doi:10.1111/jog.14810 J. Obstet. Gynaecol. Res. Vol. 47, No.

7: 2515–2520, July 2021

Isolated fallopian tubal torsion: Reproductive age

case series

Erkan Elçi1 , Sena Sayan2 , Gülhan Elçi3 and Güneş Koç1

1
Department of Obstetrics and Gynecology, University of Health Sciences Umraniye Training and Research Hospital, Istanbul,
Turkey
2
Department of Obstetrics and Gynecology, Marmara University Faculty of Medicine, Istanbul, Turkey
3
Department of Obstetrics and Gynecology, University of Health Sciences Sancaktepe Training and Research Hospital, Istanbul,
Turkey

Abstract
Aim: To present our experiences in isolated fallopian tubal torsion (IFTT) case series, which are difficult to
diagnose, in light of the literature.
Methods: The data of the patients diagnosed with IFTT surgically in our tertiary hospital between 2018 and
2019 were evaluated.
Results: Abdominal lower quadrant pain was present in all nine cases. Abdominal pain was accompanied
by nausea in five of the nine cases with vomiting in four of the nine cases. Seven of the patients had pain
radiating to the vagina. Only one case of IFTT was diagnosed with transvaginal ultrasonography where left
tubal dilation and free fluid in the abdomen was found. Two of the nine cases were operated on with a pre-
operative diagnosis of IFTT. Seven cases were approached laparoscopically and two cases underwent a lapa-
rotomy. During the treatment, two of the nine cases underwent detorsion, while seven of the patients
underwent a salpingectomy.
Conclusion: IFTT is a very rare condition. Therefore, it is difficult to diagnose as it does not come to mind at
first glance. Delay of the operation reduces the chance of preserving the tube.
Key words: fallopian tube torsion, isolate, rare cases, reproductive age.

Introduction nausea and vomiting which may be due to the severity

Isolated fallopian tubal torsion (IFTT) has been
reported to be one in 1 500 000 women, thus it is not
common.1,2 IFTT is the torsion of the tube although the
ovary on the same side is not torsioned, this was first
described by Bland Suttonin in 1890.3 IFTT is more
common in women of reproductive age and especially
in adolescents.4 Although many etiological factors have
been described in the formation of IFTT, it can also
occur in normal tuba.5 Complaints start with non-
specific abdominal pain and are often accompanied by
of the pain or with the vagal reflex.6,7 It is thought to
have no specific clinical symptoms6,7 with no labora-
tory and radiological findings.6,8
The clinical diagnosis of IFTT is challenging. The
studies on this subject are mostly case reports and lim-
ited case series. Due to the low incidence of IFTT, we
presented our experience in the diagnosis and treat-
ment of IFTT patients. Since the literature does not
have many studies reporting on this, we presented our
experience in the diagnosis and treatment of IFTT
patients to examine the factors affecting this.

Received: August 3 2020.

Accepted: April 18 2021.
Correspondence: Erkan Elçi, University of Health Sciences Umraniye Training and Research Hospital, Adem Yavuz, Street
No. 01, Elmalıkent, Umraniye, Istanbul, Turkey.
Email: dr.erkanelci@gmail.com

