Isolated fallopian tube torsion with paraovarian cysts: a case report and review of the literature | BMC Women’s Health

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Paraovarian or paratubar cysts are present in about 10% of all adnexal masses [6]. They originate from epophores, located in the broad ligament and made up of a longitudinal canal and 10 to 20 transverse canals, and these canals are secretory (Fig. 4). Paraovarian cysts should be distinguished from hydatid cysts of Morgagni, which are usually smaller in size and located at the lined end of the fallopian tube. Paraovarian cysts are usually unilocular, contain clear fluid, and are of paramesonephrotic, mesothelial, or mesonephrotic origin. [7]. Histopathology may show secretory and ciliated cells (paramesonephrotic origin), low cubic epithelium and occasionally clear cells (mesonephrotic origin), lined with flattened epithelium with occasional tubal differentiation and surrounding fibrous tissue (mesothelial origin). Because the distension of the cavity often deforms the epithelium, absolute differentiation is difficult [8]. According to the results of this study, only 6/20 cases determined the origin of the cysts.

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Anatomical details of female internal genitalia

In general, parovarian cysts could be found at any age, and most of them were benign tumors. Paraovarian cysts are usually detected by ultrasound or during surgery. Nevertheless, due to hormonal activity, especially in adolescence or during pregnancy, cystic dilation often occurs [9]. In this study, we found that the average diameter of the cysts when the torsion occurred was approximately 5 cm (the minimum was 2 cm and the maximum was 9 cm); the median age was 15 years; 13/20 of the patients were adolescents; 6/20 patients were adults; and 1/20 was postmenopausal. In addition, 5 out of 20 cases presented with twists occurring during pregnancy (four cases) or the puerperium (one case). Cystic distension could increase the mobility of adnexal tissues, which can induce inversion, especially when cysts reach 5 cm [10]. Cysts may twist on their own or may predispose to isolated tubal torsion. It is difficult to distinguish between the two situations before surgery, and the main clinical manifestation is abdominal pain.

The patients presented with abdominal pain, which could be described as gradual or acute, persistent or intermittent, and mild or severe. We found that 17 cases had the recorded pain mode, and all had emergency abdominal pain, such as sharp pain, severe pain, and aggravated pain. Some of the cases had a history of mild pain which subsequently worsened. The associated symptoms were variable and the most common symptom was vomiting (9/20), which was considered a stress response to severe abdominal pain. On physical examination, mild tenderness was present in all patients and peritoneal signs developed in advanced cases (if disease has progressed) [11]. The median duration of pain was 3 days. Mazouni et al. [12] reported that the risk of adnexal necrosis was significantly increased when the time to intervention was greater than 10 h. A previous study also found that patients with pain for more than 24 hours were more likely to have salpingectomy, suggesting that longer periods of twisting may lead to greater tissue necrosis. [5]. Additionally, we observed that nine patients experienced vomiting, 8/9 patients had their procedure reported, and 7/8 patients underwent salpingectomy. This may show that the amount and severity of torsion necrosis is related not only to the duration of the pain but also to the degree of pain, which probably represents the varying degrees of torsion. Until now, the most important, prompt diagnosis and surgery has remained the most effective way to avoid salpingectomy.

The majority of fallopian tube twists occurred on the left (14/20). The most likely explanation was that the sigmoid colon on the left provides cushioning as an accessory to prevent twisting by limiting twisting activity, and patients with right abdominal pain have more often undergone surgery due to the suspicion of appendicitis. [13]. Fifteen of the 20 cases had the number of torsional rotations recorded, and the average number of torsional rotations was 2.38 rotations. There was no significant difference in torsion time between the salpingectomy group and the preservation group (P= 0.651), demonstrating that necrosis was not associated with torsion times.

Ultrasound was performed as the first diagnostic examination in all cases. The most specific feature of imaging of IFTT with paraovarian cysts was the presence of normal ovaries and a cystic mass, with or without a dilated fallopian tube mass, which was due to tubal edema due to the torsion. Another sign specific to IFTT was the “sign of rupture”, which showed narrowing at the end of the tube due to twisting. [14]. Color Doppler ultrasound can detect tubal blood flow, which can also be detected with incomplete obstruction, so the presence of flow cannot completely rule out twisting. However, a high impedance waveform with diastolic flow reversal could be useful, which involves twisting the tube. [15]. Compared to ultrasound, MRI might show more clearly such findings as dilated tubes, signs of beak, and crooked pedicles. In this study, two patients were diagnosed by MRI as having IFTT with paratubal cysts before surgery. Radoica Jokić et al. [16] reported that MRI and ultrasound could provide credible information without the risks of radiation, which is especially useful for pregnant patients. If a papillary projection on the cyst wall is present on ultrasound or MRI images, malignant tumors and cystadenomas should be considered despite the low incidence of paraovarian cystic cancers. [17].

In this study, most patients (13/19) underwent salpingectomy, and only six patients underwent more conservative surgical management, including tubal detorsion and removal of paraovarian cysts. Surgical decisions depended on the surgeons’ observations during the operation and whether the tubes developed normal circulation without necrosis after untwisting. Bertozzi et al. [18] reported that conservative management of IFTT could also be considered in cases of necrotic tubes because morbidity would not increase, but this could create the possibility of leaving a non-functioning tube. Considering that the majority of patients were adolescents, tubal retention should be preferred as much as possible, due to concerns for fertility in the future.

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