Torsion of uterine adnexa in neonates and children: a report of 20 cases

Clinicopathological features and surgical procedures of adnexal masses with abdominal pain in pediatric and adolescent patients

PURPOSE

This study investigated the clinicopathological features and surgical procedures of adnexal masses with abdominal pain in pediatric and adolescent patients. Our objective was to better define the clinical presentation of adnexal torsion and to distinguish characteristics of those with torsion and those with an alternate diagnosis.

METHODS

Retrospective cohort study of 212 pediatric and adolescent patients was performed who admitted for abdominal pain and presenting with an adnexal mass between March 2012 to December 2019.Medical records were reviewed for age at operation, including presentation of symptoms and signs; the levels of tumor markers; imaging examinations; pathologic findings; the size of masses; treatment; and outcome. Data management and descriptive analyses were performed using SPSS 26.0.

RESULTS

The median age of the patients was 14.5 ± 3.6 years at the operation. 126 (59.4%, 126/212) patients presented with an abrupt onset of abdominal pain. A total of 82.1% (174/212) of the participants underwent adnexal conservative surgery. 179 (84.5%, 179/212) patients underwent laparoscopic surgery with an average tumor size of 7.7 ± 3.4 cm, while 33 patients ( 15.6%, 33/212) underwent laparotomy. Rupture of mass and ectopic pregnancy accounted for 7.5% (16/212) and 0.9%(2/212), respectively. Torsion was responsible for 36.8% (78/212) of all patients. Among the patients with torsion, the symptom of nausea and vomiting was more common among girls without torsion (P < 0.0001). 88.5% of the girls with torsion had acute onset of abdominal pain, while 92.3% had persistent pain that could not be relieved or occurred repeatedly, which significantly higher than that in the patients without torsion (P < 0.001). 69.2% of patients with torsion had fixed pain sites, compared with 42.2% in patients without torsion (P < 0.001). 88.5% of girls with torsion had an ovarian cyst/mass ≥ 5 cm, compared with 75.0% in girls without torsion (P = 0.038). 66.7% of girls underwent ovary-preserving surgery, compared with 92.2% in patients without torsion. The most common pathologic types were mature teratoma and simple cyst, accounting for 29.4% and 25.6%, respectively. The multivariate analyses confirmed that mass size greater than 5 cm (OR 4.134, 95% CI: 1.349-12.669,P = 0.013), acute onset pain (OR 24.150,95%CI: 8.398-69.444,P = 0.000), persistent or recurrent pain (OR 15.911,95%CI: 6.164-41.075,P = 0.000) were significantly associated with increased risk of torsion.

CONCLUSIONS

Torsion which is a relatively rare event in the pediatric population was not an uncommon condition and responsible for more than one third of all pediatric and adolescent patients presented with adnexal masses and abdominal pain. Pain assessment in children and adolescents is important to distinguish characteristics of those with torsion and those with an alternate diagnosis.Thus, pediatric and adolescent patients particularly with a pelvic mass size greater than 5 cm, acute onset pain, persistent or recurrent pain have a benign cause and not missing the devastating condition that needs emergent attention. Thus, a strategy of earlier and liberal use of Diagnostic Laparoscopy (DL) may improve ovarian salvage.

Evaluation of the usefulness of laparoscopy in the diagnosis and treatment of adnexal pathologies in the pediatric population

INTRODUCTION

The current trend in adnexal surgery in children is to minimize the invasiveness of diagnostic and therapeutic procedures, reduce the number of complications and reduce the risk of infertility.

AIM

Evaluation of the usefulness and effectiveness of laparoscopy in diagnostics and treatment of pathological lesions of adnexa in the pediatric population and evaluation of the correlation of imaging with the intraoperative diagnosis during laparoscopy.

MATERIAL AND METHODS

The study included 89 patients aged 0-18 years (mean: 12.62) who underwent an emergency or elective laparoscopic procedure due to the suspicion of adnexa pathology in the imaging tests or in which intraoperative pathology of the adnexa was found without previous suspicion of these changes in the imaging tests. Patients were divided into 2 groups according to the procedure (emergency or elective) and into 4 age groups.

RESULTS

The most frequent postoperative diagnosis was an adnexal cyst and ovarian tumor. The ratio of malignant to benign lesions was 0.087. In 32.58% of patients appendix pathology was found. Coexistence of adnexa and appendix pathology was statistically significantly more frequent in patients undergoing emergency surgery (p = 0.013). There was no correlation between the size of the tumor or ovarian cyst and the occurrence of adnexal torsion, and no correlation between the size of the tumor and the degree of torsion of the adnexa. Three conversions were performed. The average operation time was 63.7 min.

CONCLUSIONS

Laparoscopic diagnosis and treatment of adnexal pathology seems to be safe due to the low percentage of perioperative complications. It shows high sensitivity in recognizing adnexal pathologies and other defects.

Isolated fallopian tube torsion in pediatric age: An Italian multicenter retrospective study

PURPOSE

The purpose of this study was to quantify the experience of five Italian centers on the diagnosis and management of isolated fallopian tube torsion (IFTT) in children.

METHODS

We retrospectively reviewed the data of 20 patients aged 1-16 years of age with surgically diagnosed IFTT between 1991 and 2017 from five Italian centers of pediatric surgery. We analyzed common presenting signs, symptoms, and radiographic findings, as well as surgical interventions to describe management offering further insight into the diagnosis and treatment of this rare entity.

RESULTS

Twenty cases of IFTT were collected. Median age was 13.1 years. Menarche was present in 14 cases. A clinical history of abdominal pain was present in 13 patients, whereas in 7 patients the clinical picture was an acute abdomen. Ultrasonography was the first diagnostic examination in 16 cases. Surgical approach was by laparoscopy in 16 cases and laparotomy in 4 cases. In 11 patients IFTT was associated with another pathologic condition. In 7 of the remaining 9 IFTT without pathologic association, the girls played sports. Salpingectomy was performed in 13 patients and de-torsion in 7.