© 2021 Japan Society of Obstetrics and Gynecology. 2515


Elci et al.
Methods
All procedures performed in this study were in accor-
dance with the ethical standards of the institutional
research committee and with the Helsinki Declaration
of 1975, as revised in 2000.
Written informed consent was obtained from the
patient or the patient’s legal guardians for the publi-
cation of these cases and any accompanying images.
Between December 2018 and December 2019, 260 665
patients were examined in our clinics, 9 of these
patients were diagnosed with tubal torsion after their
examinations. All physicians who performed the
radiological evaluation were gynecologists and obste-
tricians with more than 10 years of experience (E. Elci,
S. Sayan).
In these nine cases, informed consent (which was
obtained from the patient or her legal guardian)
was collected for this study. Age of the cases (years),
body mass index (BMI) (kg/m2), admission symp-
toms, fever ( C), time between pain duration and
diagnosis (hours or days), last menstrual period, risk
factors, white blood cell count (WBC), C-reactive pro-
tein (CRP), surgeries, ultrasonography (US), com-
puted tomography (CT), and magnetic resonance
image (MRI) results were collected. In addition to this,
preoperative suspected diagnoses, surgical tech-
niques, postoperative diagnosis, treatment, and surgi-
cal photos, if any, were collected. The data were
collected, and in data analysis, the mean and standard
deviation were calculated for continuous variables.
Results
Clinical information and surgical findings of the nine
cases are summarized in Table 1. Our ultrasono-
graphic evaluations were made transvaginally in
eight of the patients. One case in the radiological eval-
uation could not be evaluated transvaginally due to
her virginity. Our ultrasonographic evaluations were
made transvaginally in eight of the patients. In only
one of the cases, a preliminary diagnosis could be
with transvaginal ultrasonography of left tubal dila-
tion and free fluid in the abdomen. Two of the cases
were evaluated with an MRI and one was diagnosed
with IFTT. CT was used in five cases because the CT
was usually taken to differentiate right adnexal
pathologies from appendicitis, but IFTT could not be
diagnosed. Two of the nine cases were operated on
with a preoperative diagnosis of IFTT.
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Discussions
IFTT can be seen at any age in the general female
population, but it is most common in women under
30.9 IFTT is more common in patients of reproductive
age, it is rare in perimenarche or perimenopausal
women.10 Although it is said to be common in repro-
ductive ages, in the current literature, IFTT is mostly
presented as a case by case series in pediatric studies.1
The mean age (mean ± SD [min–max]) of our patients
was 30.1 ± 5.68 (20–39) and only three cases were
under the age of 30. There were nine cases in a year
(our study incidence 1/29 000); this is very high
according to the incidence found in the literature.
The IFTT formation mechanism is not fully under-
stood. Some intrinsic (hydrosalpinx, hematosalpinx,
previous tubal operation, etc.) and extrinsic factors
(paraovarian masses, tubal adhesions, intestinal peri-
stalsis, Morgagni cyst, etc.) have been described.9–11
In cases without predisposing factors, it has been
linked to the elongation of the ovarian ligament.1,12
Four of our cases had adnexal cysts while three had
normal adnexes. There was a positive BTL history
(Figure 1a) in one case and 37 weeks of pregnancy
(Figure 1f) in another case. Having risk factors may
lead a physician to suspect IFTT.
The most common symptom when torsion begins is
pain, this may be unilateral lower abdominal or pelvic
pain. This pain may spread to the flank and thigh.9
The pain begins suddenly accompanied by cramping
and often becomes continuous in nature.1,9 Nausea
and vomiting accompany 41.2% of cases.13 We found
lower abdominal pain in all of our cases. Examination
findings are nonspecific, a low-grade fever was
thought to be in 15% of patients and this may be due
to the necrotic changes of the fallopian tube.9 In the
vaginal examination, it has been reported that pain
can occur in 26% of cases.8,14 Seven of our cases had
pain radiating to the vagina and we think this is very
important in the diagnosis.
Laboratory findings are nonspecific and leukocyto-
sis may occur due to the necrosis, but necrosis and
leukocytosis levels are not correlated.8 It has been
reported that sedimentation and CRP values may
increase with a fever occurring as a result of this.15
Among laboratory values, WBC (mean ± SD
[min–max]) value was 10.12 ± 2.64 (7.40–15.0). In four
of our cases, the WBC value was higher than
10.0  109/L. In three of the cases, the WBC value
and body temperature (≥37 C) were high and in only
one case the CRP value was increased and was
© 2021 Japan Society of Obstetrics and Gynecology.
 TABLE 1 Clinical information and surgical findings of cases
Pain WBC Previous Post-op
Case Age BMI (kg/m2) Symptoms Fever ( C) duration LMP Risk fac. (109/L) CRP surgery Diagnosis Pre-op diagnosis Image diagnosis Surgery Treatment Figurea

1 20 22 RLQ, N 36.5 72 h 26 days prior None 8.2 0 None MRI IFTT Right ovary N, free fluid Right-IFTT L/S SGT 1(a)
in abdomen
2 25 26 LLQ, Vx 36.5 24 h 8 days prior None 7.8 0 None USG, MRI Diagnostic Left ovary N left tube Left-IFTT L/S DTR 1(b)
laparascopy dilated, free fluid in
abdomen
3 39 28 RLQ, Vx 37 72 h 21 days prior BTL 12.1 0 C/S, BTL USG, CT Right adnexial Cyst in right ovary, free Right-IFTT L/S SGT 1(c)
torsion fluid in abdomen
4 28 23 RLQ, V, N Vx 37 72 h Irr 38 days Cyst 12.5 0 C/S USG, CT Right adnexial Cyst in right ovary, free Right-IFTT L/S DTR 1(d)
prior tortion fluid in abdomen.

