagnosis is crucial to prevent morbidity and mortality. Unfortunately, some of these patients present in poor clinical conditions to the emergency department, and imaging specialists are crucial for optimal outcomes. Although the radiological diagnosis of abdominal infarcts is often straightforward, it is vital to use the appropriate imaging modalities and correct imaging techniques for their detection. Additionally, some non-infarct-related abdominal pathologies may mimic infarcts, cause diagnostic confusion, and result in delayed diagnosis or misdiagnosis. In this article, we aimed to outline the general imaging approach, present cross-sectional imaging findings of infarcts and ischemia in several abdominal organs, including but not limited to, liver, spleen, kidneys, adrenals, omentum, and intestinal segments with relevant vascular anatomy, discuss possible differential diagnoses and emphasize important clinical/radiological clues that may assist radiologists in the diagnostic process.

Ovarian Fibroma Presents As Uterine Leiomyoma in a 61-Year-Old Female: A Case Study

Uterine leiomyoma should be considered when a female patient reports symptoms of abdominal pressure and abnormal vaginal bleeding. However, the symptoms of a uterine leiomyoma are vast and overlap with other possible diseases that are difficult to distinguish even with imaging studies. This is why it is important for physicians and healthcare providers to keep an open mind and have a broad differential diagnosis.  In this case study, we present a 61-year-old postmenopausal female patient who presented to the emergency department with complaints of pelvic and abdominal pain, as well as vomiting and diarrhea. She was admitted for observation. A complete blood count (CBC), comprehensive metabolic panel (CMP), and urinalysis revealed no abnormalities; a pelvic ultrasound and CT scan reported possible adnexal torsion. The patient remained stable and the pain had subsided when she was seen the next morning by her gynecologist (GYN) who discharged her to follow-up in the office. Subsequent examinations that aided in the diagnosis included, but were not limited to pelvic and transvaginal ultrasounds, an abdominal and pelvic CT, and a pelvic MRI. In this case, the MRI revealed an 11-cm mass that could represent a torsioned pedunculated necrotic fibroid originating from the uterus. Radiology recommended surgical removal. Upon removal and review of the pathology of the mass, it was revealed to be a torsioned, partially necrotic fibroma that had originated from the ovary and not from the uterus, as imaging had originally suggested.

Acute pelvic pain: A pictorial review with magnetic resonance imaging

Acute uterine emergencies constitute both obstetric and gynecologic conditions. The superior image resolution, superior soft-tissue characterization, and lack of ionizing radiation make magnetic resonance imaging (MRI) preferable over ultrasonography (USG) and computed tomography (CT) in investigating uterine emergencies. Although USG is the first-line imaging modality and is easily accessible, it has limitations. USG is an operator dependent and limited by patient factors such as obesity and muscle atrophy. CT is limited by its risk of teratogenicity in pregnant females, poor tissue differentiation, and radiation effect. The non-specific findings on CT may lead to misinterpretation of the pathology. MRI overcomes all these limitations and is emerging as the most crucial imaging modality in the emergency room (ER). The evolving 3D MR sequences further reduce the acquisition times, expanding its ER role. Although MRI is not the first-line imaging modality, it is a problem-solving tool when the ultrasound and CT are inconclusive. This pictorial review discusses the various MRI techniques used in uterine imaging and the appearances of distinct etiologies of uterine emergencies across different MRI sequences.

Many faces of torsion in pediatric female pelvis

Pediatric patients of various ages, from infancy through adolescence, can have ovarian torsion. Torsion may not only be confined to the ovaries but may also involve the isolated cyst, tube, and even the uterus. In this pictorial review, we review the spectrum of torsion in pediatric (from infants to adolescents) female pelvis, emphasizing imaging methods.

Imaging in a Patient with Recent Cesarean Section and Acute Right Lower Quadrant Pain Due to Torsion OF Ovarian Teratoma – Diagnostic Challenges

Introduction: Ovarian teratomas are common pathology, manifested by various clinical and imaging findings, as well as different complications. The differential diagnosis can be challenging in cases with acute right lower quadrant (ARLQ) pain.

Aim: to present typical imaging findings in this pathology and possible pitfalls in their interpretation, focusing on a case with torsion of ovarian teratoma.

Methods: We describe a case of a 41-yearold female patient with a recent Cesarean section and a history of kidney stones and previous appendectomy, who presented with acute right lower quadrant pain. Her pregnancy was uneventful. The plain abdominal X-ray, ultrasound and computer tomography images revealed air-fluid levels, a fecaloma in the ascending colon and a pelvic mass of unclear origin, misinterpreted as a foreign body or postoperative complication.

Results: The patient underwent a surgical procedure that revealed an ovarian teratoma torsion. A right adnexectomy was performed. The diagnosis was confirmed by histological examination.

Conclusion: An excellent knowledge of the imaging findings in the diseases presented with ARLQ pain is of vital importance, however patient’s co-morbidities and recent surgical procedures may hinder the correct interpretation.

Testicular Torsion Appearance and Diagnosis on Computed Tomography of the Abdomen/Pelvis: Case Report

Introduction: Testicular torsion, or the twisting of the spermatic cord compromising blood flow to the testis, is a urologic emergency with the potential to cause infertility in male patients. The diagnosis may be clinical or confirmed using imaging, with ultrasound being the modality of choice. Case Report: We present a case of right lower quadrant pain with radiation to the groin and right scrotum in a young male. A computed tomography of the abdomen and pelvis was ordered to assess for appendicitis, which showed a “whirl” sign on the inferior periphery of the images near the scrotum. The finding was not appreciated during the emergency department visit and the patient was discharged home. He returned 48 hours later due to continued pain and was ultimately diagnosed with testicular torsion via ultrasound and surgical pathology. Conclusion: This is the first reported case to our knowledge identifying “whirl” sign for the diagnosis of testicular torsion. This finding was not appreciated by multiple clinicians during the initial patient presentation, highlighting the uncommon nature of the finding.