CONCLUSIONS

IFTT is a rare condition that seems to occur in younger adolescents. Vague clinical presentation contributes to low preoperative suspicion. IFTT should be considered in girls with abdominal pain who practice sports with sudden body movements. Preoperative suspicion may be increased based on radiographic findings of an enlarged tubular/cystic structure with adjacent normal ovary. Conservative management is controversial but could be preferred in order to provide the best option for future fertility of these girls.

TYPE OF STUDY

Treatment Study (Retrospective Study) - Level IV.

Pediatric ovarian torsion: Follow- up after preservation of ovarian tissue

BACKGROUND

The aim of this study was to evaluate the efficiency of the preservation of ovarian tissue in cases of ovarian torsion.

MATERIALS AND METHODS

A retrospective study was performed of patients treated at our hospital for ovarian torsion from January 2007 to December 2017. This research does not include patients with antenatal ovarian torsion and 1 girl with an immature teratoma, in whom the twisted ovary was removed during the initial operation. Follow-up ultrasonography of all patients was performed after 4-6 weeks and again after more than 12 weeks. Volume, blood flow and folliculogenesis of the ovary were measured and assessed.

RESULTS

All 42 ovaries (39 patients) preserved their normal anatomy and folliculogenesis after detorsion. All patients had an enlarged ovary at the time of detorsion. In all cases of ovarian torsion, enlargement of the ovary up to an average of 58.14 ± 52.86 (17.37-86.83) ml was detected. After 4-6 weeks, all untwisted ovaries decreased in volume by an average of 9.01 ± 13.69 (2.33-9.30) times, and 59.5% of them became normal in size. In 3 girls, enlarged ovaries were still observed after 12 weeks. Teratoma was diagnosed for these patients and ovarian sparing operations were performed.

CONCLUSIONS

It is safe to perform detorsion regardless of the level of ischemia or volume of the affected ovary. The follow-up is essential, especially for the further diagnostics of potential pathological structures or tumors; therefore, the normalization of blood flow and the volume of the ovary must be monitored.

TYPE OF STUDY

Prognosis retrospective study.

LEVEL OF EVIDENCE

II.

A Case-Control Study of Sonographic Maximum Ovarian Diameter as a Predictor of Ovarian Torsion in Emergency Department Females With Pelvic Pain

BACKGROUND

Color and power Doppler ultrasound are commonly used in the evaluation of ovarian torsion but are unreliable. Because normal-sized ovaries are unlikely to cause torsion, maximum ovarian diameter (MOD) could theoretically be used as a screening test in the ED. Identification of MOD values below which torsion is unlikely would be of benefit to providers interpreting radiology department or point-of-care pelvic ultrasound.

OBJECTIVES

The objective was to determine if sonographic MOD can be used as a screening tool to rule out torsion in selected patients.

METHODS

Via a retrospective case-control study spanning a 14-year period, we examined the ultrasound characteristics of patients with torsion and age-matched controls, all presenting to the emergency department with lower abdominal pain and receiving a radiology department pelvic ultrasound for "rule-out torsion." Standardized data collection forms were utilized. Distributions of MOD were compared and sensitivity, specificity, and likelihood ratios were calculated for multiple cutoffs.

RESULTS

We identified 92 cases of surgically confirmed ovarian torsion and selected 92 age-matched controls. In postmenarchal patients the sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio of 3- and 5-cm MODs were 100% (96%-100%), 30% (20%-41%), 1.4 (1.3-1.7), and 0 and 91% (83%-97%), 92% (83%-97%), 11.2 (5.5-22.9), and 0.09 (0.04-0.19), respectively. The 5-cm MOD, however, excluded an additional 52 of 84 (62%) postmenarchal patients.

CONCLUSIONS

A threshold MOD of 5 cm on pelvic ultrasound may be useful to rule out ovarian torsion in postmenarchal females presenting with lower abdominal and pelvic pain.

Rates and Technique for Oophoropexy in Pediatric Ovarian Torsion: A Single-Institution Case Series

STUDY OBJECTIVE

Ovarian torsion (OT) is uncommon, but can result in loss of reproductive function. Traditionally managed using adnexectomy, torsed adnexae are now being conserved, increasing the potential for recurrent OT. As a result, some experts suggest oophoropexy (OP) to prevent recurrence. We report on a series of 11 patients who underwent OP. DESIGN, SETTING, PARTICIPANTS, INTERVENTIONS, AND MAIN OUTCOME MEASURES: A retrospective case series was conducted from 2004 to 2013 to identify patients younger than the age of 18 years with OT. From this, data for patients with OP were extracted for detailed review.

RESULTS

We identified 97 patients with OT; 6 of 97 (6.2%) had recurrent OT. The rate of recurrence was higher (14.8%, 4/27) in the group with torsion without an adnexal mass. Eleven of 97 patients (11.3%) underwent OP. The mean age of patients with OP was 8.8 years. Nine patients had normal adnexae at initial torsion. Five of 11 had OP during their initial procedure. OP was most commonly performed for long utero-ovarian ligaments (n = 6), recurrence (n = 4), or bilateral OT (n = 2). Eight of 8 patients with follow-up ultrasound imaging after torsion showed at least 1 marker of normal ovarian function. One of 11 patients (9%) had a recurrence of OT of an oophoropexied ovary. There were no complications due to the OP portion of the procedure.

CONCLUSION

In our series of OT, a small percentage of patients underwent prophylactic OP. Recurrence might still occur after OP. It seems reasonable to offer OP to patients at higher risk of recurrent OT although level 1 evidence is lacking. Future research should focus on techniques and long-term outcomes of OP.

Pediatric Ovarian Torsion and its Recurrence: A Multicenter Study

STUDY OBJECTIVE

To report results of a retrospective multicentric Italian survey concerning the management of pediatric ovarian torsion (OT) and its recurrence.

DESIGN

Multicenter retrospective cohort study.

SETTING

Italian Units of Pediatric Surgery.