© 2021 Japan Society of Obstetrics and Gynecology.

Right adnexial
torsion
5 28 25 RLQ, V, N 36.5 48 h 4 days prior Cyst 8.3 0 None USG, CT Diagnostic bilateral ovaries N, right Right-IFTT L/S SGT 1(e)
laparascopy adnexial cyst
6 35 27 RLQ, V, Vx 36.4 24 h 37 week prior Pregnancy 11.1 0 C/S USG Acute abdomen 37 weeks pregnancy, Right-IFTT L/T SGT 1(f)
findings free fluid in
abdomen.
7 32 30 LLQ, N, Vx 36.5 24 h 24 days prior None 7,4 0 C/S USG, IFTT Left ovary N left tube Left-IFTT L/S SGT -
dilated, free fluid in
abdomen
8 30 22 RLQ, V, N, Vx 37.5 432 h 19 days prior Cyst 15 9,2 None USG, CT Pelvic mass Cyst in right ovary, free Right-IFTT L/T SGT -
(18 day) fluid in abdomen.
Right adnexial
torsion
9 34 27 LLQ, Vx 36.5 96 h 26 days prior Cyst 8.7 0 None USG, CT Left adnexial Cyst in left ovary, free Left-IFTT L/S SGT -
torsion fluid in abdomen.
Left adnexial torsion
Total 30.1 ± 5.6 25.5 ± 2.7 36.7 ± 0.37 96 ± 128.6 10.15 ± 2.64 1.0 ± 3.0
mean ± SD (min–max) (20–39) (22–30) (36.4–37.5) (24–432) (7.4–15.0) (0–9)

Abbreviations: BTL, bilateral tubal ligation; CRP, C-reactive protein; DTR, detorsion; IFTT, isolated fallopian tube torsion; Irr, irregular; L/S, laparoscopy; L/T, laparotomy;
LLQ, left lower quadrant; LMP, last menstrual period; N, nausea; RLQ, right lower quadrant; SGT, salpengectomy; V, vomit; Vx, vaginal pain. and aFigure 1.
Isolated Fallopian Tubal Torsion

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 14470756, 2021, 7, Downloaded from https://obgyn.onlinelibrary.wiley.com/doi/10.1111/jog.14810 by Egyptian National Sti. Network (Enstinet), Wiley Online Library on [28/01/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Elci et al.

FIGURE 1 (a) Laparoscopic

view of right IFTT (blue
dot: right ovary, yellow
dot: uterus). (b) Laparo-
scopic view of left IFTT
(blue dot: right ovary, yel-
low dot: uterus). (c) Right
isolated fallopian tube
torsion with previously
BTL (white arrow) (yel-
low dot: uterus). (d) Lap-
aroscopic view of
detorsioned right isolated
fallopian tube torsion
(arrow: line of detorsion).
(e) Right IFTT (blue dot:
right ovary, yellow dot:
uterus, arrow: line of
detorsion). (f) Twisted
(arrow) right IFTT in
cesarean section (blue
dot: right ovary). *IFTT,
isolated fallopian tube
torsion; BTL; bilateral
tubal ligation

measured as 9.2 mg/L. The case with the CRP is not sufficient to evaluate WBC correlation with
elevation was the case with a history of 18 days del- necrosis. Laboratory findings are not helpful in
ayed tubal torsion. We think that the number of cases diagnosis.

2518 © 2021 Japan Society of Obstetrics and Gynecology.


