Hiller et al.

Genitourinar y Imaging • Clinical Obser vations

CT of Adnexal Torsion

CT Features of Adnexal Torsion

Nurith Hiller1 OBJECTIVE. Adnexal torsion is most commonly a clinical diagnosis, often aided by sono-
Liat Appelbaum1 graphic findings. At times, the clinical presentation can mimic nongynecologic causes of acute
Natalia Simanovsky1 lower abdominal pain. In these cases, CT may be the initial imaging study. The purpose of this
Ahinoam Lev-Sagi2 study was to define the CT features associated with adnexal torsion.
Dvora Aharoni3 CONCLUSION. On CT, a well-defined adnexal mass abnormally located in the pelvis with
ipsilateral deviation of the uterus in a woman or girl with lower abdominal pain should raise the
Tamar Sella1
suspicion of adnexal torsion. Inflammatory signs on CT suggest the presence of necrosis.
Hiller N, Appelbaum L, Simanovsky N, Lev-
Sagi A, Aharoni D, Sella T dnexal torsion is a gynecologic standard parameters for abdominal CT for each ma-

A emergency caused by partial or

Keywords: adnexa, adnexal torsion, CT, pelvic imaging,
women’s imaging
DOI:10.2214/AJR.06.0073
Received January 15, 2006; accepted after revision
October 31, 2006.
1Department
of Radiology, Hadassah-Hebrew University
Medical Center, PO Box 12227, Jerusalem, Israel, 91121.
Address correspondence to T. Sella
(tamarse@hadassah.org.il).
2Department of Gynecology, Hadassah-Hebrew University
Medical Center, Jerusalem, Israel.
3Department of Radiology, Shaare Zedek Medical Center,
Jerusalem, Israel.
AJR 2007; 189:124–129
0361–803X/07/1891–124
© American Roentgen Ray Society
complete twisting of the mesovar-
ium. Early surgical intervention is
needed to save the ovary. The diagnosis is
most commonly a clinical one aided by
sonography. However, because the clinical
presentation of adnexal torsion can mimic
other causes of acute abdominal pain, CT
sometimes is performed in equivocal cases. In
addition, if the clinical presentation is un-
clear, CT may be the initial diagnostic imag-
ing examination performed. Thus familiarity
with the spectrum of CT characteristics of ad-
nexal torsion is essential for prompt recogni-
tion of this potentially serious condition. Our
review of the literature revealed descriptions
of the CT characteristics of adnexal torsion in
only a few small series of patients [1–3]. The
goal of our study was to define the CT fea-
tures associated with adnexal torsion and to
correlate these features with the clinical,
sonographic, surgical, and pathologic find-
ings. To our knowledge, our series is the larg-
est described in the literature.
Materials and Methods
A search of two university hospital registries for
the years 1995–2005 identified the records of 328
patients with surgically proven adnexal torsion.
Thirty-five (10.7%) of these patients underwent CT
as part of a preoperative evaluation. CT examina-
tions were performed with one of the following
scanners: 2400 Elite scanner (Elscint), helical Twin
Flash scanner (Philips Medical Systems), 4-MDCT
MX 8000 scanner (Philips Medical Systems). The
chine were used, that is, 5-mm slice thickness with
a table increment of 5 mm and a pitch of 1–1.5.
Tube current and kilovoltage were adjusted to the
type of machine and size of the patient. Oral con-
trast material (1,000 mL meglumine ioxithalamate,
Telebrix 3%, Guerbet) was administered to all pa-
tients 90 minutes before CT. Intravenous contrast
material (100 mL meglumine ioxithalamate, Te-
lebrix 30, Guerbet) was administered to all but four
patients according to a standard injection protocol
at an injection rate of 2.5 mL/s.
Clinical information obtained from the patients’
medical records included age, medical history, and
clinical signs and symptoms at presentation. Fever
was defined as body temperature exceeding 37.5°C.
Abdominal pain was defined as lower abdominal
pain, flank pain, or both. The onset of abdominal pain
was defined as acute when occurring up to 24 hours
before admission, subacute if it had lasted up to 1
week, and chronic if it had persisted for more than 1
week before admission. Laboratory values were re-
viewed with emphasis on inflammatory markers. An
elevated WBC count was defined as greater than
10,000/mm3. Sonographic findings were extracted
from the charts, and images were reviewed when
available. Hospital institutional review board ap-
proval was obtained for this retrospective study.
Two radiologists, each with more than 10 years
of experience in body imaging, retrospectively re-
viewed all CT scans. For each adnexal mass found
on CT scans, the size, nature (cystic, solid, or com-
bined), borders, and location within the pelvis were
assessed. For adnexal findings with a cystic compo-
nent, mural thickness was measured and defined as
abnormal when greater than 3 mm. Uterine loca-