PARTICIPANTS

Participants were female aged 1-14 years of age with surgically diagnosed OT between 2004 and 2014.

INTERVENTIONS

Adnexal detorsion, adnexectomy, mass excision using laparoscopy or laparotomy. Different kinds of oophoropexy (OPY) for OT or recurrence, respectively.

MAIN OUTCOME MEASURES

A total of 124 questionnaires were returned and analyzed to understand the current management of pediatric OT and its recurrence. The questionnaires concerned patient age, presence of menarche, OT site, presence and type of mass, performed procedure, OPY technique adopted, intra- and postoperative complications, recurrence and site, procedure performed for recurrence, OPY technique for recurrence, and 1 year follow-up of detorsed ovaries.

RESULTS

Mean age at surgery was 9.79 ± 3.54 years. Performed procedures were open adnexectomy (52 of 125; 41.6%), laparoscopic adnexectomy (25 of 125; 20%), open detorsion (10 of 125; 8%), and laparoscopic detorsion (38 of 125; 30.4%). Recurrence occurred in 15 of 125 cases (12%) and resulted as significant (P = .012) if associated with a normal ovary at the first episode of torsion. Recurrence occurred only in 1 of 19 cases after OPY (5.2%). Ultrasonographic results of detorsed ovaries were not significant whether an OPY was performed or not (P = 1.00).

CONCLUSION

Unfortunately, oophorectomy and open technique are still widely adopted even if not advised. Recurrence is not rare and the risk is greater in patients without ovarian masses. OPY does not adversely affect ultrasonographic results at 1 year. When possible OPY should be performed at the first episode of OT.

Ovarian Torsion in the Normal Ovary: A Diagnostic Challenge in Postmenarchal Adolescent Girls in the Emergency Department

Background

Ovarian torsion can be seen in the otherwise-normal ovary and is a challenging issue in the emergency department. The aims were (1) to evaluate and compare the surgically verified ovarian torsion cases in otherwise-normal ovaries and ovaries including a mass or cyst and (2) to investigate whether the normal-appearing ovaries on ultrasound examination affected the diagnosis of ovarian torsion or not.

Material/Methods

A retrospective cohort study design was used. The medical records of all postmenarchal adolescent girls with surgically verified ovarian torsion treated in a university hospital from 2010 to 2016 were reviewed.

Results

Twenty-nine post-menarchal girls were identified. The subjects were divided into two groups. Eight girls (group 1) had ovarian torsion in a normal ovary, and twenty-one girls (group 2) had ovarian torsion including a mass or cyst. The median ages of group 1 and 2 were 13 and 14 years, respectively. Abdominal pain was the main presenting symptom for all cases in both groups. Doppler flow studies were abnormal in 6/9 (66.6%) in group 1 and 12/21 (57.1%) in group 2. The time from first admission to the operation was statistically longer in group 1 than in group 2 (34.5±24.3 hours vs. 19.5±9.2 hours, respectively; p=0.001). The longitudinal axis of uterine size was significantly shorter in group 1 than in group 2 (34.3±2.9 mm vs. 47.6±4.5 mm, respectively; p=0.001).

Conclusions

Ovarian torsion in adolescent girls can be seen within the otherwise-normal ovary. The normal-appearing ovaries on ultrasound in the emergency department may lead to delay in the diagnosis of ovarian torsion in adolescent girls.

Pediatric Adnexal Torsion: Not Just a Postmenarchal Problem

BACKGROUND

Pediatric adnexal torsion is rare, can be challenging to recognize, and may result in ovarian loss.

OBJECTIVE

We sought to identify and compare the defining characteristics of adnexal torsion in premenarchal and postmenarchal girls.

METHODS

A retrospective cohort study was performed at a tertiary care children's hospital, including patients diagnosed postnatally with adnexal (ovarian or tubal) torsion between 1997 and 2013. Proportions were compared using relative risk regression.

RESULTS

Adnexal torsion was found in 59 premenarchal and 43 postmenarchal girls. Abdominal pain was the most common chief complaint (54%). History included reports of pain (96%), vomiting (67%), and fever (19%). Excluding 12 patients with isolated tubal torsion and 19 with a teratoma, there were no statistically significant differences in ovarian loss in premenarchal vs. postmenarchal girls (47% and 25% respectively; relative risk [RR] = 1.8 [95% confidence interval {CI} 0.9-3.8]), left- vs. right-sided torsion (47% and 32%; RR = 1.5 [95% CI 0.8-2.7]), pain duration ≤ 2 days vs. > 2 days (31% and 41%; RR = 0.8 [95% CI 0.4-1.5]; n = 64) and severe pain vs. mild to moderate (38% and 33%; RR = 1.1 [95% CI 0.7-1.5]; n = 56).

CONCLUSIONS

The diagnosis of pediatric adnexal torsion is difficult and often delayed. Pain and tenderness may not be isolated to a unilateral lower quadrant. Although traditionally considered a postmenarchal problem, in a pediatric academic emergency department adnexal torsion occurred with similar frequency in premenarchal and postmenarchal girls. The potential for organ salvage means that adnexal torsion should be considered in all females presenting with acute abdominal pain regardless of age or menstrual history.

High risk of recurrent torsion in premenarchal girls with torsion of normal adnexa

OBJECTIVE

To compare adnexal torsion characteristics and torsion recurrence rates in a pre- and postmenarchal pediatric and adolescent population.

DESIGN

Retrospective cohort study.

SETTING

University-affiliated medical center.

PATIENT(S)

Females <18 years old with surgically diagnosed adnexal torsion.

INTERVENTION(S)

Adnexal detorsion, cystectomy, salpingectomy, or salpingo-oophorectomy by laparoscopy or laparotomy. Oophoropexy using the utero-ovarian ligament plication technique was performed in cases of recurrent torsion of normal adnexa.

MAIN OUTCOME MEASURE(S)

The clinical presentation, laboratory and ultrasound characteristics, surgical findings, surgical procedures, pathologic diagnosis, and torsion recurrence rates were analyzed and compared between pre- and postmenarchal patients.

