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.