The process of torsion occludes the lymphatic and venous drainage of the involved adnexa; therefore, the torqued viscus rapidly increases in size and can be easily palpated on examination or visualized by ultrasound. However, the presence of Doppler blood ﬂow to the ovary on ultrasound does not definitely rule out torsion.
Adnexal torsion must be treated surgically. The adnexa may be untwisted and a cystectomy performed if appropriate. Even if it appears that necrosis occurred, there is evidence that it remains functional and sparing the adnexa can preserve its hormonal and reproductive function (16). Treatment can be accomplished by laparoscopy or laparotomy, depending on the size of the mass.
The diagnosis and management of acute salpingo-oophoritis and PID are discussed in Chapter 18 (17,18)
All cases of PID are polymicrobial, involving gram-negative and -positive aerobic and anaerobic bacteria; however, PID initiated by Neisseria gonococcus or chlamydia is manifested by the acute onset of pelvic pain that increases with movement, fever, purulent vaginal discharge, and sometimes nausea and emesis. Subclinical PID can be seen with chlamydial salpingooophoritis, with more insidious symptoms that can be confused with the symptoms of irritable bowel syndrome. Bacterial vaginosis has been commonly associated with PID (19).
Elevated temperature and tachycardia are typical. Abdominal examination may show distention and decreased bowel sounds caused by secondary ileus. Direct and rebound abdominal tenderness with palpation are marked. The most important signs of acute salpingo-oophoritis are cervical motion tenderness and bilateral adnexal tenderness. Evaluation of the pelvis may be difficult because of pain and guarding, but lack of a discrete mass or masses differentiates acute salpingooophoritis from tubo-ovarian abscess or torsion. Right upper quadrant can be a distinct sign of PID-related perihepatitis involving the liver capsule and peritoneal surfaces, called Fitz-Hugh– Curtis syndrome.
Leukocytosis and elevated erythrocyte sedimentation rate (ESR), a nonspecific, although more sensitive, sign of inﬂammation, are found in patients with acute PID. Pregnancy test is usually negative because PID as co-existent intrauterine pregnancy (IUP) is rare. If the pregnancy test is positive, an infected or very inﬂamed ectopic pregnancy, or instrumented IUP or infected, incomplete abortion should be suspected. Appendicitis and diverticulitis can be mistaken for PID. Laparoscopy can be useful if the diagnosis is uncertain. The Centers for Disease Control and Prevention guidelines for diagnosing PID state that PID should be suspected and treatment started if the patient is at risk for PID and she has uterine, cervical, or adnexal motion tenderness without any apparent cause (19a). Findings that support the diagnosis include cervical or vaginal mucopurulent discharge, elevated ESR or C-reactive protein (CRP), laboratory confirmation of gonorrhea or chlamydia, oral temperature of 38.3◦C or higher, or white blood cells on wet mount of vaginal secretions or culdocentesis ﬂuid. Most specific criteria for the diagnosis include endometritis on endometrial biopsy, laparoscopic evidence of PID (tubal edema, erythema, and purulent discharge), or thickened, ﬂuid-ﬂuid fallopian tubes on pelvic ultrasound or magnetic resonance imaging (MRI).