RESULT(S)

Twenty premenarchal and 24 postmenarchal patients were identified. The clinical presentation, laboratory findings, and ultrasound characteristics were similar between the two groups, except for a higher prevalence of paraovarian cysts on preoperative ultrasound in the postmenarchal compared with in the premenarchal group (20.8% vs. 0%). For the whole cohort, torsion of normal adnexa constituted 25.0% (11/44) of cases, while torsion of "pathologic" adnexa constituted 75.0% (33/44) of torsion cases. Torsion recurrence was significantly more common among girls whose first torsion episode occurred in the premenarchal period compared with in postmenarche (35% vs. 4.2%). On multivariate logistic regression analysis, torsion recurrence was significantly associated with premenarchal status (odds ratio [OR] = 12.7; 95% confidence interval [CI], 1.1-152.0) and with torsion involving normal adnexa (OR = 19.1; 95% CI, 2.3-154.5).

CONCLUSION(S)

Recurrent torsion is common in patients whose first torsion episode occurred in the premenarchal period and involved otherwise normal adnexa. Ovarian fixation procedures may be considered in patients at risk for torsion recurrence.

Recurrent Ipsilateral Ovarian Torsion: Case Report and Literature Review

BACKGROUND

Recurrent ipsilateral ovarian torsion at pediatric age is a rare event. Different surgical techniques for its prevention are available. We present a case of recurrent ipsilateral ovarian torsion in a prepubertal girl and we reviewed the literature about the management of this condition.

CASE

A 6-year-old girl presented with right ovarian torsion and underwent a laparoscopic untwisting. Nine months later an ipsilateral recurrence occurred. Laparoscopic untwisting and right-sided oophoropexy with plication to the round ligament was performed.

SUMMARY AND CONCLUSION

In addition to our presented case, four cases of recurrent ipsilateral ovarian torsion in pediatric patients were identified in the literature. The few available reports in the pediatric literature show different management techniques. A long-term study is necessary to define the most effective treatment.

Factors affecting recurrence after surgery for ovarian mature cystic teratoma

We aimed to evaluate the risk factors for recurrence of surgically managed ovarian mature cystic teratoma (MCT). A total of 178 women with MCT managed surgically at our clinic were included in this retrospective study. The cases were followed for a minimum of 34 months. Risk factors recorded were age, gravidity, diameter of MCT, tumour markers, bilaterality, operation time and recurrence time. One hundred forty-one women (79.2%) underwent laparoscopy and the other thirty-seven patients (20.8%) underwent laparotomy. The mean age of patients with cyst recurrence was significantly lower than that of patients without recurrence (p = 0.02). There was a significantly lower median gravidity and parity in this group. The capacity of younger age, lower gravidity and parity in predicting the recurrence of ovarian MCT was analysed using receiver operating characteristic curve analysis. The cut-off value of age, number of gravidity and parity was 26, 1 and 0, respectively. In conclusion, younger age and lower gravidity and parity were predictive of recurrence due to a more conservative approach in young and nulliparous patients. Therefore, we suggest regular follow-up visits during the postoperative period, especially for younger patients and those with lower numbers of gravidity and parity.

Update on the management of ovarian torsion in children and adolescents

BACKGROUND

Ovarian torsion is commonly seen in young girls. Unfortunately it is often misdiagnosed because of its non-specific symptoms and lack of diagnostic modalities. This article focuses on the diagnostic challenge and also the changes in the management of ovarian torsion.

DATA SOURCES

We reviewed original reports on the management of ovarian torsion in young girls published from 1984 till 2014. A literature search was conducted by electronic scanning of five electronic database: MEDLINE, EMBASE, SCI, SSCI and CINAHL. In addition, relevant papers and review articles were hand-searched. The search was limited to English language and human studies. The search was conducted by combining the textwords "ovarian torsion", "adnexal torsion", "adolescents" and "oophoropexy".

RESULTS

There are no specific symptoms that can be identified as a pathognomonic feature of ovarian torsion. Ultrasound is a useful diagnostic tool, but it is not always reliable in absence of an enlarged ovary. Laparoscopic detorsion is recognized as the mainstay of treatment regardless the condition of the ovaries. Reports have shown favorable ovarian function after detorsion. The role of oopheropexy remains controversial.

CONCLUSIONS

Clinicians should be aware of ovarian torsion in girls presenting with abdominal pain. A timely management in this young population can help preserve their ovaries and fertility.

A 3-year-old female with abdominal pain, vomiting, and an abdominal mass

We present a case of a 3-year-old female with a 10-day history of lower abdominal pain, distention, and vomiting, as well as fatigue, low-grade fever, and subjective weight loss who was found to have utero-ovarian torsion with pathology revealing hemorrhagic and infarcted tissue. While the literature is limited, it suggests that utero-adnexal torsion in children may be more common than previously recognized. A missed, or even delayed, diagnosis of utero-adnexal torsion has the potential to result in irreversible ischemic damage. Utero-adnexal torsion should therefore be included in the differential diagnosis for girls presenting with acute abdominopelvic pain. Pelvic ultrasound to evaluate the uterus and adnexae is an important non-invasive first step in establishing the diagnosis. Computed tomography scan or magnetic resonance imaging can be considered in the case of indeterminate ultrasound. The diagnosis of utero-adnexal torsion must be made early, and surgical intervention must be timely in order to preserve fertility.

Imaging of common solid organ and bowel torsion in the emergency department

OBJECTIVE

This article will discuss the most common forms of torsion encountered in the emergency department.

CONCLUSION

Torsion refers to the twisting of an object about its axis and represents the pathophysiologic mechanism underlying an important group of disorders affecting both the bowel and the solid organs of the abdomen and pelvis. Although these disorders typically present with the acute onset of pain, clinical findings are often nonspecific, with imaging playing a key role in diagnosis. Missed or delayed diagnosis may result in complications, such as ischemia; end-organ loss; and, in some cases, death. Therefore, it is critical to have a thorough understanding of the pathophysiology and imaging findings of these entities to avoid the morbidity and mortality associated with a missed or delayed diagnosis.

