Discussion
This case report describes the extremely rare clinical entity of an
isolated tubal torsion with coexisting hydrosaplinx in a17-year-old
patient without history of sexual intercourses.
A possible explanation for ITTH in adolescents could be the presence of
a congenital malformation of the tube in the peripubertal period. As the
reproductive axis is stimulated between 9 and 14 years, menses may
activate ovarian and tubal function, revealing a previously asymptomatic
distal occlusion of the tube. An episode of asymptomatic pelvic
inflammation near tubes may cause a distal occlusion, hydrosalpinx and
then torsion. Besides, torsion of the hydatid cyst of Morgani, located
near the fimbriated end of the tubes, could also cause the pathologic
process.
Diagnosis of ITT is usually difficult because symptoms are non-specific
and common with many other conditions [6]. The typical presentation
of ITTH is acute lower abdominal pain with nausea and vomiting, but no
specific clinical feature allow with safety to distinguish this from
torsion involving the whole adnexa. Absence of fever and normal
C-reactive protein levels may be helpful to make the differential
diagnosis from appendicitis.
Regarding most common location, Boukaidi et al.(2011) conducted a review
of the literature and targeted reports published from 1999 to 2009 where
13 cases of ITTH in adolescents were reported[2]. In their series
ITTH occurred on the left side in 9 of the 13 cases. This might suggest
that ITTH occurs more frequently on the left tube although confirmation
by a larger series of patients is needed.
Ultrasound is the imaging modality of choice as it is non-invasive and
avoids radiation exposure but diagnosis is not always definitive.
Abdominal ultrasound showing the fallopian tubes as fluid-filled tubular
structures folded onto themselves to form a C or S hape and separated
from ovaries is consistent with a diagnosis of hydrosalpinx. Color
Doppler may be useful, but the presence of normal flow does not
necessarily rule out torsion [19-21]. Computerized tomography (CT)
as well as magnetic resonance imaging (MRI) are of some value as they
may indicate a thickened fallopian tube, twisting of the adnexal
pedicle, eccentric thickening and a septal appearance of the fallopian
tube dilated and fluid-filled[19-21]. However, the gold standard for
confirming diagnosis is laparoscopy, with all relative advantages of
minimally invasive procedure that permit quick recovery and minimal
morbidity [22].
Finally, severity of the disease are significantly affected by duration
and extent of torsion. Boukkaidi et al proposed a classification of the
tubal status by conducting salpingoscopy. Grades I and II would
correspond to potentially salvageable fallopian tube, whereas grades III
or more would require salpingectomy. According to this proposal, Grade I
and II are treated by puncturing the hydrosalpinx and completing a
detorsion. The correction of the distal occlusion is established by
salpingoplasty few weeks later. In contrary, grade III represents a
compromised tube that indicates the necessity of salpingectomy [2].
In conclusion, isolated tubal torsion associated with
hydrosalpinx in children and sexually inactive adolescents is an
extremely rare entity. Its presentation raises difficulties in the
differential diagnosis. Ultrasonography with Doppler should be the
first-choice imaging approach, but laparoscopy is the gold standard of
diagnosis and therapy.