124 AJR:189, July 2007


Fig. 1—26-year-old
woman with torsion of
right ovarian dermoid.
Unenhanced CT scan
shows well-defined fat-
containing mass (M) to
left of uterus (U). Uterus
is deviated to right.
Infiltration of fat (arrow)
anterior to twisted mass
is evident. Pathologic
examination revealed
necrosis.
tion, visualization of the contralateral ovary, and
changes in the adjacent pelvic fat and blood vessels
also were assessed. Surgical and pathologic find-
ings were recorded separately, and the radiologists
evaluating the CT scans were blinded to these find-
ings. Data were collected and analyzed with de-
scriptive statistics.
Results
Clinical Presentation
The age range of the patients was 5–85
years (mean, 38.5 years). Three (9%) of the
35 patients (ages 5, 9, and 12 years) were
premenarchal, and 10 (29%) were post-
menopausal. Abdominal pain was clinically
present in all patients. Pain was located in
the lower abdomen in 29 (83%), in the flank
in three (8.5%), and in both the lower abdo-
men and the flank in another three (8.5%) of
the patients. The pain was ipsilateral to the
involved adnexa in 26 (74%) of the patients.
The onset of pain was acute in 21 (60%),
subacute in nine (26%), and chronic in five
(14%) of the patients. Additional clinical
signs and symptoms included nausea or
vomiting in 16 (46%), elevated WBC count
in 15 (43%), peritoneal signs in 12 (34%),
and fever in seven (20%) of the patients.
Peritoneal signs correlated invariably with
the presence of adnexal necrosis at patho-
logic examination. All other signs and symp-
toms showed no such correlation.
AJR:189, July 2007
CT of Adnexal Torsion
Sonographic Findings
Sonography was performed on 33 (94%)
of the 35 patients, revealing an adnexal mass
in 31 patients. The size range of the lesions
was 3–20 cm (mean, 9.5 cm). Findings were
solid on sonography in seven (23%), simple
cyst in three (10%), multiloculated cystic in
10 (32%), and mixed solid and cystic in 11
(35%) of the 31 cases. In 25 patients, the
sonographic study preceded CT. Torsion was
not diagnosed in 16 of these 25 patients. The
sonographic findings were interpreted as
hemorrhagic corpus luteum cyst in three pa-
tients, pedunculated necrotic myoma in two
patients, uncomplicated dermoid cyst in two
patients, benign cyst in two patients, pelvic
mass unrelated to the adnexa in one patient,
and endometrioma in one patient. In the
other five patients, the adnexa appeared ab-
normal on sonography, but a specific diagno-
sis was not made, and patients were referred
for CT for further evaluation. The correct di-
agnosis of adnexal torsion was made on
sonography before CT in nine cases and was
later confirmed on CT. Doppler sonography
was performed on only 11 (33%) of 33 pa-
tients, revealing abnormal adnexal vascular
flow in six (55%) and normal flow in five
(45%) of the patients. On the basis of clinical
and sonographic findings, the diagnosis of
adnexal torsion was made before CT in only
nine (26%) of 35 cases.
Surgery
Twenty-five (71%) of the 35 patients un-
derwent laparotomy, and 10 (29%) underwent
laparoscopic surgery. The surgical finding
was full torsion (at least 360o) in 29 (83%)
and partial torsion (90–270o) in six (17%) of
the patients. Torsion of the ovary and fallo-
pian tube was found in 21 (60%), torsion of
the ovary alone in 13 (37%), and isolated tu-
bal torsion in only one (3%) of the patients.
The surgical procedure included total abdom-
inal hysterectomy and bilateral salpingo-
oophorectomy in 11 (31.5%), unilateral salp-
ingo-oophorectomy in 13 (37%), removal of a
benign ovarian tumor with preservation of the
ovary in three (8.5%), adnexal detorsion and
cyst aspiration in four (11.5%), and adnexal
detorsion with no further intervention in four
(11.5%) of the patients.
Pathology
Pathologic examination revealed an ovarian
cyst or mass in 25 (71%) of the 35 patients. The
mean age of patients with an underlying
ovarian lesion was 44 years (median, 45
years); the mean age of patients with no under-
lying lesion was 25 years (median, 19 years).
Two patients with an ovarian mass were pre-
menarchal, and both had a mature teratoma.
The most common histologic diagnosis was
mature teratoma (Fig. 1), found in eight (32%)
of the 25 patients. Additional histologic diag-
noses included benign cystadenoma in six
(24%), simple cyst in three (12%), cystade-
nofibroma in three (12%), fibroma in three
(12%), fibrothecoma in one (4%), and Brenner
tumor in one (4%) of the patients. Necrosis of
the torsed adnexa was encountered at patho-
logic examination in 20 (57%) of the 35 cases.
CT Findings
For 32 patients, CT was performed up to 1
week after admission, the interval ranging
from less than 24 hours to 1 week (mean, 1.7
days; median, 1.5 days). Three patients un-
derwent CT before admission to the hospital
for further evaluation of the CT finding. Ad-
nexal enlargement was found on CT of all pa-
tients, the maximal diameter ranging from 4
to 20 cm (mean, 9.5 cm; median, 10 cm). Ab-
normalities were found equally on the right
and left sides (on the right in 18 and on the left
in 17 patients). All of the torsed adnexa had
well-defined smooth margins on CT. In 28
(80%) of the cases, the torsed adnexa had at
least a partially cystic component on CT
(Fig. 2), and in one half of these cases mural
thickening was present. The adnexal structure
125
 Hiller et al.

