Postgrad Med J: first published as 10.1136/pgmj.54.632.423 on 1 June 1978. Downloaded from

Postgraduate Medical Journal (June 1978) 54, 423-424.

Unexplained absence of an and uterine tube L. A. W. SIRISENA* M.B., M.S., M.R.C.O.G. Department of Obstetrics and , Hillingdon Hospital, Uxbridge, Middlesex.

Summary episodes of severe acute abdominal pain during A case is reported of an incidental laparotomy childhood. An intravenous pyelogram showed a finding of absence of left ovary and ipsilateral distal normal renal tract. . This is the fourth case to be reported in She continues to menstruate regularly, indicating theEnglish language literature. The three previous cases normal ovarian function. are reviewed and the probable aetiology discussed. Introduction Discussion Torsion of normal adnexae can happen in child- Unilateral absence of an adnexa in the absence hood and is an established surgical emergency. of previous surgery results either from unilateral In the absence of early intervention, the result is failure of development of the urogenital ridge or adnexal . Adnexal torsion seen in adult from adnexal torsion with infarction. In the present life is usually associated with some abnormality case, a developmental anomaly seems unlikely- such as . In fetal life, normal adnexae she had a normal , a right uterine appendage or adnexal tumours torsion and in- and also a normal renal tract. Further, there were may undergo no obvious Miillerian duct abnormalities. Thus farction, their discovery being incidental, some time copyright. after . previous torsion with consequent infarction becomes the most likely explanation. The fibrous band stretch- Case report ing from the left uterine cornu to the left lateral A 19-year-old Caucasian girl was admitted with pelvic wall and adhesions at the back of the left a history of right-sided abdominal pain of 2 weeks' broad further substantiate this. duration. There was no nausea, vomiting or fever. The previously reported cases are summarized Her had occurred at 13 years, with regular in Table 1. normal periods thereafter. She had had no previous Authors of the first two cases came to the con-

abdominal operations. clusion that 'asymptomatic torsion and infarction of http://pmj.bmj.com/ A right-sided ovarian swelling was diagnosed a normal adnexa' had occurred some time earlier and the patient was prepared for exploratory in life. In the third case the aetiology was not dis- laparotomy on the following day. Laparotomy cussed. findings were as follows: uterus normal in size and Torsion of a normal adnexa usually occurs in shape and displaced to the left; right ovary enlarged childhood and is a well documented surgical emer- (12 x 7 cm), mostly cystic but containing small hard gency. At least forty-five cases occurring in children solid areas, with the Fallopian tube elongated and under 13 years of age have been reported in the stretched over the ovarian swelling; the pedicle not literature (James, Barber and Graber, 1970; Grosfeld, on October 1, 2021 by guest. Protected twisted; left ovary absent; left Fallopian tube 1969), and in every case the acute abdominal con- also absent except for a length of 2 cm from its cor- dition led to surgical exploration. Thus adnexal nual end; round ligament on each side normal; torsion and infarction occurring after birth is thin fibrous band stretched from the left cornu of necessarily associated with acute symptoms and the uterus to the left lateral pelvic wall; filmy there cannot be such an entity as 'asymptomatic' adhesions on the posterior aspect of the left broad torsion and infarction, as assumed by the previous ligament; left ovarian fossa explored but no trace authors. In all these cases there lies a possibility - of the missing ovary; left visualized in the although it is unlikely- that infarction did occur pelvis and a healthy appendix in the right iliac fossa. during childhood and that the associated severe Right ovarian cystectomy was performed and the acute pain was so transient that it was overlooked, specimen removed was a . or that it was attributed to some other cause, as is Detailed inquiry during the postoperative phase, sometimes the case with abdominal pain in infancy which evolved uneventfully, did not reveal any and childhood. * Present address: Department of Gynaecological Onco- In these rare cases of incidental discovery of logy, Queen Elizabeth Hospital, Gateshead NE9 6SX. infarcted ovary and uterine tube, the more likely 0032-5473/78/0600-0423 $02.00 © 1978 The Fellowship of Postgraduate Medicine Postgrad Med J: first published as 10.1136/pgmj.54.632.423 on 1 June 1978. Downloaded from

