Ovarian torsion: clinical and imaging presentation in children

Adnexal torsion in a pediatric population: Acute presentation with question of chronicity

OBJECTIVES

To establish the frequency of torsion with multiple twists of the adnexa in girls 19 years old and younger surgically diagnosed with torsion.

STUDY DESIGN

A retrospective chart review using an institutional tool to review charts of female patients 19 years old or younger who presented with acute abdominal pain leading to a surgical diagnosis of adnexal torsion.

RESULTS

Of 141 pediatric patients with torsion, 61 (43%) had documentation of multiple twists, with 2 to 12 rotations present. 33% reported acute pain (<24 hrs) whereas most (67%) had pain > 24 h up to 4 weeks without abatement (23%) or experienced discrete episodes with pain resolution between episodes (44%). Even when vascular flow was demonstrated, multiple twists were frequently found (14/36 = 39%). When multiple twists were documented, more patients had an extirpative procedure due to a nonviable appearing ovary than when a single or unstated number of twists twist was found, although the results were not statistically significant (53.5% vs 42.9%, p = 0.098).

CONCLUSIONS

Forty-three percent of girls presenting with symptoms of torsion had multiple twists in the adnexa. Many had provided a history of previous similar episodes of pain and presentation to emergency departments, suggesting possible previous undiagnosed episodes of torsion. Earlier diagnosis may provide a better opportunity for ovarian conservation prior to a recurrent torsion. Further study may reveal whether multiple twists are more likely to result in a nonviable ovary and need for oophorectomy.

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.

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.

Is It Ovarian Torsion? A Systematic Literature Review and Evaluation of Prediction Signs

OBJECTIVES

This study aimed to identify, through systematic literature review, the most reliable clinical, biological, and radiological signs of ovarian torsion in the pediatric population and to compare their diagnostic value.

METHODS

This is a systematic review of the literature, searching MEDLINE, EMBASE, and Cochrane Databases for articles published between January 1990 and January 2014.

RESULTS

From the 946 references initially identified, 14 retrospective publications fulfilled the inclusion criteria, involving a total of 663 episodes of ovarian torsion. Sudden onset abdominal pain with nausea and/or vomiting is the most frequent symptom of ovarian torsion. It can occur at any age, not only in menarchal or perimenarchal patients. Abdominal tenderness is present in 88.4% of patients, whereas only 24% have a palpable mass. Blood tests are commonly requested (51.4% of cases) but are not diagnostic. Abnormalities on plain abdominal radiograph include masses, calcifications, and ossified images. Ultrasound has a sensitivity for ovarian torsion of 79% and computerized tomographic scan of 42.2%. There is a significant diagnostic delay at 101.8 hours (median).

CONCLUSIONS

Abdominal pain in children and adolescents is difficult to evaluate, and the diagnosis of ovarian torsion remains a challenge. Because of its potential complications, we need effective clinical tools. From our review of the literature, it was not possible to develop a diagnostic algorithm. Further research is needed to improve our practice and shorten the delay to diagnosis. Considering the low incidence of ovarian torsion, a multicenter prospective study would be required.

The protective effects of beta-carotene against ischemia/reperfusion injury in rat ovarian tissue

INTRODUCTION

Beta-carotene is a well-known antioxidant and precursor of Vitamin A that has a preventative role in the oxidative damage process. Our aim was to investigate the possible preventive effects of beta-carotene on oxidative damage via experimental ischemia and ischemia-reperfusion models in rat ovaries.

MATERIALS AND METHODS

A traumatic vascular clamps were used for 3h to induce ischemia (Group 2, 3, 4, 5, 6, 7). The clamps were then removed to allow reperfusion for 3h (Group 3, 6, 7). Sham-operated rats (Group 1) underwent laparotomy without the induction of ischemia/reperfusion injury. Real-Time-PCR was performed to determine IL-1-beta, IL-6 and iNOS expression levels. Histopathological (H&E) and immunohistochemical staining (NF-kβ p65) processes were then performed. Finally, SOD, GSH, and MDA levels were determined.