A B
Fig. 2—58-year-old woman with torsion of left adnexa manifesting as left flank pain.
A and B, Contrast-enhanced CT scan (A) and transabdominal sonogram (B) show large midline well-defined cystic mass with thickening of posterior wall (straight arrow, A)
and internal septations (curved arrows). Pathologic examination revealed necrotic adnexa with no underlying tumor.

Fig. 3—41-year-old woman with left adnexal torsion. Contrast-enhanced CT scan
shows abnormally located left ovary (LO) on contralateral side of pelvis in far
posterior location. Ipsilateral fallopian tube (arrow) is distended. Right ovary
(asterisk) is in normal position. Uterus (U) is deviated anteriorly. At surgery, ovary and
fallopian tube were found to be torsed, and underlying mass was found. Pathologic
examination revealed necrotic cystadenofibroma of ovary.
Fig. 4—42-year-old woman with torsion of right ovary manifesting as chronic right
lower abdominal pain that gradually increased in severity. Contrast-enhanced CT
scan shows enlarged right cystic ovary (RO) crossing midline of pelvis anterior to
uterus (U). Spiral appearance of adnexal vascular pedicle (arrow) is whirl sign.
Pathologic examination revealed serous cystadenoma without necrosis.

involved was found in an abnormal location tralateral side of the pelvis (Fig. 3), and the posterior location, in the pouch of Douglas,
in the pelvis in 22 (63%) of the patients. One other half were found in a midline position. and three were in a far anterior position, abut-
half of these abnormalities were on the con- Five of the 11 midline lesions were in a far ting the anterior pelvic fascia (Fig. 4). The

126 AJR:189, July 2007

 CT of Adnexal Torsion

Fig. 5—50-year-old woman with torsion of left adnexa manifesting as acute left
abdominal pain. Contrast-enhanced CT scan shows left ovarian mass (LO) crossing
midline to right side. Twisted vascular pedicle and dilated fallopian tube (arrow) are
evident to left of mass. Uterus (U) is deviated to side of torsed adnexa. Right ovary,
which contains small simple cyst (asterisk), is in normal location. At surgery, ovary
and fallopian tube were found to be torsed, and underlying mass was found.
Pathologic examination revealed necrosis of left ovary and fallopian tube with
ovarian mucinous cystadenoma.
Fig. 6—20-year-old woman with acute lower abdominal pain. Contrast-enhanced CT
scan shows torsion of left ovary (LO) in right side of pelvis. Right ovary (RO) is in
normal location, and uterus (U) is markedly deviated to involved left side. Mild fat
stranding (arrow) anterior to torsed ovary is evident. Pathologic examination
revealed necrotic adnexa with no underlying mass. B = bladder.

