torsion of the vascular pedicle of an ovary , fallopian tube , or paratubal cyst or of a fallopian tube alone results in ischemia and rapid onset of acute pelvic pain . the clinical presentation of ovarian torsion is non - specific , and its recognition and differentiation from other pathologies pose a diagnostic challenge . ovarian torsion has been described in all age groups from the fetal / neonatal period to elderly women , with 80% of cases occurring in females under the age of 50 years . the 2 most common presenting features are lower abdominal pain ( 83% ) and an adnexal mass ( 72% ) . the diagnosis should be considered in women with lower abdominal pain , especially in the setting of ovarian cyst / mass and diminished or absent blood flow in the ovarian vessels , but the definitive diagnosis of ovarian torsion is based on surgical findings . we 
 report an even more unusual case of bilateral torsion of the adnexa complicated by simultaneous bilateral adnexal entanglement . to the best of our knowledge , a 43-year - old female , para 2 , was admitted to the gynecologic emergency department with the complaint of severe lower abdominal pain lasting for 2 days . the pain was cramping and not accompanied by nausea or vomiting . the patient was afebrile , her pulse rate was 107/min regular , and her blood pressure was 123/61 mm hg . the abdominal examination was normal except for a slight tenderness on the right lower abdomen . speculum examination revealed no abnormality , and bimanual vaginal examination revealed that the uterus was normal in size , diverted to the right , mobile , and not tender . a smooth nontender 10-cm cystic mass was palpated separate from the uterus in the douglas pouch . on ultrasonography , the uterus appeared to be normal in size and diverted to the right , and a multilocular cystic mass ( 11x8 cm ) was seen on the left side of the uterus . the ovaries could not be visualized separately because of the extent of their entanglement with one another . no free fluid was present in the douglas pouch . the hemoglobin count was 12.8 g / dl , the total leukocyte count was 8900/ml and hcg in the urine was negative the patient was diagnosed with ovarian torsion , and a laparoscopy was scheduled . at surgery , both adnexas were seen to be entangled with each other ( figure 1 ) . the left ovary was also enlarged ( 10 cm in diameter ) and cystic , and twisted twice around the ovarian proprii ligament . each ovary was displaced to the opposite side of the pelvis as a result of these entanglements . adnexa entangled with each other . to free both adnexas , we had to first fenestrate the right ovarian cyst and then use a grasper to return each adnexa to its correct anatomic position . the patient underwent left salpingo - oophorectomy and biopsy of the collapsed right ovarian cyst . the histopathological examination revealed a mucinous cyst adenoma in the left ovary and a simple cyst in the right ovary . we conducted a review of the literature by searching the world wide web for published reports on  bilateral adnexal torsion , complex adnexal torsion ,   synchronous bilateral adnexal torsion ,  and  adnexal entanglement . we found 2 case reports on increased risk for bilateral adnexal torsion after clomiphene citrate or other ovulation - inducing therapy , but the bilateral torsions were not entangled as they were in our patient . an earlier review of the 15 cases of bilateral adnexal torsion reported in the world literature5 revealed that fever ( 82% ) , nausea or vomiting , or both together ( 73% ) , and abdominal pain ( 93% ) were the most common presenting symptoms . previous recurrent attacks of abdominal pain had occurred in 53% of patients and that may be the only finding that is directly suggestive of this entity . the adnexas were histologically normal in 50% of the specimens , and evidence existed of tubal infection ( hydrosalpinx and pyosalpinx ) in several cases . we describe a unique case of simultaneous torsion and entanglement of bilateral adnexas unassociated with prior ovulation induction treatment . elongation of ovarian proprii ligament or infundibulopelvic ligament could be attributed to the collagen type or connective tissue strength of the tissue . another likely cause in our patient is that both her ovaries were cystic and enlarged , and their being enlarged could explain the bilateral adnexal torsion . the additional finding of entanglement makes this a very unique case . although the usual presentation of adnexal torsion is unilateral pelvic pain , we recommend that the diagnosis of concomitant bilateral adnexal torsion and entanglement be considered when the presentation is diffuse , severe , lower abdominal pain .
we report the first case of bilateral adnexal torsion complicated by concomitant entanglement of both adnexas . 
 the clinical presenting symptoms and signs were similar to those described in unilateral adnexal torsion without adnexal entanglement . 
 the final diagnosis was established by diagnostic laparoscopy , and aspiration of one of the ovarian cysts was required to disentangle the adnexas .