RESULTS

Intense hemorrhagic areas were observed in both the ischemia and ischemia/reperfusion groups, whereas minimal hemorrhage was observed in the treatment groups. The ischemia and ischemia/reperfusion groups exhibited extreme immunoreactivity, detected by NF-kβ p65 staining; this reactivity decreased after the application of beta-carotene. The expression of IL-1-beta, IL-6, and iNOS in the injury groups increased significantly, whereas a dose-dependent improvement was observed in the treatment groups. Finally, MDA levels increased significantly and SOD and GSH levels decreased drastically in the injury groups. However, these values obtained from I/R groups were normalized after beta-carotene treatment.

DISCUSSION

In this study, we demonstrated via molecular and biochemical parameters the protective effect of beta-carotene, which is a potent antioxidant, on the experimental ischemia-reperfusion model.

Outcome Following Detorsion of Torsed Adnexa in Children

STUDY OBJECTIVE

To examine the postoperative course and outcomes of young females with ovarian torsion treated with detorsion and ovarian preservation. The secondary objective was to determine which operative findings correlated with higher follicular counts following detorsion.

DESIGN

Retrospective chart review.

SETTING

Tertiary academic center.

PARTICIPANTS

29 females (mean age 10.3 ± 4.9 y) who underwent surgery for ovarian torsion with detorsion and ovarian preservation at our institution between July 2007 and July 2010 and who had follow-up pelvic ultrasonography available for review.

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

Surgical findings, postoperative complications, and follicular counts on follow-up ultrasonography.

RESULTS

Mean duration of abdominal pain on presentation was 77.5 ± 78.8 h. The detorsed ovary was described as "dusky/purple" in 21 cases (72.4%), "normal" in 1 (3.4%), "necrotic" in 1 (3.4%), and not described in 6 (20.7%). All pubertal patients resumed menstrual function. No patients required reoperation for removal of the salvaged ovary. There were no instances of postoperative fever or concern for ovarian venous thrombosis. Average timing of follow-up ultrasonography was 8.1 ± 6.7 months, with 28 patients (96.6%) showing ovarian follicles on the affected side (mean 4.6 ± 1.9 and 4.7 ± 3.3 follicles on the right and left ovary, respectively). No correlation was found between the side affected, gross appearance of the torsed ovary or the number of follicles found on follow-up ultrasonography.

CONCLUSIONS

Detorsion with ovarian preservation is a safe and effective treatment, and should be considered the primary treatment for girls with ovarian torsion, even for those with ovaries that appear necrotic.

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.

Does gradual detorsion protect the ovary against ischemia-reperfusion injury in rats?

AIM

Adnexal torsion is an infrequent and serious gynecologic surgical emergency. Adnexal torsion may result from pre-existing tubal or ovarian pathology or hyperstimulation of the ovary during ovulation. Early diagnosis and emergency surgical treatment (detorsion) are important to preserve fertility and to prevent peritonitis or loss of the adnexa. However, during reperfusion, tissue damage is more severe than during ischemia because of oxygen-derived radicals. The present study aimed to investigate the protective effect of gradual detorsion on adnexal torsion.

MATERIALS AND METHODS

Twenty-one adult female rats were divided into three groups as sham-operated (Sh group, n = 7); torsion + detorsion (TD group, n = 7); and torsion + gradual detorsion (TGD group, n = 7). A midline laparotomy was performed under anesthesia. In the TD and TGD groups, the left adnexa along with tubal and ovarian vessels were twisted three times in a clockwise direction and fixed to the abdominal wall. After 30 h, detorsion was performed on the mesenteries of both TD and TGD groups. In the TGD group, however, detorsion was performed gradually: the ovarian mesentery was detorsioned 360°, followed by a 5-min pause, then a repeat of the cycle until full detorsion was achieved. Rats were killed 1 week later. Left ovaries were removed and evaluated histopathologically.