uterus was deviated to the side of the involved
adnexa in 16 (46%) of the 35 patients (Fig. 5).
Thickening of the fallopian tube manifested
on CT as greater than 3 mm wall thickness and
tubular distention. Thickening resulted in a tu-
bular masslike lesion or a target lesion, de-
pending on the configuration of the adnexa
(Fig. 5). This finding was present in six (17%)
of the 35 patients. Infiltration of periadnexal fat
was seen in 10 (29%) of the patients. All cases
of infiltration were associated with the patho-
logic finding of necrosis (Fig. 6). In one case a
plasma–erythrocyte level was clearly seen,
suggesting internal hemorrhage (Fig. 7).
The aforementioned and additional CT find-
ings are summarized in Table 1. The correct
preoperative diagnosis of adnexal torsion
based on CT findings was made for 12 (34%)
of the 35 patients. Overall, 14 cases of adnexal
torsion were diagnosed on the basis of preop-
erative imaging findings. The CT diagnosis
agreed with the sonographic diagnosis of ad-
nexal torsion in seven (50%) of the 14 cases.
Discussion
Twisting of the adnexal vascular pedicle re-
sults in venous compromise followed by arte-
rial occlusion and ischemia of the adnexa with
subsequent necrosis. Although this condition
is a surgical emergency, the diagnosis is often
missed [4]. The clinical presentation is nonspe-
cific and can mimic other abdominal condi-
tions, such as tuboovarian abscess, acute
appendicitis, torsion of epiploic appendix,
diverticulitis, and rupture of a corpus luteum.
Findings at physical examination are nonspe-
cific, and the examination is often limited by
pain. Although it is generally considered an
acute condition, adnexal torsion occasionally
takes a subacute or intermittent chronic course,
further complicating the diagnosis [5].
In our study, the clinical presentation of
adnexal torsion was not acute in 40% of the
patients. The pain was nonspecific, rarely
manifesting as flank pain, which is a symp-
tom of renal colic. Gastrointestinal symp-
toms such as nausea and vomiting were quite
common (46%). No correlation was found
between these symptoms and the presence of
adnexal necrosis. Peritoneal signs were
present in 34% of the patients, all of whom
had complete torsion and pathologically
confirmed necrosis of the adnexa. Labora-
tory tests are usually not helpful in the diag-
nosis of adnexal torsion. Imaging therefore
plays a central diagnostic role.
Sonography is usually the initial imaging
technique performed when adnexal torsion or
another gynecologic pathologic condition is
suspected. The sonographic findings of ad-
nexal torsion are nonspecific and include the
presence of a cystic, solid, or complex pelvic
mass with or without mural thickening or the
presence of pelvic ascites [6]. A more specific
sonographic sign of torsion of a normal ovary
is evidence of multiple small homogeneous
cysts in the periphery of an enlarged ovary
[7]. However, such an appearance in a young
fertile women is not sufficient for a diagnosis
because a normal ovary with prominent folli-
cles has a similar appearance.
The added value of color Doppler sonogra-
phy in the diagnosis of adnexal torsion has not
been fully established. In several studies with
small numbers of patients, investigators [6–9]
have concluded that the diagnosis or exclu-
sion of adnexal torsion cannot be reliably
based on the absence or presence of flow on
color Doppler sonography. Those authors re-
marked that normal blood flow commonly is
seen in torsed adnexa. The identification of a