Should the ovary always be conserved in torsion? A tertiary care institute experience

AIM

The aim of this study was to analyze our experience in conserving ovarian tissue in cases of ovarian torsion, irrespective of grade of necrosis at exploration.

MATERIALS AND METHODS

All children with a diagnosis of ovarian torsion admitted to our hospital from January 2009 to January 2013 were included. Patients with underlying ovarian pathology were excluded.

RESULTS

There were 13 torsions in 12 children (one bilateral). All underwent detorsion with or without evacuation of hematoma. Follow-up ultrasonography (USG) with color Doppler was done for all 13 ovaries, which showed an ovary with good vascularity and follicular development in 12 ovaries (92%). In 76% (10 of 13) of cases, intraoperatively, the ovary was judged to be moderately to severely ischemic/necrotic. Yet, follow-up sonograms showed the ovary with follicular development in all cases except one (7%). There were no major complications in our series.

CONCLUSION

Simple detorsion, instead of traditionally advocated oophorectomy, was not accompanied by an increase in morbidity. On follow-up, almost all patients studied had functioning ovarian tissue despite the grave ischemia observed intraoperatively. Detorsion should be the procedure of choice for all cases of simple ovarian torsion in children.

The auto-amputated adnexa: a review of findings in a pediatric population

STUDY OBJECTIVE

To quantify our experience and that of the literature with diagnosis and management of the auto-amputated adnexa in a pediatric population.

DESIGN

Case series and literature review.

SETTING

Tertiary care medical center.

PARTICIPANTS

Case series of pediatric patients (<18 years of age) with surgically documented adnexal auto-amputation collected from our medical center and the literature.

INTERVENTIONS

None.

MAIN OUTCOME MEASURE

Auto-amputated adnexa.

RESULTS

In addition to the 3 cases discussed from our institution, 91 cases of auto-amputated adnexa were identified in the literature dating back to 1943, for a total of 94 cases. Forty-nine percent (46/94) of the cases involved girls in a pediatric population (<18 years of age). Of these, the majority (n = 26) were identified in a subgroup of girls who were diagnosed with an adnexal cyst by antenatal ultrasound. Most of these neonates were asymptomatic at birth or had a palpable abdominal mass (n = 6) and at the time of surgical exploration were found to have an auto-amputated adnexa. 34 out of 46 cases were analyzed in detail. The right adnexa were involved in 56% of the cases. The most common presenting complaint verbalized by the older girls was pain; however, 8 cases were identified in asymptomatic girls undergoing unrelated diagnostic testing.

CONCLUSION

The auto-amputated adnexa is a rare finding in the pediatric population, but it must be considered as a possible explanation for the incidental finding of absence of the fallopian tube or ovary in the subgroup of patients who undergo surgery for any reason. Patients with an antecedent history of pelvic pain either chronic or intermittent in nature may be diagnosed with torsion or less frequently auto-amputation of the adnexa. A fetal "pelvic mass" or "ovarian cyst" may predispose the adnexa to torsion and subsequent auto-amputation either in-utero or post-delivery. Many of these antenatally diagnosed cysts and even subsequent auto-amputations are completely asymptomatic, however, and do not compromise fertility assuming the contralateral adnexa are normal. Thus expectant management is appropriate for small (less than 4 cm), asymptomatic simple cysts and even suspected auto-amputated adnexa in an asymptomatic patient.

Ovarian torsion in children: management and outcomes

BACKGROUND

The purpose of this study is to evaluate the clinical symptoms, diagnosis, management, and outcomes in children with ovarian torsion.

METHODS

The charts of 50 patients with 53 cases of ovarian torsion treated between January 1989 and March 2012 were reviewed retrospectively. Long term follow up was available for 20 girls who had their ovaries left in the abdominal cavity after detorsion.

RESULTS

In 22 cases ovaries were removed, and in 31 cases the torsion was relieved and the ovaries left in the abdominal cavity. Twenty-five of the salvaged ovaries were black-bluish and 10 bluish in color. Since 2005, after a change in preferred treatment, all ovaries treated by detorsion were left in the abdominal cavity. The long term results were observed clinically and by ultrasound in 20 girls. Multifollicular ovaries were found in 17 girls. One girl had a normal size paucifollicular ovary, a one-year-old girl had a normal size ovary with microfollicles, and one girl had no ovarian material detectable by ultrasound.

CONCLUSIONS

Long term analysis of the treatment of ovarian torsion revealed that ovaries treated by detorsion and left in the abdominal cavity preserved their normal anatomy and function. Conservative surgical treatment proved to be safe. None of the girls had thromboembolism or peritonitis, and no malignant tumors were found in the operated ovaries.

The positive and negative predictive value of transabdominal color Doppler ultrasound for diagnosing ovarian torsion in pediatric patients

PURPOSE

The purposes of this study were to (1) determine the positive and negative predictive value (NPV) of transabdominal color Doppler ultrasound (CDU) for diagnosing ovarian torsion (OT) in pediatric patients and 2) identify predictors of a false-positive CDU result for OT.

METHODS

An IRB-approved retrospective chart review was performed on all female patients who underwent transabdominal CDU evaluation of the ovaries (664 CDUs in 605 patients) for acute abdominal pain. CDU reports were categorized as positive for OT if the report stated "cannot rule out torsion" or "positive for torsion."

RESULTS

There were 47 false-positive ultrasounds, 3 false negatives, 11 true positives, and 603 true negatives for OT. Sensitivity was 78.6%, specificity 92.3%, positive predictive value (PPV) 19.0%, and NPV 99.5%. False-positive CDU when compared to true positives were more common in older patients (p=0.004) and were more commonly read as "cannot rule out torsion" (p<0.001). Ovarian cysts were larger in true-positive CDU than in false-positive CDU (p<0.001). However, cyst presence/absence did not predict a true positive result.