RESULTS

The histopathological mean grade was significantly higher in the TD than in the TGD group (p < 0.05).

CONCLUSION

Gradual detorsion can reduce reperfusion injury in a rat model of ovarian torsion. This method is easily applicable and may be a useful method for human patients with ovarian torsion.

Key clinical predictors in the early diagnosis of adnexal torsion in children

OBJECTIVE

Adnexal torsion (AT) accounts for 2.7% of cases of acute abdominal pain in children. When AT is undiagnosed, ovarian blood supply is compromised, eventually leading to tissue necrosis. Because the clinical presentation of AT is nonspecific, preoperative diagnosis is challenging. The purpose of this study was to identify predictors that differentiate AT from other sources of acute abdominal pain.

METHODS

This study was an IRB-approved retrospective chart review of girls age 4-18 y/o with acute abdominal pain who then underwent surgical evaluation. Data collected included age, menarchal status, symptoms, physical exam findings, laboratory tests, imaging studies, operative procedures and postoperative diagnosis. Factors associated with AT were included in a logistic regression model. A receiver operator characteristic (ROC) curve based on this model was then constructed in order to determine its ability to predict AT.

RESULTS

94 patients presented with acute abdominal pain; 45 were diagnosed with AT and 49 with other causes of abdominal pain. Presence of intermittent pain (P < .0217), non-radiating pain (P < .0229) and increased adnexal size (P < .0032) were significantly associated with AT in the final model. The area under the ROC curve was equal to 0.8601, suggesting excellent discrimination between AT and other causes of acute abdominal pain by using these 3 parameters.

CONCLUSION

Key clinical and imaging findings can aid in the early diagnosis of AT in children. Future prospective studies will focus on development of a clinical predictive model for the diagnosis of AT in the pediatric population.

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.

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.

Thirteen cases of isolated tubal torsions associated with hydrosalpinx in children and adolescents, proposal for conservative management: retrospective review and literature survey

BACKGROUND/PURPOSE

Isolated tubal torsion associated with hydrosalpinx is a rare pathology. Our goal was to analyze the clinical and imaging features and discuss the different treatment options available.

METHODS

We retrospectively reviewed all the cases of adnexal torsion treated in our department of pediatric surgery over a 10-year period. We searched 2 electronic databases (Medline and Sciencedirect) and targeted reports published during the same period using the key words tubal torsion and hydrosalpinx.

RESULTS

A total of 13 cases, 6 from our hospital and 7 in the medical literature, were identified and analyzed. In 9 (69%) of 13 cases (n = 9/13), torsion and hydrosalpinx occurred on the left fallopian tube. Salpingectomy was performed in 11 of the patients. The resected tubes showed the persistence of ciliated cells associated with signs of moderate ischemic infarction in 50% (n = 3/6) of the cases.

CONCLUSIONS

Isolated tubal torsion associated with hydrosalpinx is too often misdiagnosed and treated by salpingectomy regardless of the negative impact on the future reproductive potential of our young patients. As is commonly advocated for ovarian salvage in adnexal torsions, tubal conservation should be favored when possible.

Growth hormone reduces tissue damage in rat ovaries subjected to torsion and detorsion: biochemical and histopathologic evaluation

OBJECTIVE

To evaluate the effects of growth hormone (GH) as an antioxidant and tissue-protective agent and analyse the biochemical and histopathological changes in rat ovaries due to experimental ischemia and ischemia/reperfusion injury.