Computed Tomography Features of Adnexal Torsion: A Meta-Analysis

OBJECTIVES

We performed a meta-analysis of studies examining the computed tomography (CT) features of adnexal torsion (AT).

METHODS

We searched PubMed, Embase, Web of Science, and the Cochrane Library for studies involving the proportion of CT features in patients with AT and that used surgery as the reference test. Study quality was assessed using the Newcastle-Ottawa scale and the Agency for Healthcare Research and Quality tool.

RESULTS

Twelve articles involving 483 patients were included. The pooled proportion of right-sided adnexal lesion was 54% (95% confidence interval [CI]: 49%-56%). The pooled proportions of the ovarian lesion histopathological types were: benign germ cell tumors, 33% (95% CI: 28%-37%); benign cystic lesions, 26% (95% CI: 21%-30%); benign epithelial neoplasms, 24% (95% CI: 20%-29%); sex cord-stromal tumors, 4% (95% CI: 2%-6%); borderline neoplasms, 3% (95% CI: 1%-6%); and hemorrhagic cysts, 2% (95% CI: 0%-3%). The pooled proportions of CT features were: Adnexal enlargement, 99% (95% CI: 98%-99%); adnexal with mass, 98% (95% CI: 97%-100%); twisted pedicle, 81% (95% CI: 78%-83%); mass with thickened wall, 77% (95% CI: 73%-81%); tubal thickening, 73% (95% CI: 68%-77%); abnormal location of adnexa, 69% (95% CI: 63%-75%), pelvic ascites, 43% (95% CI: 38%-49%); pelvic fat infiltration, 41% (95% CI: 34%-48%); uterine deviation, 37% (95% CI: 31%-42%); and lack of enhancement, 20% (95% CI: 14%-25%).

CONCLUSION

Adnexal enlargement, adnexal mass, and twisted pedicle may be the most important CT features for diagnosing AT.

Mimics and Pitfalls of Primary Ovarian Malignancy Imaging

The complex anatomy and similarity of imaging features of various pathologies in the pelvis can make accurate radiology interpretation difficult. While prompt recognition of ovarian cancer remains essential, awareness of processes that mimic ovarian tumors can avoid potential misdiagnosis and unnecessary surgery. This article details the female pelvic anatomy and highlights relevant imaging features that mimic extra-ovarian tumors, to help the radiologists accurately build a differential diagnosis of a lesion occupying the adnexa.

All that glitters are not gold: holds true in female adnexal lesions

Background

Adnexal mass lesions are commonly encountered pathologies that creates diagnostic challenges for radiologist. Diffusion weighted imaging is a vital tool in the radiologist armamentarium for improving the diagnostic accuracy of adnexal lesions other than routine spine echo sequences.

Main body

Functional information about the lesion regarding the mobility of the water molecules in its tissue is assessed by diffusion weighted imaging. In addition to the solid malignant neoplasm, normal blood, fat, necrosis and pus also shows restricted diffusion.

Conclusion

All the lesion that shows restriction in the DWI are not malignant, but converse is mostly true. Knowledge regarding the non-malignant lesion in the ovary that shows restricted diffusion will give a clue in diagnosis, management and treatment of the adnexal lesions.

Computed Tomography Appearance of the "Whirlpool Sign" in Ovarian Torsion

Case Presentation

A 28-year-old female presented to the emergency department complaining of right lower abdominal pain. A contrast-enhanced computed tomography (CT) was done, which showed a 15-centimeter right adnexal cyst with adjacent “whirlpool sign” concerning for right ovarian torsion. Transvaginal pelvic ultrasound (US) revealed a hemorrhagic cyst in the right adnexa, with duplex Doppler identifying arterial and venous flow in both ovaries. Laparoscopic surgery confirmed right ovarian torsion with an attached cystic mass, and a right salpingo-oophorectomy was performed given the mass was suspicious for malignancy.

Discussion

Ultrasound is the test of choice for diagnosis of torsion due to its ability to evaluate anatomy and perfusion. When ovarian pathology is on the patient’s right, appendicitis is high in the differential diagnosis, and CT may be obtained first. Here we describe a case where CT first accurately diagnosed ovarian torsion by demonstrating the whirlpool sign, despite an US that showed arterial flow to the ovary. Future studies should determine whether CT alone is sufficient to diagnose or exclude ovarian torsion.

Can various complete blood count parameters helpful in preoperative diagnosis of adnexal torsion?

OBJECTIVE

Adnexal torsion is an important gynecological emergency due to nonfrequent but possible adverse reproductive outcomes. There is no specific laboratory marker to support the preoperative diagnosis or that can be used clinically. The aim of this study was to investigate the diagnostic values of platelet, neutrophil, lymphocyte, and red cell markers as an early indicator of ovarian torsion.

METHODS

This retrospective study included 28 female patients who were treated surgically for adnexal torsion between August 2010 and July 2020, and 29 control group women. The demographic data and routine hematological values of patients were compared for adnexal torsion prediction.

RESULTS

There were no differences between the groups in terms of the platelet count, platelet distribution width, red cell distribution width, and mean platelet volume values, and there were no differences in the demographic data. Statistical differences were found among white blood cell, hemoglobin, hematocrit, neutrophil and lymphocyte counts, neutrophil/lymphocyte ratio, and platelet/lymphocyte ratio, and 81.5% sensitivity and 82.1% specificity were identified for neutrophil/lymphocyte ratio 2.45 (area under the curve AUC 0.892; 95%CI 0.808-0.975; p<0.001). Odds ratio for neutrophil/lymphocyte ratio was 2.62 (95%CI 0.861-7.940, p=0.029).

CONCLUSION

According to the regression analysis, neutrophil/lymphocyte ratio was found to be the most beneficial among all blood count parameters for the pre-diagnosis of AT.