CONCLUSION

Transabdominal CDU has a low PPV and a high NPV for ovarian torsion in pediatric patients. False-positive results are more common in older patients and associated with small ovarian cysts.

Pediatric ovarian torsion: case series and review of the literature

BACKGROUND

Ovarian torsion in children is an uncommon cause of acute abdominal pain but mandates early surgical management to prevent further adnexal damage. The clinical presentation mimics other pathologies, such as appendicitis. We sought to more completely characterize ovarian torsion with respect to pain and ancillary studies, such as urinalysis.

METHODS

We performed a retrospective review of hospital charts of all patients aged 0-18 years with a diagnosis of ovarian torsion at the Children's Hospital at London Health Sciences Centre, in London, Ont., from 1993 to 2008.

RESULTS

We analyzed 13 charts of patients aged 7 months to 18 years. Most patients presented with peripheral leukocytosis, vomiting and right lower quadrant pain that did not radiate or migrate. On urinalysis, about half the patients demonstrated pyuria without bacteruria. Pelvic ultrasound revealed an ovarian cyst on the same side of the pain in 11 of 13 patients. Most were found to have a hemorrhagic cyst or ovary and underwent salpingo-oophorectomy or cystectomy within 48 hours of presentation.

CONCLUSION

Ovarian torsion should be considered in any female child with acute onset lower abdominal pain accompanied by vomiting. Pain can be characterized as constant or colicky, but unlike with appendicitis, does not typically migrate. Sterile pyuria is found in a substantial proportion of cases. Ultrasound is the most useful initial diagnostic modality, but the absence of flow on Doppler imaging is not always present. Conservative management with detorsion and oophoropexy is recommended.

Torsion of the gonad in the pediatric population: spectrum of histologic findings with focus on aspects specific to neonates and infants

Histopathologic findings of gonadal torsion in neonates and infants (GTNI) are poorly defined in the literature. We describe herein the histopathologic spectrum of GT with emphasis on the pediatric population and on features specific for NI (≤1 year of age). Twenty-four cases of GTNI (6 females/18 males), 33 cases of GT in an older pediatric population (OPP) (19 females/14 males), and 43 cases of GT in adults (35 females/8 males) were found in our pathology files between 2003 and 2011. Our findings disclosed 2 categories of GT: 1) the group of NI, and 2) that of OPP and adults who share a similar presentation as acute hemorrhagic necrosis of the gonad. Although findings in NI were rather uniform, a few differences were demonstrated between the 2 genders. All GTNI revealed calcifications, fibrosis, siderophages, and extensive necrosis. However, prominent necrotizing palisaded granulomatas were seen in most (4 of 6) cases of ovarian torsion but not in the testicular counterpart. Furthermore, complete gonad regression was encountered exclusively in neonatal testicular torsion cases. In conclusion, 1) pathologic findings in GT are distinctly different between NI and OPP, the latter being more comparable to adults, presenting with acute hemorrhagic necrosis; 2) the distinctive findings in GTNI of both genders include calcifications, siderophages, and fibrosis, in addition to background necrosis; 3) of particular note, complete gonadal regression is seen only in the testis in GTNI; and 4) necrotizing palisaded granulomatas are unique to the ovarian subgroup and are often extensive, obscuring the nature of the process.

Ovarian torsion in a 5-year old: a case report and review

Ovarian torsion represents a true surgical emergency. Prompt diagnosis is essential to ovarian salvage, and high clinical suspicion is important in this regard. Confounding the diagnosis in general are more commonly encountered abdominal complaints in the Emergency Department (ED) such as constipation, diarrhea, and urinary tract infections and more common surgical emergencies such as appendicitis. Prompt diagnosis can be further complicated in low-risk populations such as young children. Herein, we describe the case of a 5-year-old girl with a seemingly benign presentation of abdominal pain who was diagnosed in the ED and treated for acute ovarian torsion after two prior clinic visits. A brief discussion of evaluation, treatment, and management of ovarian torsion follows.

The First Report of an Intraperitoneal Free-Floating Mass (an Autoamputated Ovary) Causing an Acute Abdomen in a Child

A free-floating intraperitoneal mass is extremely rare, and almost all originate from an ovary. Here, we present the first case with an intraperitoneal free-floating autoamputated ovary that caused an acute abdomen in a child and also review the literature. A 4-year-old girl was admitted with signs and symptoms of acute abdomen. At surgery, the patient had no right ovary and the right tube ended in a thin band that pressed on the terminal ileum causing partial small intestine obstruction and acute abdomen. A calcified mass was found floating in the abdomen and was removed. The pathological examination showed necrotic tissue debris with calcifications. An autoamputated ovary is thought to result from ovarian torsion and is usually detected incidentally. However, it can cause an acute abdomen.

Oophorectomy in children. Who and why: 13-year experience in a single centre

AIM

Oophorectomy performed in children is extremely uncommon. We aimed to investigate the disease pattern and the association between the underlying pathology and the clinical presentation among those patients who had their ovaries removed in their childhood.

METHODS

A retrospective study was performed on 41 consecutive children who underwent oophorectomy in a tertiary referral centre in the period between June 1995 and May 2008.

RESULTS

  The median age was 11 years, ranged from 11 weeks to 15 years at the time of surgery. The primary presentations were acute lower abdominal pain (n= 20), progressive abdominal distension or abdominal mass (n= 13), chronic abdominal pain (n= 3), irregular menses (n= 1), antenatal diagnosis (n= 3) and incidental finding (n= 1). Ultrasound examination was performed in 31 patients and positive findings of ovarian pathology were found in all but one examination. Twenty cases of ovarian torsion were confirmed intra-operatively. Patients presenting with acute abdominal pain were more likely to have torsion than other presentations (P < 0.01). Non-neoplastic conditions and ovarian neoplasms were found in 11 and 30 patients, respectively. The most common neoplasm was mature teratoma (52%). Malignant neoplasms included immature teratoma (n= 3), dysgerminoma (n= 1), mixed dysgerminoma + yolk sac tumour (n= 2), yolk sac tumour (n= 2) and juvenile granulose cell tumour (n= 1). Malignant neoplasms were found to have more chronic presentation and less torsion than benign pathologies (P < 0.05).

