Adnexal Torsion: Clinical Presentations and Challenges QC26-QC31
Dr. Anirban Dasgupta
D-15, Sarojini Naidu Path, Non Company, City Centre, Durgapur-713216, West Bengal, India.
Introduction: Adnexal torsion contributes to 2.7-7.4% of all gynaecological emergencies and delayed or misdiagnosis results in loss of ovarian function. Diagnosis is not straight forward, both clinically and radiologically, and it can be confused with a number of other surgical and gynaecological emergencies.
Aim: The aim of the present study was to correctly identify ovarian torsion among different cyst accidents, its overall incidence, the types of surgery involved and the histopathological diagnoses of the twisted adnexal masses in a prospective observation over two years.
Materials and Methods: The clinical scoring was used in one group (n=14) and its reliability was assessed in correct identification of adnexal torsion by comparing with another group without the scoring (n=12). This scoring was developed in an Institute in Paris in (2000-04) using logistic regression model to select a combination of five best parameters namely: unilateral lumbar or abdominal pain, pain duration of less than 8 hours at first presentation, vomiting, absence of leucorrhoea and metrorrhagia, and cyst size more than 5 cm on ultrasound; to develop a combined score to diagnose torsion. A combined score of more than 60 was used to diagnose torsion in present study, and a score less than 40 to rule it out. For the intermediate range 41-60, clinical judgement was used in addition to scoring, to screen for torsion. Common differential diagnoses masquerading as torsion were also noted. Simple measures like specificity, sensitivity, PPV were calculated in both groups and compared between the two groups using Fischerís-exact test for significance.
Results: Cyst accidents and torsion accounted for 5% (n=19) and 3.7% (n=14) of all gynaecological emergencies (n=374). Lower abdominal pain and fever were the most common symptoms. Clinical diagnosis aided by the scoring correctly identified torsion in (n=8) 89% patients as compared to (n=6) 60% in group without scoring. The most common histopathological diagnosis was dermoid while the common procedures were de-torsion and cystectomy and unilateral salpingo-oophorectomy. Several interesting scenarios like torsion and bilateral dermoid cysts, torsion of one ovary over the pedicle of contralateral ovarian cyst, a bulky ovary with an enlarged appendicular lump, endometriomas, tubo-ovarian masses mimicking torsion were also noted and diagnostic challenges were discussed.
Conclusion: Clinical detection of adnexal torsion with perfect accuracy remains a challenge in emergency and a clinical scoring with careful imaging can help in refining diagnostic accuracy and plan appropriate surgery.