CT Imaging in Predicting Ovarian Torsion: Report of Two Cases, With and Without Infarction

Ovarian torsion is one of the common abdominal and gynecologic surgical emergencies with serious morbidity in the form of ovarian infarct or necrosis. Various imaging modalities like USG, CT, and MRI have been used in the evaluation of ovarian torsion. Two middle-aged females presented with lower abdominal pain. Imaging showed an ovarian cystic lesion in the first patient and thickened and twisted ovarian pedicle or ‘helical swirling’ sign in the second. Intraoperatively, the first case turned out to be a 180* twist with mild ovarian edema and the second showed more than 720* torsion with ovarian infarction. The CT findings of twisted pedicle with pericystic fat stranding might be predictive of hemorrhagic infarction in cases of torsion.

Problem-solving with MRI in acute abdominopelvic conditions, part 2: gynecological, obstetric, vascular, and renal diseases

The purpose of this article is to illustrate the benefits of magnetic resonance imaging (MRI) in the setting of abdominopelvic emergencies. Owing to intrinsically high soft-tissue contrast resolution, and ability to resolve different soft tissue, MRI holds notable advantages over other imaging modalities and can be used as a problem-solving tool. Additional advantages of MRI include lack of radiation-related risks to children and pregnant women, and the ability to acquire detailed diagnostic information even without intravenous contrast which can be beneficial in patients with contrast allergy and end-stage renal disease. In the part 2, the authors focus on MRI features of female pelvic gynecological diseases, pregnancy- related complications, abdominal vascular complications, and renal diseases.

Ovarian teratomas: clinical features, imaging findings and management

Ovarian teratomas are the most common type of germ cell tumors. There are three major subtypes of ovarian teratomas including mature, immature, and monodermal teratomas. Ultrasound, computed tomography and magnetic resonance imaging can demonstrate specific imaging findings for mature teratoma. Imaging features of immature and monodermal teratomas are less specific, but a combination of clinical features and imaging findings can help in the diagnosis. Imaging is also very helpful in guiding management. In this article, we review the epidemiology, histopathology, clinical presentation, imaging features and management of ovarian teratomas.

ACR Appropriateness Criteria® Postmenopausal Acute Pelvic Pain

Acute pelvic pain is a common presenting complaint in both the emergency room and outpatient settings. Pelvic pain of gynecologic origin in postmenopausal women occurs less frequently than in premenopausal women; however, it has important differences in etiology. The most common causes of postmenopausal pelvic pain from gynecologic origin are ovarian cysts, uterine fibroids, pelvic inflammatory disease, and ovarian neoplasm. Other etiologies of pelvic pain are attributable to urinary, gastrointestinal, and vascular systems. As the optimal imaging modality varies for these etiologies, it is important to narrow the differential diagnosis before choosing the initial diagnostic imaging examination. Transabdominal and transvaginal ultrasound are the best initial imaging techniques when the differential is primarily of gynecologic origin. CT with intravenous (IV) contrast is more useful if the differential diagnosis remains broad. MRI without IV contrast or MRI without and with IV contrast, as well as CT without IV contrast may also be used for certain differential considerations. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

CT predictive model for torsion angle as a marker for risk of necrosis in patients with adnexal torsion

AIM

To assess the feasibility of preoperative computed tomography (CT) prediction of torsion angle for stratifying the risk of necrosis in patients with adnexal torsion.

MATERIALS AND METHODS

In this multicentre, retrospective study, 72 patients underwent preoperative CT and surgically verified adnexal torsion. Surgeons identified the torsion angle and adnexal necrosis requiring adnexectomy. The twisted angles were compared between conservative surgery group and salpingo-oophorectomy group. Variables included demographic, pathological and CT details. Logistic analysis was used to identify the indicators of twisted angle associated with high-risk necrosis.

RESULTS

The necrosis associated with adnexal torsion treated with adnexectomy was performed more often in patients with a torsion angle of ≥720° (odds ratio [OR]=7, 95% confidence interval [CI]: 1.314-37.295, p=0.023). The enlarged twisted pedicle (OR=14.592, 95% CI: 2.048-103.953, p=0.007) and pedicle haemorrhage (OR=5.612, 95% CI: 1.088-28.941, p=0.039) can predict a torsion angle of ≥720°, and area under the receiver operating characteristic (ROC) curve (AUC=0.758±0.058) was generated with the combined variables.

CONCLUSION

The risk of adnexal necrosis is high in patients with torsion angle of ≥720°. CT findings of enlarged twisted pedicle and pedicle haemorrhage can be used to predict torsion angle of ≥720° and can imply adnexal necrosis indirectly.

Comprehensive review of imaging features of sex cord-stromal tumors of the ovary

Sex cord-stromal tumors of the ovary (SCST) are uncommon ovarian tumors arising from sex cord and/or stromal cells of the ovaries. They may be nonfunctional and asymptomatic or functional presenting with hyperestrogenic, hyperandrogenic or cushingoid symptoms. They present in a wide age group of women, mostly in early stages and follow a nonaggressive clinical course after surgical resection. They differ from more prevalent epithelial ovarian tumors which tend to present in older women in advanced stages with poor prognosis. Some of SCSTs are associated with clinical syndromes. We will review imaging features on ultrasound, computed tomography and magnetic resonance imaging, epidemiology and clinical presentations of these tumors.

Original Articles Preoperative Hematological Parameters for Predicting Ovarian Torsion in Patients with Mature Cystic Teratoma

Objective

The objective of this study is to evaluate the preoperative hematological parameters to predict ovarian torsion in patients with ovarian mature cystic teratoma. We also analyzed the diagnostic value of these makers to predict ovarian necrosis in cases of torsion as well as the effect of torsion on ovarian reserve.

Patients and Methods

This is a retrospective study of 132 patients who received either laparoscopic or laparotomy surgery for OMCT at a single university hospital. Clinical characteristics and preoperative hematological parameters were compared between patients with or without torsion. Patients with torsion were further classified as infarction and non-infarction group. Preoperative parameters were compared between the two groups as well.

Results

White blood cell (WBC) count, neutrophil percent, neutrophil count, and neutrophil to lymphocyte ratio (NLR) were higher in the torsion group (n=37) than the non-torsion group (n=95) (p<0.05 for all). Although statistically insignificant, the preoperative anti-Mullerian hormone (AMH) was lower in the torsion group than the non-torsion group (4.07 ± 3.38 vs 6.1 ± 3.6, p=0.122). In cases of torsion, the infarction group showed higher WBC count and lymphocyte count but lower hemoglobin level and platelet to lymphocyte ratio (PLR) than the non-infarction group (p<0.05 for all).