STUDY DESIGN

Forty-eight adult female rats were randomly divided into eight groups. In Group 1, a period of bilateral ovarian ischemia was applied. In Groups 2 and 3, 1 and 2 mg/kg of GH was administered, and 30 min later, bilateral ovarian ischemia was applied (after a 3-h period of ischemia, both ovaries were surgically removed). Group 4 received a 3-h period of ischemia followed by 3h of reperfusion. Groups 5 and 6 received 1 and 2 mg/kg of GH, respectively, 2.5 h after the induction of ischemia. At the end of a 3-h period of ischemia, bilateral vascular clips were removed, and 3h of reperfusion continued. Group 7 received a sham operation plus 2mg/kg of GH. Group 8 received a sham operation only. After the experiments, superoxide dismutase and myeloperoxidase activity and levels of glutathione and lipid peroxidation were determined, and histopathological changes were examined in all rat ovarian tissue.

RESULTS

Ischemia and ischemia/reperfusion decreased superoxide dismutase activity and glutathione levels in ovarian tissue, but increased lipid peroxidation levels and myeloperoxidase activity significantly in comparison to the sham group. The 1 and 2 mg/kg doses of GH before ischemia and ischemia/reperfusion decreased lipid peroxidation levels and myeloperoxidase activity in the experimental groups. The administration of GH before ischemia and ischemia/reperfusion treatments also increased superoxide dismutase and glutathione levels. The histopathological findings also suggested a protective role of GH in ischemia/reperfusion injury. That is, ovarian tissues in the ischemia groups showed histopathological changes, such as haemorrhage, cell degeneration, and necrotic and apoptotic cells, but these changes in the GH groups were lesser. Moreover, in the ischemia/reperfusion groups, acute inflammatory processes--such as neutrophil adhesion and migration, apoptotic and degenerative cells, stromal oedema and haemorrhage--were present. However, the ovarian tissues of the IR+GH (1 mg) group had minimal apoptotic cells, and the IR+GH (2 mg) group had no apoptotic cells. In addition, the general ovarian histological structures of these groups were similar to those of the healthy control group.

CONCLUSIONS

The administration of GH is protective against ischemia and/or ischemia/reperfusion-induced ovarian damage. This protective effect can be attributed to the antioxidant properties of GH.

Protective effects of montelukast on ischemia-reperfusion injury in rat ovaries subjected to torsion and detorsion: biochemical and histopathologic evaluation

OBJECTIVE

To reveal the effects of montelukast as an antioxidant and tissue protective agent and study the biochemical and histopathologic changes in experimental ischemia and ischemia-reperfusion (I/R) injury in rat ovaries.

DESIGN

Experimental study.

SETTING

Experimental surgery laboratory in a university department.

ANIMAL(S)

Forty-eight rats with experimentally induced ovarian torsion.

INTERVENTION(S)

Group 1: sham; Group 2: ovarian ischemia; Group 3: a 30-hour period of ischemia followed by a 3-hour reperfusion. Groups 4 and 5: rats administered 10 and 20 mg/kg doses of montelukast before a half-hour of ischemia, then ovarian ischemia applied; after a 3-hour period of ischemia, the bilateral ovaries removed. Groups 6 and 7: 3-hour period of ovarian ischemia applied, then 2.5 hours after the ischemia induction, rats given montelukast. Group 8: sham operation and 20 mg/kg of montelukast; at the end of a 3-hour period of ischemia, 3-hours of reperfusion continued.

MAIN OUTCOME MEASURE(S)

Measurement of ovarian tissue concentrations of superoxide dismutase (SOD), glutathione (GSH), lipid peroxidation (LPO) and myeloperoxidase (MPO) activity; and histopathologic examination of all ovarian rat tissue.

RESULT(S)

Montelukast treatment normalized changes of LPO and MPO and stimulated an overproduction of endogenous SOD and GSH. The results of the histologic parameters showed that treatment with montelukast in the I/R group of rats ameliorated the development of ischemia and reperfusion tissue injury.

CONCLUSION(S)

Montelukast at different doses attenuates ovarian I/R-induced ovary tissue injury in rats.

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.