CONCLUSION

Although ovarian pathology is uncommon in children, a girl presenting with acute lower abdominal pain or progressive abdominal distension should raise the suspicion and prompt immediate investigation to rule out ovarian torsion or ovarian neoplasms.

Pediatric ovarian torsion in a medical center in Taiwan: case analysis

BACKGROUND

Abdominal pain is one of the most common complaints made by patients visiting emergency departments; however, ovarian torsion is an uncommon cause of abdominal pain, especially in young children. Early diagnosis is essential in order to salvage the ovaries. We performed a retrospective analysis of patients under 18 years of age who visited Changhua Christian Hospital with adnexal torsion between June 2003 and June 2010.

METHODS

Medical records were reviewed for age, associated symptoms, past and present medical histories, physical findings, diagnostic tests performed, clinical course, pathological findings, and diagnoses.

RESULTS

A total of 21 patients were identified and included in the analysis; their mean (SD) age was 13.62 (3.75) years. Abdominal pain was the universal symptom. Vomiting or nausea was the second most common symptom (33.3%). The average period between symptom onset and diagnosis was 3.29 (6.39) days. Right-side adnexal torsion occurred in 14 patients, and left-side torsion in seven patients. Ovarian cysts, most often dermoid cysts (e.g., teratomas), were found in 16 patients (76%). Except for one conservatively treated case and one malignant case (adult granulose cell tumor), the other results of the pathological examination were as follows: eight dermoid cysts, two cystadenomas, one follicular cyst, and eight simple cysts.

CONCLUSION

Although it is uncommon, adnexal torsion should be included in the differential diagnosis of lower abdominal pain in all girls, regardless of age. Sonography is helpful for making such a diagnosis. Time is a critical factor, and early laparoscopy or laparotomy may save a viable ovary.

Intermittent torsion of a normal ovary in a child associated with use of a trampoline

BACKGROUND

Ovarian torsion is rare in children. It usually occurs in the presence of ovarian or pelvic pathology. The course of symptoms is typically hours to days. Some authors have speculated that sudden acceleration/deceleration movements may precipitate torsion.

OBJECTIVES

The objective of this report is to describe a case of intermittent abdominal pain lasting nearly 6 months, which started when the child began playing regularly on a trampoline, and was ultimately diagnosed as intermittent ovarian torsion of an otherwise normal ovary.

CASE REPORT

A 12-year-old girl presented to the Emergency Department (ED) with 2 h of abdominal pain and vomiting. She reported similar episodes over the previous 6 months. Initial ultrasound, obtained between episodes, was normal. Repeat ultrasound at ED presentation showed no blood flow to the left adnexa. Surgery confirmed the ovary to be twisted 1080 degrees and markedly edematous due to vascular engorgement. The family retrospectively identified the onset of the first episode as happening the same week the child had begun playing regularly on a trampoline. After surgery, she no longer played on the trampoline. At follow-up 22 months later, she had had no recurrence of her symptoms.

CONCLUSION

Intermittent ovarian torsion should be considered as a rare cause of recurrent abdominal pain in children. The presence of blood flow with Doppler ultrasound during acute symptoms does not exclude the diagnosis. Clinicians might also ask about unusual physical activities because several authors have theorized that ovarian torsion could be precipitated by sudden acceleration/deceleration movements.

Incidence and trends of pediatric ovarian torsion hospitalizations in the United States, 2000-2006

OBJECTIVE

There is significant variation in the literature regarding the characteristics that are associated with pediatric ovarian torsion and its management. National data regarding the demographics and management of pediatric ovarian torsion are lacking. Our objective was to describe the epidemiology of pediatric ovarian torsion and the rate of oophorectomy by using nationally representative data. Demographic factors and hospital characteristics that are associated with rates of oophorectomy were also explored.

METHODS

This was a cohort analysis of the Healthcare Cost and Utilization Project Kids' Inpatient Database (KID) 2000, 2003, and 2006. All females aged 1 to 20 years who were hospitalized with ovarian torsion in states participating in KID 2000, KID 2003, and KID 2006 representing 900, 1224, and 1232 ovarian torsion-related hospitalizations, respectively, were included. Primary outcome measures included the incidence of ovarian torsion and rate of associated oophorectomy. Multivariable regression was used to control for patient and hospital characteristics.

RESULTS

Among females aged 1 to 20 years, there were 1232 cases of ovarian torsion in KID 2006, an estimated incidence of 4.9 per 100000. A total of 713 (58%) were treated with oophorectomy. The rate of ovarian torsion-associated oophorectomy remained unchanged from 2000 to 2006. The adjusted odds of having an oophorectomy decreased by 0.95 for every increasing year of age. Residing in a lower quartile of household income by zip code increased the adjusted odds of oophorectomy. A diagnosis of benign neoplasm increased the adjusted odds of oophorectomy by 2.16. Fewer than 0.5% of ovarian torsion hospitalizations were associated with malignant neoplasm.

CONCLUSIONS

Nationally representative hospital data indicate that ovarian torsion is uncommon but occurs in all ages and is typically associated with normal ovaries or benign lesions. Improved awareness of the epidemiology may help to guide management. Ongoing analysis to identify factors that are associated with successful conservative management is warranted.

Ovarian autoamputation in a neonate: a case report with literature review

A case of ovarian autoamputation in an asymptomatic neonate is presented. An abdominal cyst was detected in a 30-week-gestation fetus on an antenatal ultrasound scan (USS). Postnatal USS confirmed the presence of a cyst in the right pelvis and revealed it to be 3.2 cm in diameter. CT and MRI revealed cyst wall calcification and intracystic hemorrhage. To confirm the diagnosis and treatment, the cyst was surgically removed. During the operation, a free autoamputated right ovarian cyst was found and removed from the abdomen. Ovarian cyst autoamputation is an extremely rare complication. In this article, we review the infantile ovarian autoamputation cases reported in the literature and assess their diagnosis and therapeutic management.