After the physical examination, ultrasonography is
the first radiological test performed.10 There are insuf-
ficient data for ultrasonographic findings for IFTT.
Erdem et al. reported that they diagnosed IFTT with
ultrasonography in five cases and correlated it
with surgery.16 Smiti et al. reported that they saw five
cases which they had operated on with a preoperative
diagnosis of adnexal torsion as IFTT.5 It has been said
that IFTT should be suspected when there is ultraso-
nographic findings of a dilated fallopian tube and/or
a high impedance or no flow despite a normal ovar-
ian structure and free fluid in the abdomen is
detected.17,18 In our cases, a preoperative diagnosis of
IFTT could be made in only one case with ultrasonog-
raphy left tubal dilation and free fluid in the abdo-
men. One case was operated on with a preoperative
diagnosis of a pelvic mass and a pregnant case was
operated on with a diagnosis of an acute abdomen.
Four other cases were operated on with a preopera-
tive diagnosis of adnexal torsion.
CT was performed in three of the eight cases in the
pediatric case series and only one case was diag-
nosed.19 However, occasionally, a CT examination is
not more conclusive than an ultrasound examina-
tion.19 In our cases, a CT was usually taken to differ-
entiate right adnexial pathologies from appendicitis.
A CT was used in five cases, but a diagnosis of IFTT
could not be made.
It is reported that an MRI may be a valuable diag-
nostic tool in the recognition of IFTT with the most
common findings being tubal thickening, ascites, and
uterine deviation to the torsioned side.6,19 It was
reported that the whirlpool sign on the MRI T2
sequence correlated with surgery in 12 cases.6 Two of
our cases were evaluated with an MRI and only one
was diagnosed preoperatively with IFTT.
The duration of diagnosis is important for a tissue that
will undergo necrosis. Establishing the diagnosis, espe-
cially in the first 24 h, increases the chance of the tube
being protected.20,21 In the publications about IFTT, the
average admission period was reported to be 26 days in
17 cases.13 In another series of 11 cases, the admission
period was reported to be an average of 48 h.13 The
average admission time of our cases was 96 h (24 h to
18 days). However, in the time interval between admis-
sion to hospital and diagnosis (6–10 h), diagnostic sur-
gery was decided when there was no change in pain or
no reason to explain the pain (except one elective case).
The gold standard for the diagnosis and treatment
of IFTT is surgery.8 In terms of diagnosis as a surgical
approach, it is said that the laparoscopic approach is
© 2021 Japan Society of Obstetrics and Gynecology.
14470756, 2021, 7, Downloaded from https://obgyn.onlinelibrary.wiley.com/doi/10.1111/jog.14810 by Egyptian National Sti. Network (Enstinet), Wiley Online Library on [28/01/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Isolated Fallopian Tubal Torsion
the best in terms of protecting fertility.22 In the pediat-
ric group, it was emphasized that laparoscopy was
the gold standard in a series of 20 cases.22 Seven of
our cases were approached laparoscopically. In the
treatment options, whether the tube should be surgi-
cally protected or taken out, although there is not
much data, the preferred treatment is a
salpingectomy.22 In the conservative approach,
detorsion can be performed to protect fertility of
young patients. However, Razi et al. reported that
there may be recurrent torsion in a few cases.23 There-
fore, some authors have suggested tubal fixation.10,22
Detorsion was performed in two of our nine cases,
and a salpingectomy was performed in seven cases
(Figure 1a,c,e). Our approach is to always carry out a
detorsion in adnexal torsions and to perform a -
salpingo-oophorectomy if the color change does not
occur after waiting approximately 30 min. Since we
did not have enough experience for detorsion in IFTT,
two cases were detorted (Figure 1b,d). No complica-
tions were observed during the 7-month follow-up.
A limitation of our study is the low number of
cases and the lack of adequate radiological (CT, MR)
examinations in all patients. In a study published in
1970, the incidence was stated as 1/1 500 000, and
in our study, the incidence was found to be approxi-
mately 1/29 000. We think that this difference is due
to early diagnostic surgical approaches.
In conclusion, IFTT is very difficult to diagnose
because it is very rare and is not considered highly in
the differential diagnosis. Clinical symptoms, radiologi-
cal, and laboratory findings for IFTT are not specific and
patients generally apply to the hospital under emergency
conditions. Because of this, early diagnostic surgery deci-
sions are not made. Therefore, IFTT diagnosis is missed
or delayed. We think that IFTT is more common than in
the literature because we decided on surgery early. In
the surgical treatment, it is always necessary to give a
chance for detorsion to protect the tuba. Our recommen-
dation is not to avoid early diagnostic surgery.
Conflicts of Interest
The authors declared no potential conflicts of interest.
Consent
Written informed consent was obtained from the
patient or the patient’s legal guardians for publication
2519

Elci et al.
of these case reports and any accompanying images.
A copy of the written consent is available for review
by the Editor-in-Chief of this journal.
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© 2021 Japan Society of Obstetrics and Gynecology.