Conclusion

The WBC count, neutrophil percent, neutrophil count, and NLR were higher in the cases of OMCT with torsion, and these parameters may be useful to diagnose OMCT with torsion. Also, adnexal torsion may deteriorate ovarian reserved as indicated by decreased AMH in torsion group.

Preoperative CT image-based assessment for estimating risk of ovarian torsion in women with ovarian lesions and pelvic pain

PURPOSE

To define and weight the preoperative CT findings for ovarian torsion and to develop an integrated nomogram for estimating the probability of ovarian torsion in women with ovarian lesion and pelvic pain.

METHODS

This retrospective study included 218 women with surgically resected ovarian lesions who underwent preoperative contrast-enhanced CT for pelvic pain from January 2014 to February 2019. Significant imaging findings for torsion were extracted using regression analyses and a regression coefficient-based nomogram was constructed. The diagnostic performance with sensitivity, specificity, and accuracy of the significant imaging findings and the nomogram were assessed.

RESULTS

A total of 255 ovarian lesions (123 lesions with torsion and 132 lesions without torsion) were evaluated. Multivariable regression analysis showed that whirl sign (odds ratio [OR] 11.000; p < 0.001), tubal thickening (OR 4.621; p = 0.001), unusual location of ovarian lesion (OR 2.712; p = 0.020), and hemorrhagic component within adnexal lesion (OR 2.537; p = 0.028) were independent significant parameters predicting ovarian torsion. Tubal thickening showed the highest sensitivity (91.1%) and whirl sign showed the highest specificity (94.7%). When probabilities of ovarian torsion of 0.5 or more in the nomogram were diagnosed as ovarian torsion, sensitivity, specificity, and accuracy of the nomogram were 78.1%, 91.7%, and 85.1%, respectively.

CONCLUSION

The whirl sign, tubal thickening, unusual location of ovarian lesion, and hemorrhagic component within adnexal lesion, and an integrated nomogram derived from these significant findings can be useful for predicting ovarian torsion.

Pearls and Pitfalls in Imaging of Pelvic Adnexal Torsion: Seven Tips to Tell It's Twisted

Pelvic adnexal torsion is a collective term referring to twisting of an ovary, fallopian tube, or paraovarian cyst on its axis with varying degrees of vascular compromise. Although it is the fifth most common gynecologic emergency, the diagnosis is challenging and often missed due to symptoms, physical examination findings, and imaging features that are nonspecific. Delay in salvage surgery may lead to ovarian or tubal loss, dysfunction, and infertility. The tips shared herein are based on the authors' observations of key clinical and imaging features of torsion, with the intent of heightening radiologists' index of suspicion and diagnostic accuracy in a clear and memorable fashion. Clinically, severe acute pain with a known adnexal mass or of severity to elicit nausea or vomiting should raise concern. At imaging, features of ovarian edema are key to the diagnosis, including asymmetric ovarian enlargement, peripheralized follicles, adjacent free fluid, and foci of stromal hemorrhage. The converse finding of symmetric nonenlarged ovaries in a normal location with any imaging modality has a high negative predictive value for torsion, obviating the need for additional imaging. The whirlpool sign (twisted vascular pedicle), abnormal ovarian location, and uterine tilting are additional key imaging manifestations. The presence of color Doppler flow or contrast enhancement only suggests that an ovary is still viable and should not be used to exclude the diagnosis of torsion. In cases of isolated tubal or paraovarian cyst torsion, the ovaries may appear normal; therefore, recognition of this entity along with appreciation of several key imaging findings may assist with this difficult diagnosis. An invited commentary by Dighe is available online. Online supplemental material is available for this article. ^©RSNA, 2021.

Clinical and CT features of ovarian torsion in infants, children and adolescents

OBJECTIVE

To investigate the clinical features and computed tomography (CT) findings of pediatric ovarian torsion.

METHODS

A retrospective analysis of the clinical and CT data of 61 newborns, infants, children, and adolescents with ovarian torsion confirmed by histopathology was performed.

RESULTS

Clinical features included abdominal mass, abdominal pain, nausea and vomiting, and fever. The tumor marker α-fetoprotein was increased in five cases. Ovarian enlargement was found in 26 cases, and follicles were detected in the peripheral region of the ovary in 21 cases. Twenty-one cases presented as solid mixed-density masses on CT images. A total of 30 cases of ovarian torsion were associated with a benign ovarian mass. Among 27 cases of cystic or predominantly cystic masses, the mass had a thickened wall in 26 cases and showed an uneven density in 23 cases. Among all 61 patients, a torsed pedicle was detected in 47 cases. A torsed ovary or mass exhibited mild contrast enhancement in seven cases. Uterine deviation toward the involved side, blurred fat space around lesions, and pelvic free fluid were also found.

CONCLUSION

Pediatric ovarian torsion presents a relatively characteristic CT appearance. Correct diagnosis can be established based on clinical and imaging features.

Adnexal Torsion: Review of Radiologic Appearances

Adnexal torsion is the twisting of the ovary, and often of the fallopian tube, on its ligamental supports, resulting in vascular compromise and ovarian infarction. The definitive management is surgical detorsion, and prompt diagnosis facilitates preservation of the ovary, which is particularly important because this condition predominantly affects premenopausal women. The majority of patients present with severe acute pain, vomiting, and a surgical abdomen, and the diagnosis is often made clinically with corroborative US. However, the symptoms of adnexal torsion can be variable and nonspecific, making an early diagnosis challenging unless this condition is clinically suspected. When adnexal torsion is not clinically suspected, CT or MRI may be performed. Imaging has an important role in identifying adnexal torsion and accelerating definitive treatment, particularly in cases in which the diagnosis is not an early consideration. Several imaging features are characteristic of adnexal torsion and can be seen to varying degrees across different modalities: a massive, edematous ovary migrated to the midline; peripherally displaced ovarian follicles resembling a string of pearls; a benign ovarian lesion acting as a lead mass; surrounding inflammatory change or free fluid; and the uterus pulled toward the side of the affected ovary. Hemorrhage and absence of internal flow or enhancement are suggestive of ovarian infarction. Pertinent conditions to consider in the differential diagnosis are a ruptured hemorrhagic ovarian cyst, massive ovarian edema, ovarian hyperstimulation, and a degenerating leiomyoma. Online supplemental material is available for this article. ^©RSNA, 2021.