Pearls and pitfalls in diagnosis of ovarian torsion

Ovarian torsion is defined as partial or complete rotation of the ovarian vascular pedicle and causes obstruction to venous outflow and arterial inflow. Ovarian torsion is usually associated with a cyst or tumor, which is typically benign; the most common is mature cystic teratoma. Ultrasonography (US) is the primary imaging modality for evaluation of ovarian torsion. US features of ovarian torsion include a unilateral enlarged ovary, uniform peripheral cystic structures, a coexistent mass within the affected ovary, free pelvic fluid, lack of arterial or venous flow, and a twisted vascular pedicle. The presence of flow at color Doppler imaging does not allow exclusion of torsion but instead suggests that the ovary may be viable, especially if flow is present centrally. Absence of flow in the twisted vascular pedicle may indicate that the ovary is not viable. The role of computed tomography (CT) has expanded, and it is increasingly used in evaluation of abdominal pain. Common CT features of ovarian torsion include an enlarged ovary, uterine deviation to the twisted side, smooth wall thickening of the twisted adnexal cystic mass, fallopian tube thickening, peripheral cystic structures, and ascites. Understanding the imaging appearance of ovarian torsion will lead to conservative, ovary-sparing treatment.

Adnexal torsion leading to death of an infant

BACKGROUND

Torsion of the uterine adnexa is an uncommon occurrence in infants, but when it does occur, the consequences may be catastrophic.

CASE

A 4-month-old female presented with sudden cardiac and respiratory arrest. There were no prior signs of illness. The infant was resuscitated and survived for one day after the event. Autopsy revealed a left ovarian cyst with torsion. Necrosis of the transverse colon was also seen. Other organs revealed signs of shock. The cause of death was felt to be related to the torsion.

SUMMARY AND CONCLUSION

Torsion of the uterine adnexa is rare in infants. In the few reported cases, antecedent symptoms were present. Clinicians should be aware of this possibility and include it in the differential diagnosis of death in infancy.

Sonographic findings of ovarian torsion in children

BACKGROUND

The clinical diagnosis of ovarian torsion is challenging and findings on pelvic sonography can be pivotal in making the correct diagnosis.

OBJECTIVE

To determine the sonographic characteristics in children of surgically and pathologically proven ovarian torsion.

MATERIAL AND METHODS

We performed a retrospective review of the sonograms and medical records of 41 patients with surgically and pathologically proven ovarian torsion at a pediatric hospital between 1994 and 2005. All sonograms were reviewed retrospectively by two pediatric radiologists with attention to the size, echotexture, location, presence of peripheral round cysts, and evidence of flow on Doppler sonography within the torsed ovary. The amount of free pelvic fluid was also recorded.

RESULTS

The most common sonographic finding of ovarian torsion was an enlarged ovary/adnexal mass. All torsed adnexa were larger than the normal contralateral ovary, with the median volume 12 times that of the normal contralateral side. The majority (61%, n = 25) of the torsions occurred on the right. Color flow, either venous or arterial, was present in 62% (n = 21/34) of the torsed ovaries for which flow on Doppler sonography was documented. In 63% of the torsed ovaries (n = 26), the torsed adnexa appeared heterogeneous. Ovarian or para-ovarian pathology that may have acted as a potential lead point was present in 55% (n = 24) of torsed ovaries. The volume ratio of the torsed to normal ovary can predict the presence of an ovarian mass within the torsed ovary. In 70% of torsed ovaries with a volume ratio greater than 20, an ovarian mass was present, and in approximately 90% of those with a volume ratio less than 20, an internal mass was absent.

CONCLUSION

An enlarged heterogeneous appearing ovary is the most common finding in ovarian torsion. The presence or absence of flow by Doppler sonography is not helpful in the diagnosis. The volume ratio of the torsed to the normal ovary can predict the presence of an internal mass within the torsed adnexa.

Torsion of normal adnexa in postmenarchal women and risk of recurrence

OBJECTIVE

To compare the incidence of recurrent torsion of normal adnexa to recurrent torsion of abnormal adnexa in postmenarchal women.

METHODS

All cases of surgically confirmed adnexal torsion operated on in our department from January 2002 to April 2006 were retrospectively analyzed. Classification as torsion of pathologic adnexa versus torsion of normal adnexa was based on pre- and postoperative pelvic sonograms, operative findings, and pathologic diagnoses (when available). The torsion recurrence rates were evaluated by a telephone questionnaire, with 90.5% compliance.

RESULTS

Twelve women had twisted normal adnexa and 50 women had twisted abnormal adnexa. The women with twisted normal adnexa were younger (25.5+/-7.9 years versus 31.4+/-11.4 years, P=.10) and had a lower median parity (0 versus 1, P=.06). Both groups had similar clinical presentations and a similar mean time from admission to surgery. The torsion recurrence rates were 63.6% (95% confidence interval [CI] 0.3-0.9) in the twisted normal adnexa group and 8.7% (95% CI 0.02-0.2) in the twisted abnormal adnexa group (P<.001). The retorsion risk of the pathologic adnexa was especially low after cystectomy (5.3%, 95% CI 0.001-0.3) or salpingo-oophorectomy (0%). The Kaplan-Meier life table analysis also showed a higher retorsion risk for normal adnexa (P=.008).

CONCLUSION

The current adnexa-sparing laparoscopic management of adnexal torsion by simply untwisting may predispose to recurrent torsion of normal adnexa. The role of ovariopexy procedures in the prevention of recurrent torsion events remains uncertain.

LEVEL OF EVIDENCE

III.

Torsion of the normal ovary and oviduct in a pre-pubertal girl

We encountered a 10-year-old prepubertal girl with a normal ovary and oviduct torsion. Hemorrhagic infarction of the ovary and oviduct occurred, and these structures were laparoscopically removed. Torsion of the normal ovary and oviduct in a prepubertal girl is discussed.