424 Case reports

TABLE 1. Summary of cases of absence of adnexa recorded in the literature Age of patient Side Mode of Indication Source (years) involved diagnosis for procedure Sebastian, Baker and 18 Right Laparotomy Contralateral Cordray (1973) ovarian cyst Georgy and 45 Left Abdominal Menorrhagia Viechnicki (1974) Lashgari (1975) 33 Left Sterilization Features common to all three cases were: (i) Absence of previous abdominal surgery. (ii) Absence of history of significant acute abdominal pain. (iii) Absence of uterine abnormalities. (iv) Presence of the opposite appendage. (v) Absence of obvious Miillerian duct abnormalities. (vi) Presence of a normal renal tract. explanation is that torsion occurred during fetal life. acute abdominal symptoms and is a surgical emer- It has long been known that the abdominal testis gency. There cannot be any such condition as is particularly liable to torsion (Scorer, 1962). Some 'asymptomatic' torsion and infarction. The inci- cases of 'anorchia' and 'monorchia' have been dental finding of an absent adnexa is probably the attributed to testicular disappearance by torsion and result of torsion and infarction of a normal or infarction occurring during fetal life (Abeyratne, abnormal adnexa, occurring during fetal life. Aherne and Scott, 1969). A similar mechanism may well operate in the case of the ovary, with the Acknowledgments distal uterine tube being involved in the process. I am indebted to my Consultant Mr E. G. Jonas, for thecopyright. Furthermore, in the infarcted appendage it is opportunity to manage a patient admitted under his care, almost impossible to ascertain its state before in- and Mr C. G. Scorer for helpful suggestions. farction. Although the authors of the first two cases state that torsion and infarction of normal adnexae References ABEYRATNE, M.R., AHERNE, W.A. & SCOTT, J.E.S. (1969) had occurred, there is no evidence that the involved Vanishing testes. Lancet, ii, 822. adnexae had in fact been normal. On the other hand, GEORGY, F.M. & VIECHNICKI, M.B. (1974) Absence of an an abnormal adnexa such as that associated with ovary and uterine tube. Obstetrics and Gynecology, 44, 441. an ovarian is more liable to torsion than a GROSFELD, J.L. (1969) Torsion of normal ovary in the first cyst two years of life. American Journal 726. of Surgery, 117, http://pmj.bmj.com/ normal uterine adnexa. There are many reports of GRAVES, G.Y., MCILVOY, D.B. & HUDSON, G.W. (1951) ovarian cysts presenting in the neonatal period, Ovarian cyst in a premature infant. American Journal of both in full term and premature infants (Korobkin, Diseases of Children, 81, 256. De Loromier and Mc JAMES, D.F., BARBER, H.R.K. & GRABER, E.A. (1970) Gooding, 1970; Graves, Ilvoy Torsion of normal uterine adnexa in children. Obstetrics and Hudson, 1951). It may be inferred that many and Gynecology, 35, 226. of these were present during fetal life. Inasmuch as KOROBKIN, M., DE LOROMIER, A.A. & GOODING, C.A. (1970) an adult ovarian cyst is liable to torsion, so would Ovarian cysts presenting in the neonatal period. British be a fetal ovarian cyst. For obvious reasons, torsion Journal of Radiology, 43, 820. LASHGARI, M. (1975) Absence of ovary. Obstetrics and on October 1, 2021 by guest. Protected occurring in fetal life cannot be diagnosed and will Gynecology, 46, 115. only come to light later if laparotomy or laparoscopy SCORER, C.G. (1962) The of testicular descent - is performed for some other reason. This may be normal and incomplete. British Journal of Surgery, 49, the in all four cases. 357. aetiology reported SEBASTIAN, J.A., BAKER, R.L. & CORDRAY, D. (1973) Asymp- In conclusion it may be said that torsion of a tomatic infarction of ovary and distal uterine tube. uterine adnexa after birth is always associated with Obstetrics and Gynecology, 41, 531.