Pediatric ovarian malignancy presenting as ovarian torsion: incidence and relevance

PURPOSE

With ovarian torsion, concern for underlying malignancy in the enlarged ovary has previously driven surgeons to resection. Detorsion alone has been recommended to allow for resolution of edema of the ovary with follow-up ultrasound surveillance to evaluate for a persistent mass, yet is not routine practice. However, the incidence of malignancies presenting as ovarian torsion is not documented. Does the risk of an underlying malignancy justify salpingoophorectomy and decreased fertility?

METHOD

After institutional review board exemption (IRB#-022008-095), a 15(1/2)-year retrospective review was conducted to identify cases of operative ovarian torsion in our medical center. Tumors with neoplastic pathology (malignant and benign) were analyzed and compared with all reported cases in the literature.

RESULTS

A total of 114 patients (mean +/- SEM age, 10 years, 2 days to 19 years +/- 0.53) with operatively proven ovarian torsion were identified. Four malignancies (3.5%) and 26 benign neoplasms (23%) were present in this age group. Malignancies consisted of serous borderline tumors (2), juvenile granulosa cell tumor (1), and dysgerminoma (1). All were stage I: the former were stage IA and cured with resection alone, and 1 was a stage IB dysgerminoma, which required chemotherapy. The literature yielded a total of 593 cases of operative ovarian torsion with 9 (1.5%) malignancies and 193 (33%) benign neoplasms. The malignancies were juvenile granulosa cell tumor (n = 4), dysgerminoma (n = 2), serous borderline tumors (n = 2), and 1 undifferentiated adenocarcinoma.

CONCLUSION

By combining our series with 13 in the literature, a 1.8% malignancy rate occurred in 707 patients with ovarian torsion, markedly less than the reported malignancy rate of 10% in children with ovarian masses. Thus, neither a pathologic nor malignant lead point should be assumed in cases of torsion. In our series, which represents the largest series of torsion in the pediatric literature, all malignancies presented as stage I. These data further support the implementation of operative detorsion and close postoperative ovarian surveillance, with reoperation for persistent masses. Further study is needed to determine if delaying resection by weeks in those cases of persistent masses would result in tumor progression and thus change prognosis.

Cannot exclude torsion--a 15-year review

BACKGROUND

Ovarian torsion remains a challenging diagnosis, often leading to delayed operative intervention and resultant ovarian loss.

METHODS

Charts of patients with ovarian operative cases were retrospectively reviewed at a free-standing children's hospital over 15 years. Torsion was based on intraoperative findings.

RESULTS

Of 328 operative ovarian cases, 97 (29.6%) demonstrated torsion. Mean patient age was 9.2 years (2 days to 17 years, +/-0.54 SEM), with 52% occurring between 9 and 14 years. Of the patients, 97% presented in pain. Presence of a pelvic mass 5 cm or larger on imaging had 83% sensitivity for torsion: an ultrasound reading was only 51% sensitive. Elevated white blood cell count was the only preoperative characteristic associated with prompt operative intervention. Utilization of laparoscopy increased during the latter half of the study (18%-42%, P < .0434). There was a positive trend, although insignificant, in the use of laparoscopy and ovarian salvage. Pathology was overwhelmingly benign (infarction [46%], cysts [33%], and benign neoplasms [19%]).

CONCLUSION

Torsion was responsible for one third of all operative ovarian cases. Sonography is not reliable in diagnosis or exclusion of ovarian torsion. Thus, a strategy of earlier and liberal use of Diagnostic Laparoscopy (DL), particularly with a pelvic mass of approximately 5 cm, may improve ovarian salvage. Because pathology is predominantly benign, the edematous detorsed ovary is safe to salvage.

Emergency management and conservative surgery of ovarian torsion in children: a report of 40 cases

INTRODUCTION

The authors describe and discuss the clinical and therapeutic features of 40 ovarian torsions (OT) in children with its urgent treatment that has advanced in recent years.

MATERIALS AND METHODS

A retrospective study of 40 cases of OT in 38 children under 16 years of age, excluding adnexal torsions in neonates.