"Perifollicular rim sign" in an enlarged ovary-an additional non-contrast CT finding in ovarian torsion

PURPOSE

To look for the presence of "perifollicular rim sign" on non-contrast CT in surgically proven cases of ovarian or adnexal torsion.

METHODS

A retrospective analysis of abdominopelvic non-contrast CT examinations in surgically proven cases of ovarian or adnexal torsion was conducted seeking the presence of "perifollicular rim sign" in torsed ovaries. "Perifollicular rim sign" was defined as a complete ring of perifollicular hyperdensity around ovarian follicles with an attenuation value of > 50 HU and thickness > 1-2 mm. A positive sign was equated to the presence of perifollicular hemorrhage. Pre-operative non-contrast CT was available in 7 out of the 39 ovarian or adnexal torsions included in our study.

RESULTS

"Perifollicular rim sign" was present in 5 out of the 7 ovarian torsions on pre-operative non-contrast CT. MRI correlation was available in one patient. Ovarian enlargement (>4 cm) was present in all 7 cases.

CONCLUSION

In an appropriate clinical setting, presence of "perifollicular rim sign" in an enlarged ovary on non-contrast CT examination can be considered a useful additional sign for ovarian torsion.

The Diagnostic Accuracy of Magnetic Resonance Imaging for Maternal Acute Adnexal Torsion during Pregnancy: Single-Institution Clinical Performance Review

Background: For acute adnexal torsion of pregnant women, appropriate treatment based on an accurate diagnosis is especially important for fertility preservation and timely treatment. The 2017 American College of Obstetricians and Gynecologists (ACOG) Committee Opinion No. 723 announced its practice-changing guidelines to ensure that diagnostic magnetic resonance imaging (MRI) conducted during the first trimester and gadolinium exposure at any time during pregnancy are safe for fetal stability. Unfortunately, few studies have been performed to evaluate the usefulness of the diagnostic accuracy of MRI for acute adnexal torsion during pregnancy. Objective: We sought to determine the efficacy of diagnostic MRI modality using multiparameter for maternal adnexal torsion during pregnancy. Methods: From 1 January 2007 to 31 January 2019, 131 pregnant with MRI tests were reviewed. In this retrospective cohort study, 94 women were excluded due to conditions other than an adnexal mass, and 37 were identified through MRI analyses conducted before surgery for suspected adnexal torsion. The primary outcome was the diagnostic accuracy of sonography and MRI, and the secondary outcome was the usefulness of Apparent diffusion coefficient (ADC) values for predicting the severity of hemorrhagic infarction between the medulla and cortex of the torsed ovarian parenchyma. Results: Our study demonstrates that in the diagnosis of adnexal torsion during pregnancy, the sensitivity, specificity, positive predictive value, and negative predictive value are 62.5%, 83.3%, 90.9%, and 45.5% for sonography and 100%, 77.8%, 90.5%, and 100% for MRI. MRI results in surgical-proven adnexal torsion patients revealed unilocular ovarian cysts (36.8% (7/19)), multilocular ovarian cysts (31.6% (6/19)), and near normal-appearing ovaries (31.6% (6/19)). Pathology in adnexal torsion revealed a corpus luteal ovarian cyst (63.2% (12/19)) and underlying adnexal pathology (46.8% (7/19)). Maternal adnexal torsion during pregnancy was more likely to occur in corpus luteal ovarian cysts than in underlying adnexal masses (odds ratio, 2.14; 95% confidence interval (CI), 0.428–10.738). MRI features for adnexal torsion were as follows: tubal wall thickness, 100% (19/19); ovarian stromal (medullary) edema, 100% (19/19); symmetrical or asymmetrical ovarian cystic wall, 100%(19/19); prominent follicles in the ovarian parenchyma periphery, 57.9% (11/19); periadenxal fat stranding, 84.2% (16/19); uterine deviation to the twisted side, 21.1% (4/19); and peritoneal fluid, 42.1% (8/19). The signal intensity of the ADC values of the ovarian medulla and cortex were compared between the cystectomy and detorsion (CD) and salpingo-oophorectomy (SO) groups. The ADC values of the CD and SO groups were 1.81 ± 0.09 × 10⁻³ mm²/s and 1.91 ± 0.18 × 10⁻³ mm²/s, respectively (P = 0.209), in the ovarian medulla and 1.37 ± 0.32 × 10⁻³ mm²/s and 0.96 ± 0.36 × 10⁻³ mm²/s, respectively (P = 0.022), in the ovarian cortex. The optimal cut-off value of ADC values for predictable total necrosis in the torsed ovarian cortex was ≤ 1.31 × 10⁻³ mm²/s (area under the curve (AUC) = 0.81; 95% CI 0.611–1.0; P = 0.028). Conclusion: Our data showed that maternal adnexal torsion during pregnancy occurred in most corpus luteal cystic ovary cases and some normal-appearing ovary during the 1st and 2nd trimesters of gestation. Therefore, this study is the first study to elaborate on the existence or usefulness of the diagnostic MRI for acute maternal adnexal torsion during pregnancy and to provide a predictive diagnosis of the severity of hemorrhagic infarction for deciding surgical radicality.

Added value of MRI for the diagnosis of adnexal torsion in children and adolescents after inconclusive ultrasound examination

PURPOSE

The purpose of this study was to assess the performance of magnetic resonance imaging (MRI) in children and adolescents with suspected adnexal torsion (AT) after inconclusive initial ultrasound examination.