AJR:189, July 2007 127


Fig. 7—49-year-old
woman with torsion of
right ovary manifesting
as subacute right lower
abdominal pain.
Contrast-enhanced CT
scan shows enlarged
myomatous uterus (U).
Right ovary is in normal
position but is cystic in
appearance with
plasma–erythrocyte
level (straight arrow)
suggestive of internal
hemorrhage. Thickened
twisted pedicle (curved
arrow) is posterior to
mass. Pathologic
examination revealed
torsed right ovary with
hemorrhagic necrosis.
whirlpool sign on Doppler sonography has
been suggested pathognomonic of adnexal
torsion [10]; however, this sign is not com-
monly seen. Although 94% of our patients
underwent pelvic sonography, Doppler tech-
nique was used in only one third of the exam-
inations. Doppler technique was not used in
the other cases because a clinical diagnosis of
adnexal torsion was not suspected before
sonography. Normal adnexal blood flow was
documented in almost one half of the patients
who underwent Doppler sonography, a find-
ing consistent with previous reports [9]. The
presence of normal blood flow can be attrib-
uted to partial torsion, torsion and then detor-
sion of the adnexa, or the presence of collat-
eral blood supply through branches of the
uterine artery. The complexity of reaching a
correct diagnosis of adnexal torsion is illus-
trated by the fact that only 26% of the patients
in this study were believed to have adnexal
torsion on the basis of clinical and sono-
graphic findings.
Our series is, to our knowledge, the largest
to date in which the CT findings of surgically
proven adnexal torsion have been assessed. In
all cases the CT finding was a well-defined
enlarged adnexal structure with a smooth bor-
der. Deviation of the uterus to the involved
side and misplacement of the torsed structure
in the pelvis (to the contralateral side or a
midline position) proved to be important CT
signs of adnexal torsion. The combination of
both of these signs was found in 40% of the
patients in this study. When present in the ap-
propriate clinical setting, these signs should
raise suspicion of adnexal torsion.
128
Hiller et al.
TABLE 1: Prevalence of CT Findings in
Pathologically Proven
Adnexal Torsion (n = 35)
CT Finding No. %
Adnexal enlargement (4–20 cm) 35/35 100
Smooth margins 35/35 100
Partially cystic mass 28/35 80
Mural thickening 14/28 50
Deviation of uterus to side of 16/35 46
involved ovary
Misplacement of adnexa to 11/35 31
contralateral side
Midline position of adnexa 11/35 31
Far anterior 3/11 27
Far posterior 5/11 45
Visualization of uninvolved ovary 26/35 74
Tubal thickening 6/35 17
Infiltration of pelvic fat 10/35 29
Pelvic ascites 14/35 40
To accurately diagnose adnexal misplace- Whirl sign 2/35 6
ment, it is imperative to clearly visualize the
normal uninvolved ovary. Another important
CT finding in our study was infiltration of the of displacement of the involved adnexa as an
periadnexal fat. In all cases in which this sign important clue in the CT diagnosis of adnexal
was visualized, pathologic examination re- torsion. Ghossain et al. [11] suggested that if
vealed necrosis. Absence of periadnexal fat serial CT is available, a change in the config-
stranding, however, does not exclude necro- uration of internal ovarian elements may aid
sis. The finding of necrosis at pathologic ex- in the diagnosis of adnexal torsion. Adnexal
amination was more common than the associ- torsion usually is acute, however; therefore,
ated CT finding. serial imaging is uncommon.
The largest previous series of CT findings An underlying ovarian lesion is commonly
of adnexal torsion included 25 patients and the cause of adnexal torsion and is usually be-
was described by Rha et al. [3]. Those authors nign. In our study, as reported earlier by Rha et
concluded that the most important CT find- al. [3], these lesions were invariably benign,
ings are tubal thickening, cystic mass with a most commonly mature teratoma. This finding
smooth thickening wall, ascites, and uterine may be related to the fact that most ovarian le-
deviation to the twisted side. These findings sions are benign. In addition, fixation of the
are consistent with our observations, except ovaries by a malignant tumor theoretically can
for tubal thickening, which we found in only limit their mobility and prevent torsion. Further
six patients. Visualization of the fallopian studies are needed to evaluate this hypothesis.
tube is challenging when a large complex ad- CT appearance was insufficient for accurate
nexal mass is present on CT scans. This diffi- detection and prediction of the nature of an un-
culty may explain why tubal involvement was derlying pathologic process causing torsion. In
found in our patients less commonly on CT our series 80% of torsed adnexa were deemed
than at pathologic examination. Adnexal at least partially cystic on CT; pathologic ex-
hemorrhage is another previously described amination, however, showed that only 48% of
feature of adnexal torsion [1, 3]. We found the lesions were cystic. In some cases, necrosis
this feature difficult to assess because most of was the cause of a cystic appearance on CT.
the CT scans in our study were contrast en- Our study had a number of limitations, most
hanced. On unenhanced images, hemorrhage of them inherent to the nature of the study. Al-
can manifest as an area of increased attenua- though we present the largest, to our knowl-
tion. Contrast enhancement limits the ability edge, series of cases of CT depiction of ad-
to evaluate this sign. MRI may be helpful in nexal torsion to date, the number of patients was
the diagnosis of hemorrhage [2, 3] but is not still relatively small. Adnexal torsion has an un-
always available in an acute care setting. Our common occurrence, estimated as the cause of
study specifically emphasized the importance only 2.7% of gynecologic emergencies in the
AJR:189, July 2007

United States [12], and most of the patients do
not undergo CT. It therefore is difficult to col-
lect a larger series of cases. Our observations
were subject to selection bias because only pa-
tients referred for CT were included, and these
patients usually posed a complicated diagnos-
tic challenge. The retrospective nature of this
study also was a limiting factor, especially in
view of the major technical advancements in
CT and sonography over the long study period.
Further examination of this topic with a large
prospective study based on modern imaging
technology may be warranted.
Evaluation of adnexal torsion with CT is in-
frequent; however, recognition of the CT find-
ings of this potentially serious condition is ex-
tremely important. In cases of lower abdominal
pain in a woman or girl, the CT finding of a
smooth adnexal mass abnormally located in the
pelvis with ipsilateral deviation of the uterus
should raise suspicion of adnexal torsion.
AJR:189, July 2007
CT of Adnexal Torsion
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