RESULTS

Abdominal and/or pelvic pain was the presenting symptom ; 8 of these children had pain between 2 to 9 months prior to surgery and 27/40 (67.5%) had associated vomiting. Before the procedure, ultrasound (US) diagnosed 29 ovarian lesions, related to 14 mature teratomas (MTE) and 10 cystadenomas (CA), one association of MTE and CA in the same ovary, 2 functional cysts and 2 malignant neoplasms. 19/40 torsions could benefit from conservative management. Eleven torsions occurred, 10/11 of these ovaries had an increased volume, and 5/11 had US evidence of small subcortical cysts. Three detorsions with incomplete removal of CA were followed by enlargement of the tumor and re-torsion in 2 of them. Five children had bilateral ovarian pathology which led to unilateral ovariectomy, while the other benefited from conservative treatment.

CONCLUSIONS

In any girl presenting with abdominal pain, the diagnosis of an ovarian torsion must be considered. US is performed emergently, but only surgery, most often a laparoscopic procedure, assures diagnosis. The treatment of the torsion is an emergency and must be as conservative as possible in order to preserve the ovarian function. Bilateral torsions are not unusual.

Protective effects of amlodipine on ischemia-reperfusion injury of rat ovary: biochemical and histopathologic evaluation

OBJECTIVE

To evaluate the effects of amlodipine as an antioxidant and analyze the histopathologic changes in experimental ischemic and ischemic-reperfusion (I/R) injury in rat ovaries.

DESIGN

Experimental study.

SETTING

Experimental surgery laboratory.

ANIMAL(S)

Forty-two rats with experimentally induced ovarian torsion.

INTERVENTION(S)

Group 1: sham operation; group 2: bilateral ovarian ischemia; group 3: 3-hour period of ischemia plus 3 hours of reperfusion; groups 4 and 5: amlodipine administration at 3 and 5 mg/kg respectively before one half hour of ischemia, and then bilateral ovarian ischemia. The ovaries were removed at the third hour of ischemia. Groups 6 and 7: 3-hour period of bilateral ovarian ischemia. Two and a half hours after the induction of ischemia, the rats received amlodipine. At the end of a 3-hour period of ischemia, 3 hours of reperfusion was continued; then the ovaries were removed.

MAIN OUTCOME MEASURE(S)

Ovarian tissue superoxide dismutase and nitric oxide activity; histopathologic examination of all ovarian rat tissue.

RESULT(S)

Ischemia and I/R increased the inducible nitric oxide synthase activity while decreasing the superoxide dismutase activity significantly in comparison with the sham group. Both doses of amlodipine before ischemia and I/R reversed the trend in nitric oxide synthase activities and reversed the trend in the rat's ovary.

CONCLUSION(S)

Conservative treatment with amlodipine is effective in reducing tissue damage induced by ischemia, I/R, or both in ovaries.

Preoperative sonographic and clinical characteristics as predictors of ovarian torsion

OBJECTIVE

The purpose of this study was to determine the most closely associated sonographic and clinical characteristics of ovarian torsion.

METHODS

The medical records and sonographic studies of 39 patients with pathologically proven ovarian torsion diagnosed at our institution from July 1, 2000, through December 31, 2005, were retrospectively reviewed. The volumes of the affected ovaries and ovary/mass complexes were compared with an age-appropriate standard. Statistical significance of the data was assessed by a likelihood ratio chi(2) analysis.

RESULTS

All patients (100%) had a chief symptom of abdominal pain. Thirty-three (85%) reported vomiting; 22 (56%) had leukocytosis; and 7 (18%) had a documented elevated temperature. All affected ovaries and ovary/mass complexes were enlarged. Twenty-one (54%) had arterial flow on Doppler interrogation, and 18 (46%) had no arterial flow. Thirteen (33%) had venous flow, and 26 (67%) had no venous flow. Differences in the arterial and venous flow patterns between the premenarchal and reproductive age groups were not statistically significant.