MATERIALS AND METHODS

Twenty-eight girls with a mean age of 12±4 (SD) years (range: 1 month to 18years) were included. All had clinically suspected AT and inconclusive initial ultrasound findings followed by pelvic MRI as a second-line imaging modality. The final diagnosis was obtained by surgery or follow-up. Two radiologists blinded to the clinical, ultrasound and surgical data, retrospectively and independently reviewed MRI examinations. Clinical and MRI features associated with AT were searched for using univariate analyses.

RESULT

Among the 28 patients, 10/28 patients (36%) had AT and 22/28 (79%) had an ovarian or tubal mass. AT was associated with an age<13years (OR: 10.7; 95% CI: 1.3-148.2) (P=0.022) and a whirlpool sign at MRI (OR: 61.0; median unbiased estimate, 7.2) (P<0.0001). When a mass was present, the best quantitative MRI criteria for AT were mass volume and ovary-corrected volume≥30cm³ (κ=0.72 and 0.61, respectively), mass axis length≥5cm (κ=0.90), and mass surface area≥14 cm² (κ=0.58), with moderate to almost perfect interobserver agreement. The overall sensitivity, specificity and accuracy of MRI for the diagnosis of AT were 100% (10/10; 95% CI: 69-100), 94% (17/18; 95% CI: 73-100) and 96% (27/28; 95% CI: 82-100) respectively, with perfect interobserver agreement (κ=1).

CONCLUSION

In pediatric patients with suspected AT and inconclusive initial ultrasound examination, a strategy including MRI as a second-line imaging modality should be considered if MRI does not delay a potential surgery.

Whirlpool sign of adnexal torsion on CT: where can we find it?

Background

Whirlpool sign on computed tomography (CT) is pathognomic of adnexal torsion.

Purpose

To evaluate the visibility and common location of the whirlpool sign in adnexal torsion on CT.

Material and Methods

This retrospective study included 143 consecutive patients who underwent preoperative CT imaging and subsequent surgically confirmed as adnexal torsion. Two readers independently recorded the presence and location of whirlpool sign in adnexal torsion on CT. Patients with and without whirlpool sign were compared with regard to the size of the adnexal mass and the degree of torsion.

Results

Whirlpool sign was detected in 60 (42.0%) patients on the transverse CT plane and 79 (55.2%) patients on the coronal CT plane of 143 patients. The sign was significantly better detected on the coronal CT plane than on the transverse CT plane ( P = 0.03). The most common location of the sign included the posterolateral aspect of the adnexal mass on the transverse CT plane (25/60, 41.7%, P = 0.04) and the upper-lateral aspect of the adnexal mass on the coronal CT plane (45/79, 60.0%, P < 0.001). The size of the adnexal mass with whirlpool sign was significantly larger than the mass without whirlpool sign on the transverse CT plane (median 9.6 vs. 8.6 cm, P = 0.03). No significant difference in the degree of torsion was found between patients with and without whirlpool sign on CT ( P = 0.56–0.62).

Conclusion

Whirlpool sign of adnexal torsion is well detected at the upper-lateral aspect of adnexal mass on the coronal CT plane.

Ovarian torsion: developing a machine-learned algorithm for diagnosis

BACKGROUND

Ovarian torsion is a common concern in girls presenting to emergency care with pelvic or abdominal pain. The diagnosis is challenging to make accurately and quickly, relying on a combination of physical exam, history and radiologic evaluation. Failure to establish the diagnosis in a timely fashion can result in irreversible ovarian ischemia with implications for future fertility. Ultrasound is the mainstay of evaluation for ovarian torsion in the pediatric population. However, even with a high index of suspicion, imaging features are not pathognomonic.

OBJECTIVE

We sought to develop an algorithm to aid radiologists in diagnosing ovarian torsion using machine learning from sonographic features and to evaluate the frequency of each sonographic element.

MATERIALS AND METHODS

All pediatric patients treated for ovarian torsion at a quaternary pediatric hospital over an 11-year period were identified by both an internal radiology database and hospital-based International Statistical Classification of Diseases and Related Health Problems (ICD) code review. Inclusion criteria were surgical confirmation of ovarian torsion and available imaging. Patients were excluded if the diagnosis could not be confirmed, no imaging was available for review, the ovary was not identified by imaging, or torsion involved other adnexal structures but spared the ovary. Data collection included: patient age; laterality of torsion; bilateral ovarian volumes; torsed ovarian position, i.e. whether medialized with respect to the mid-uterine line; presence or absence of Doppler signal within the torsed ovary; visualization of peripheral follicles; and presence of a mass or cyst, and free peritoneal fluid. Subsequently, we evaluated a non-torsed control cohort from April 2015 to May 2016. This cohort consisted of sequential girls and young adults presenting to the emergency department with abdominopelvic symptoms concerning for ovarian torsion but who were ultimately diagnosed otherwise. These features were then fed into supervised machine learning systems to identify and develop viable decision algorithms. We divided data into training and validation sets and assessed algorithm performance using sub-sets of the validation set.

RESULTS

We identified 119 torsion-confirmed cases and 331 torsion-absent cases. Of the torsion-confirmed cases, significant imaging differences were evident for girls younger than 1 year; these girls were then excluded from analysis, and 99 pediatric patients older than 1 year were included in our study. Among these 99, all variables demonstrated statistically significant differences between the torsion-confirmed and torsion-absent groups with P-values <0.005. Using any single variable to identify torsion provided only modest detection performance, with areas under the curve (AUC) for medialization, peripheral follicles, and absence of Doppler flow of 0.76±0.16, 0.66±0.14 and 0.82±0.14, respectively. The best decision tree using a combination of variables yielded an AUC of 0.96±0.07 and required knowledge of the presence of intra-ovarian flow, peripheral follicles, the volume of both ovaries, and the presence of cysts or masses.

