Isolated Tubal Torsion in the Absence of Ovarian Pathology: A Case Report and Literature Review

Introduction

Isolated fallopian tube torsion (IFTT) is an exceptionally rare gynecological emergency with estimated incidence of 1 in 1.5 million women, IFTT poses significant diagnostic challenges due to its nonspecific clinical presentation often mimicking more common conditions like appendicitis or ovarian torsion with reliance on surgical exploration for diagnosis.^1,2 This diagnostic uncertainty often results in delayed intervention, increasing the risk of tubal necrosis. Teenage girls with preexisting tubal pathology are notably susceptible.^3,4 Prompt surgical intervention is usually warranted and different surgical techniques have been reviewed in this study.^5,6

Case Presentation

A 13 year-old girl presented to the emergency department (ED) with sudden onset right lower abdominal pain. The pain was sharp with associated nausea and vomiting with normal bowel and micturition habits. She had no fever, vaginal bleeding or discharge. She was premenarchal with no prior sexual activity, contraceptive use, or use of recreational drugs.

She weighed 104kg, heart rate was 68bpm and blood pressure of 113/76mmHg. She had severe right-iliac-fossa tenderness but no guarding or rebound tenderness. Laboratory tests showed beta HCG of 2miu/mL, hemoglobin 129g/L, white-cell-count 8.2x10^9/L, C-reactive-protein 8 mg/L. Pelvic ultrasound showed a 67x53mm complex right adnexal hypoechoic mass with no torsion or free fluid with a differential diagnosis of a dermoid cyst. Tumour markers done, cancer-antigen 125 and alpha-fetal-protein, were negative. She was given oral analgesia with great effect and was discharged with a plan for gynaecology clinic review. She, however, returned to ED the following day with worsening right iliac fossa pain, nausea and vomiting. A repeat pelvic ultrasound scan revealed a 75x73mm right para-ovarian complex hypoechoic mass containing several internal septations with no evidence of torsion (Figure 1).

Figure 1 Hypoechoic right adnexal mass on trans abdominal ultrasound scan. The right adnexa is labelled “RT ADNEXA”, the uterus is labeled as “UT” and the right ovary is labelled at “RT OV”.

In view of the worsening symptoms, she was consented for laparoscopy with possible ovarian cystectomy, salpingectomy, oophorectomy, or salpingo-oophorectomy. The surgical risks as well as possible implications on fertility were discussed together with the non-surgical alternative of expectant management.

At laparoscopy, a 7cm torted right adnexal mass was seen. This contained a hemorrhagic para-tubal cyst and an ischemic right fallopian tube (Figure 2). Both ovaries and the left fallopian tube were normal. Detorsion of the right fallopian tube was performed but it still appeared unhealthy. A right salpingectomy was subsequently performed (Figure 3). The specimen was sent for histopathology which confirmed a benign hemorrhagic left fallopian tube, and a serous cystadenoma with features consistent with torsion.

Figure 2 Ischemic isolated right fallopian tube torsion with a hemorrhagic para-tubal cyst.

Figure 3 Normal right ovary and uterus following right salpingectomy.

The patient made an uncomplicated recovery and was discharged the following day. She was reviewed at six weeks in the gynaecology clinic for a comprehensive debrief and postoperative assessment. No concerns were identified at this follow-up visit.

Discussion

IFFT is the rotation of the fallopian tube around itself without involving the ipsilateral ovary. It is a rare with a mean age at presentation of 13 years. Clinical presentation is typically nonspecific, most often with acute or subacute lower abdominal pain, sometimes accompanied with nausea and vomiting. Preoperative diagnosis is challenging, with correct identification before surgery achieved in only 13–16% of cases.^7,8

Risk factors for tubal torsion include the presence of a para-tubal cyst, tubal pathology like hydrosalpinx, increased adnexal volume, and congenital or anatomic factors such as long or lax ligaments and a relatively small uterus, which allow greater mobility of the adnexa.⁹

The clinical presentation of IFTT is characterized by acute onset lower abdominal pain, which is typically unilateral and may be associated with nausea and vomiting. The pain is often severe, intermittent, and non-radiating. In most cases, there are no specific distinguishing features between right and left-sided torsion with comparable prevalence.^5,8

Physical examination may reveal localized abdominal tenderness, sometimes with peritoneal signs if the torsion is prolonged. Fever and leukocytosis are uncommon. The clinical picture can be nonspecific, and the diagnosis is often delayed due to the rarity and lack of pathognomonic findings.⁵ Differential diagnoses include ovarian torsion, ectopic pregnancy and appendicitis.

Imaging, typically pelvic ultrasound, may show an adnexal mass or a dilated, cystic, tubular structure adjacent to a normal ovary, occasionally with a para-tubal cyst. Importantly, doppler flow is frequently preserved in isolated tubal torsion, so normal flow does not exclude the diagnosis.^6,8

The management of IFTT is prompt surgical intervention with a strong preference for organ-preserving detorsion whenever feasible regardless of the gross appearance of the tube or ovary. Oophorectomy or salpingectomy should be reserved for cases where the tissue is nonviable and falls apart with manipulation.^6,10 Delayed intervention and longer symptom duration are associated with a higher likelihood of requiring salpingectomy.^5,8,10 In cases where IFTT is associated with hydrosalpinx detorsion may be less successful, with a higher risk of recurrence and need for subsequent surgery.^11,12

Potential complications associated with detorsion include recurrence of torsion, persistent or recurrent hydrosalpinx, need for subsequent surgical intervention, and possible loss of tubal function despite initial preservation. These risks are particularly elevated when hydrosalpinx is present.^11,12

Potential complications of salpingectomy include immediate loss of the affected fallopian tube, which may reduce future fertility, especially if the contralateral tube is abnormal or becomes compromised later in life. There is no significant impact on fertility with a normal functioning contralateral tube.¹³ Salpingectomy eliminates the risk of recurrent torsion and further surgical interventions on the affected side.²

The postoperative visit should include detailed counseling about the diagnosis, surgical interventions, risk of recurrence and potential impact on future fertility.^10,14