CONCLUSIONS

Abdominal pain, vomiting, ovarian enlargement, and absence of ovarian venous Doppler flow are the most frequently shown clinical and sonographic indicators of ovarian torsion. However, ovarian enlargement, even in the presence of arterial and venous Doppler flow, is the most commonly associated sonographic finding. Suspicion of ovarian torsion should be high in the setting of clinical symptoms and ovarian enlargement regardless of the presence or absence of an ovarian Doppler signal.

Fluid-debris level in follicular cysts: a pathognomonic sign of ovarian torsion

BACKGROUND

Early diagnosis of ovarian torsion is mandatory to avoid common complications. Sonography is the imaging modality of choice, but diagnosis is still a challenge.

OBJECTIVE

To report an additional sonographic feature of ovarian torsion in order to improve diagnostic accuracy.

MATERIALS AND METHODS

Grey-scale and colour Doppler pelvic sonography was performed in 12 patients with acute onset of intermittent lower abdominal pain and in 1 asymptomatic patient with a palpable mass in the labium majus. Patient ages ranged from 4 months to 17 years.

RESULTS

In all patients an enlarged ovary with peripheral cysts was demonstrated. High-resolution sonography detected fluid-debris levels within these cystic structures in 11 of the 13 patients (sensitivity 85%) and provided an additional diagnostic sign. Six patients had cystic teratoma.

CONCLUSIONS

We confirm the fluid-debris level as a pathognomonic sonographic sign of ovarian torsion with or without associated teratoma.

Partial tubal salvage through neosalpingostomy in a 12-year-old girl with combined ovarian and fallopian tube torsion

The combined torsion of both the ovary and the fallopian tube in the pediatric population has been a rarely encountered pathology. Although detorsion of the twisted adnexa is an option, most torsion cases reported in the pediatric literature have undergone adnexectomy as the primary treatment modality. We believe that, in an attempt to maximize the future reproductive potential, a viable portion of the fallopian tube can be salvaged in selected cases. This is the first reported case where a partially necrotic twisted tube is salvaged through neosalpingostomy after the resection of the necrotic distal portion. In this article, we are presenting a 12-year-old girl with a combined torsion of the right ovary and fallopian tube as well as the surgical management of this rare condition.

Adnexal torsion in pediatric and adolescent girls

PURPOSE OF REVIEW

This review provides timely information to assist in solving the diagnostic dilemma of adnexal or ovarian torsion. Knowledge and awareness of current literature is essential to help clinicians improve diagnostic accuracy and avoid potentially catastrophic consequences, including loss of ovarian tissue and function.

RECENT FINDINGS

This article reviews recent evidence regarding radiologic tools used for efficient, timely diagnosis and management strategies for adnexal torsion, including detorsion. The role of oophoropexy in the pediatric and adolescent population is also reviewed.

SUMMARY

The discussion reinforces the role of detorsion in lieu of oophorectomy or adnextomy in an effort to preserve reproductive capacity in a young population. Long-term follow-up, including reproductive outcomes, is needed to determine the role of oophoropexy.

Sequential bilateral torsion of normal ovaries in a prepubertal child

We report a case of bilateral ovarian torsion in a prepubertal girl with normal ovaries that occurred at an interval of 1 year. The diagnosis was made on gray-scale and color Doppler sonography, and ovarian salvage was performed. The role of preventive contralateral ovarian pexy in cases of ovarian torsion is emphasized.

Laparoscopic surgery in 12 cases of adnexal disease occurring in girls aged 15 years or younger

STUDY OBJECTIVE

To evaluate the treatment by laparoscopic surgery of adnexal disease occurring in young girls.

DESIGN

Retrospective analysis (Canadian Task Force classification II-1).

SETTING

Department of gynecology at a general hospital.

PATIENTS

Twelve consecutive girls aged 15 years or younger.

INTERVENTIONS

Laparoscopic surgery.