CONCLUSION

Based on the largest series of pediatric ovarian torsion in the literature to date, we quantified sonographic features and used machine learning to create an algorithm to identify the presence of ovarian torsion - an algorithm that performs better than simple approaches relying on single features. Although complex combinations using multiple-interaction models provide slightly better performance, a clinically pragmatic decision tree can be employed to detect torsion, providing sensitivity levels of 95±14% and specificity of 92±2%.

Susceptibility-weighted MR sequence for the evaluation of ovarian masses with torsion

OBJECTIVE

Adnexal torsion is a rare gynecologic emergency caused by twisting of an adnexal mass. Twisted vascular pedicle is the most specific imaging finding for adnexal torsion, however, identification of twisted vascular pedicle can be challenging. The purpose of this study is to evaluate the feasibility of susceptibility-weighted MR sequence (SWS) for the diagnosis of adnexal torsion.

METHODS

MR imaging including SWS (SWAN: susceptibility-weighted angiography) of surgically proven four benign ovarian masses with torsion (one acute and three subacute to chronic torsions) were retrospectively evaluated. Three cystic masses and one solid mass were included in this study.

RESULTS

High signal intensity venous thrombus within the twisted vascular pedicle on T₁-weighted imaging (T₁WI) was detected in three lesions with subacute to chronic torsion (75%) but not in one lesion with acute torsion, whereas susceptibility-induced signal voids within the twisted vascular pedicle on SWAN were detected in all four lesions (100%).

CONCLUSION

The demonstration of venous thrombus in the twisted vascular pedicle by SWS may be diagnostic for adnexal torsion.

ADVANCES IN KNOWLEDGE

SWS can detect blood products sensitively and can reveal venous thrombus in the twisted vascular pedicle, which may be helpful for the diagnosis of adnexal torsion.

Adnexal torsion in the third trimester of pregnancy: a case report and diagnostic value of MR imaging

BACKGROUND

The torsion of normal adnexa is rare during pregnancy, especially in the third trimester. Nonspecific symptoms and signs as well as the limitations of ultrasound (US) make the diagnosis difficult, resulting in the loss of adnexa and fetal compromise. The magnetic resonance imaging (MRI) features of the torsion of normal adnexa are not classically described during pregnancy and only reported in a few cases. We find some different MRI features of the torsion of normal adnexa in late pregnancy and its diagnosis and treatment values are discussed in our report.

CASE PRESENTATION

A 27-year-old woman at 31 + 5 weeks' gestation presented to the emergency department with a three-day history of the left lower abdominal pain. US discovered a mass of 87 × 61 mm in the left abdomen, but did not show whether the mass originated from the left ovary or the uterus. MRI showed the left ovary was increased in size to 82 × 42 × 85 mm with peripheral follicles. On fat-suppressed T2-weighted images, the signal intensity of the lesion was significantly decreased compared with the right ovary. The adjacent fallopian tube was found to be thickened. The radiologists diagnosed ovary infarction secondary to adnexal torsion. With the provisional diagnosis of adnexal torsion, the patient was taken to surgery. The left adnexal torsion was found during surgery. There was extensive hemorrhage and necrosis, so a left salpingo-oophorectomy was performed. The histopathology confirmed an extensively hemorrhagic fallopian tube and ovary with partial necrosis.

CONCLUSION

We believe MRI is helpful where US is indeterminate in diagnosis of the torsion of normal adnexa in advanced pregnancy. We found that aside from hyperintensity on fat-saturated T1-weighted images, the low signal intensity on T2-weighted images can also reflect adnexal hemorrhage in conjunction with the torsion of normal adnexa.

Emergent MRI for acute abdominal pain in pregnancy-review of common pathology and imaging appearance

Acute abdominal pain in pregnancy remains a clinically challenging presentation, often requiring imaging. The threat of morbidity and mortality to both mother and fetus necessitates quick and accurate imaging diagnosis, often via ultrasound. However, many of the common causes of acute abdominal pain are not readily diagnosed with sonography, and magnetic resonance imaging (MRI) is increasingly favored in this setting. The purpose of this review is to familiarize the reader with common pathologies which may be encountered in pregnant females presenting with acute abdominal pain requiring emergent MRI.

Cross-sectional imaging of acute gynaecologic disorders: CT and MRI findings with differential diagnosis-part I: corpus luteum and haemorrhagic ovarian cysts, genital causes of haemoperitoneum and adnexal torsion

Acute gynaecologic disorders are commonly encountered in daily clinical practice of emergency departments (ED) and predominantly occur in reproductive-age women. Since clinical presentation may be nonspecific and physical findings are often inconclusive, imaging is required for a timely and accurate diagnosis. Although ultrasound is the ideal non-invasive first-line technique, nowadays multidetector computed tomography (CT) is extensively used in the ED, particularly when a non-gynaecologic disorder is suspected and differential diagnosis from gastrointestinal and urologic diseases is needed. As a result, CT often provides the first diagnosis of female genital emergencies. If clinical conditions and scanner availability permit, magnetic resonance imaging (MRI) is superior to CT for further characterisation of gynaecologic abnormalities, due to the excellent soft-tissue contrast, intrinsic multiplanar capabilities and lack of ionising radiation.

The purpose of this pictorial review is to provide radiologists with a thorough familiarity with gynaecologic emergencies by illustrating their cross-sectional imaging appearances. The present first section will review the CT and MRI findings of corpus luteum and haemorrhagic ovarian cysts, gynaecologic haemoperitoneum (from either ruptured corpus luteum or ectopic pregnancy) and adnexal torsion, with an emphasis on differential diagnosis. Additionally, comprehensive and time-efficient MRI acquisition protocols are provided.

MRI of Acute Gynecologic Conditions

Although usually not a first-line imaging modality in the setting of acute pelvic pain, magnetic resonance imaging (MRI) is able to depict and characterize a wide range gynecologic diagnoses with high accuracy. Lack of ionizing radiation renders MRI particularly useful for assessment of pregnant women and children. Furthermore, inherent high soft-tissue resolution of MRI allows accurate diagnosis without intravenous contrast use, which is advantageous for patients with renal insufficiency and pregnant patients. Familiarity with the typical MRI appearance of various acute gynecologic conditions helps establish the correct diagnosis. This article reviews the common MRI findings of acute gynecologic processes, in both pregnant and nonpregnant patients. Level of Evidence: 3 Technical Efficacy Stage: 3 J. Magn. Reson. Imaging 2020;51:1291-1309.

