48. Chronic Adnexal Torsion Presenting as Intermittent Pelvic Pain

Abstract

<h3>Background</h3> Adnexal torsion is typically treated as a surgical emergency to prevent ovarian necrosis. Many young women present with transient pelvic pain along with an adnexal cyst and are ruled out for torsion secondary to resolution of their pain. It is still possible, however, that when intermittent pain continues in the setting of an ovarian or para ovarian cyst, the adnexa is chronically torsed. This series includes four postmenarchal patients with likely chronic adnexal torsion who had viable ovaries at the time of surgery. <h3>Case</h3> Case 1: A 12-year-old presented with acute left lower quadrant pain and was diagnosed with a 6 cm left ovarian simple cyst. Her pain improved quickly with no intervention but continued to return intermittnetly over the next several months. She eventually underwent a scheduled laparoscopic cystectomy and was found to have a 6 cm paratubal cyst, torsed several times around the infundibulopelvic (IP) ligament with a viable ovary. See Figure 1. Case 2: A 16-year-old presented with 3 days of worsening abdominal pain that started while bowling. Imaging revealed a 9.6 cm simple ovarian cyst. Her pain resolved without intervention. One month later, after soccer practice, she -presented with another episode of acute pain and imaging revealed a 6.8 cm ovarian cyst. Pain resolved again, and she later underwent a scheduled laparoscopic cystectomy revealing torsion around the IP ligament. Pathology revealed a serous cystadenoma. Case 3: A 15-year-old presented with a 5-month history of mild right lower quadrant pain. During that period, she had 3 episodes of acute, severe pain lasting one day, before self-resolving. She presented on the third episode of severe pain, and computed tomography showed a 7.5cm cystic left ovarian mass with thickened walls. She was non-emergently referred for a persistent cyst and on laparoscopy she had an enlarged, torsed right ovary. Ovarian cystectomy was performed, and pathology revealed a mature teratoma. See Figure 2. Case 4: A 13-year-old presented with two years of inconsistent left lower quadrant pain. She was found to have an 8cm left adnexal cyst. She was seen in the ED twice and ruled out for ovarian torsion both times. After the pain woke her up in the middle of the night with accompanying nausea and emesis, she was seen in clinic and scheduled for an outpatient laparoscopic cystectomy. Torsion of the IP ligament was found due to a large paratubal cyst. <h3>Comments</h3> In a patient with an adnexal cyst and intermittent pelvic pain, chronic torsion should be considered and can be definitively diagnosed with laparoscopy. Although none of these patients lost an ovary, chronic torsion of the adnexa may impair fertility.