Cost Comparison of Ultrasound Versus MRI to Diagnose Adolescent Female Patients Presenting with Acute Abdominal/Pelvic Pain Using Time-Driven Activity-Based Costing

RATIONALE AND OBJECTIVES

To compare the cost of ultrasound (US) versus magnetic resonance imaging (MRI) using time-driven activity-based costing in adolescent female patients with suspected appendicitis.

MATERIALS AND METHODS

Process maps were created using data from electronic medical record review and patient shadowing for adolescent female patients undergoing US or noncontrast MRI exams of the abdomen and pelvis for suspected appendicitis. Capacity cost rates for all personnel, equipment, facilities, and supplies in each exam pathway were established from institutional accounting data. The cost of each process step was determined by multiplying step-specific capacity cost rates by the mean time required to complete the step. Total pathway costs for US and MRI were computed by summing the costs of all steps through each pathway, and a direct cost comparison was made between the two modalities.

RESULTS

Process maps for US and MRI pathways were generated from 231 and 52 patient encounters, respectively. Patients undergoing US exams followed one of six pathways depending on exam order (abdomen versus pelvis performed first) and whether additional time was needed for bladder filling. Mean total US pathway time was 91 minutes longer than for MRI (US = 166 minutes; MRI = 75 minutes). Total MRI pathway cost was $209.97 compared to a mean US cost of $258.33 (range = $163.21-$293.24).

CONCLUSION

MRI can be a faster and less costly alternative to US for evaluating suspected appendicitis in adolescent female patients. While precise costs will vary by institution, MRI may be a viable and at times preferable alternative to US in this patient population.

Twist and shout: magnetic resonance imaging findings in ovarian torsion

Adnexal torsion is characterized by partial or complete rotation of the suspensory ligament of the ovary and its corresponding vascular pedicle, resulting in vascular impairment that can culminate in hemorrhagic infarction, as well as necrosis of the ovary and fallopian tube. Because there are myriad causes of acute pelvic pain, the differential diagnosis of ovarian torsion is often challenging. Consequently, radiologists should be familiar with the main imaging findings. In this regard, there are typical signs of ovarian torsion on magnetic resonance imaging, including increased ovarian volume with stromal edema and peripheral distribution of the ovarian follicles, as well as thickening of the fallopian tube, an adnexal mass (causal factor) that shifts toward the midline, and the classic, pathognomonic “whirlpool sign”. The objective of this essay was to review and illustrate the various magnetic resonance imaging findings in ovarian torsion.

A New Technique of Oophoropexy: Folding and Fixating of Utero-Ovarian Ligament to Round Ligament in a Patient with Reccurrent Ovarian Torsion

Introduction

Most cases of ovarian torsion occur in the reproductive age and many are related to ovarian and paraovarian masses. If it occurs without any subtle anatomic etiology or ovarian and paraovarian masses, recurrence of ovarian torsion is more likely. Recurrent left ovarian torsion is much less common than recurrent right ovarian torsion. The authors describe a rare case with their new ovarian fixation technique.

Case and Method

A 21-year-old female patient with polycystic ovarian syndrome had a 7th recurrence of left ovarian torsion. Although ovarian fixation was performed in addition to detorsion at the 5th and the 6th laparoscopic surgeries, it had failed. Due to recurrence ovarian torsion after ovarian fixation, the authors performed a different technique:folding the utero-ovarian ligament which folded on itself. The distal part of the utero-ovarian ligament with the ovary was both fixed to the proximal part of the round ligament which was adjacent to the uterus.

Conclusion

Although a wide range of oophoropexy methods have been described in the literature, the best method remains a matter for debate. This technique can be performed even when the ovarian tissue is necrotic. Because of this, we think that this technique is useful and effective technique.

Laparoscopic Adnexal Detorsion in a 20-Week Pregnant Patient: A Case Report and Literature Review

Adnexal torsion is a cause of severe pelvic pain in reproductive aged women and during pregnancy. Adnexal torsion occurs when there is a complete turn of the ovary, tube, or both resulting in impaired blood flow to the ovary. The diagnosis of adnexal torsion is sometimes challenging due to the enlarged effect of the uterus, the displacement of abdominal and pelvic structures and the nonspecific symptoms in pregnancy. Therefore, prompt diagnosis is essential for better maternal and neonatal outcomes. The gold standard for confirmation and treatment of ovarian torsion is surgery. Laparoscopy and Laparotomy are surgical options with defined risks and benefits. Therefore, choosing the best surgical technique and surgical procedure are of utmost importance to decrease the chances of adverse events intra and postoperatively. Little literature exists regarding the laparoscopic approach of an ovarian torsion during the second trimester. Our case is a 20-week pregnant patient who had a 1080 degree rotation of the left adnexa. She required laparoscopy for adnexal detorsion and had good intraoperative, postoperative, maternal, and neonatal outcomes following management.

[Acute Pelvic pain in women-gynecological causes]

BACKGROUND

Acute pelvic pain in women may be due to gynecological, gastrointestinal, and urinary tract disorders. Ectopic pregnancy (EP), pelvic inflammatory disease (PID), and ruptured ovarian cysts are the most common gynecological causes for acute pelvic pain and their diagnosis can be challenging.

METHODS

Patient history, clinical examination, and blood tests as well as patient age and potential pregnancy status help to establish the correct diagnosis. While sonography (US) remains the primary imaging modality of choice, computed tomography (CT) plays an important role in patients with indeterminate US evaluation and for treatment planning.

CONCLUSION

Diagnostic imaging is pivotal to differentiate potentially life- and fertility-threatening conditions from those that can be treated conservatively. Profound knowledge of the most common gynecological pathologies allows prompt and correct radiological diagnosis and assists in proper treatment planning.