MEASUREMENTS AND MAIN RESULTS

Seven patients had dermoid cysts, and three of these were associated with adnexal torsion. Two patients had ruptured lutein cysts with ovarian bleeding, and one of them was pregnant. Torsion of the tube with paraovarian cyst, torsion of normal ovary, and serous cystadenoma were noted in one patient each. Although the underlying diseases varied, the chief symptom in each of these patients was lower abdominal pain. Because the symptom is nonspecific, the clinical features were confusing, especially in emergency cases; in two patients with adnexal torsion with dermoid cysts and one patient with adnexal torsion of a normal ovary, there was substantial delay in diagnosis, and salpingo-oophorectomy was required as a result.

CONCLUSION

Even in young girls, laparoscopic surgery can be performed in an acceptable manner using regular instruments designed for adults.

Paratubal cyst complicated by tubo-ovarian torsion: Computed tomography features

Paratubal cysts complicated by tubo-ovarian torsion are an uncommon cause of acute right iliac fossa pain in children and very rarely diagnosed accurately preoperatively. We report a constellation of diagnostic CT features in a 12-year-old pubertal girl.

The protective effect of caffeic acid phenethyl ester on ischemia-reperfusion injury in rat ovary

OBJECTIVE

This experimental study was designed to determine the changes in tissue levels of malondialdehyde, end-product of lipid peroxidation (MDA), reduced glutathione (GSH) and xanthine oxidase (XO) and the effect of caffeic acid (3,4-dihydroxycinnamic acid) phenethyl ester (CAPE) on these metabolite levels after adnexal torsion-detorsion model in rats.

METHOD

Forty adult female albino rats were divided into five groups: basal control (n = 8), sham operation (n = 8), torsion-detorsion plus saline (n = 8), torsion-detorsion plus CAPE (n = 8). and only torsion (n = 8). Rats in the sham operation group underwent a surgical procedure similar to the other groups but the adnexa was not torsioned. Rats in the torsion group were killed after 360 degrees clockwise adnexal torsion for 3 h and ovaries were harvested. CAPE was injected intraperitoneally 30 min before detorsion in the CAPE/detorsion group and saline was administered in the saline/detorsion group. After 3 h of adnexal detorsion, the rats in both groups were killed and adnexa were surgically removed.

RESULTS

MDA levels and XO activities in torsion-detorsion plus saline group increased significantly when compared to basal control, torsion and sham operation groups (P < 0.001). In the CAPE group, MDA levels and XO activities were lower than those of torsion-detorsion plus saline group, and differences between the two groups were statistically significant (P < 0.001). GSH levels in torsion-detorsion plus saline group were decreased significantly when compared to basal control and sham operation groups (P < 0.001). GSH levels in the CAPE group were higher than those of torsion-detorsion plus saline group, and differences between the two groups were statistically significant (P < 0.004). Morphologically, polymorphonuclear leukocytic infiltration and vascular dilatation were obvious in the ischemia-reperfusion damaged ovary, a change partially reversed by CAPE.

CONCLUSIONS

These results suggest that administration of CAPE has beneficial effects in the prevention of ischemia-reperfusion injury of the ovaries.

Adnexal torsion in very young girls: diagnostic pitfalls

OBJECTIVE

Evaluation of cases of young girls diagnosed with adnexal torsion.

STUDY DESIGN

Retrospective cohort study of 39 girls born between January 1980 and January 2000 who presented with acute abdominal pain and/or the diagnosis adnexal torsion in the Groene Hart Hospital. Seven patients, aged 6-13 years, with adnexal torsion were further evaluated.

RESULTS

In three patients, it was possible to save the adnexa. Only the time relapse between the onset of complaints and the surgical intervention correlated with the presence of microscopic necrosis in the ovary. Bluish-black appearance of an ovary did not correlate with the presence of microscopic necrosis.

CONCLUSIONS

Early recognition and treatment are essential to minimise the risk of decreased fertility after adnexal torsion in young girls. We therefore advocate prompt diagnostic laparoscopy and detorsion of the adnexa. In case a cyst is present, it should not be resected, but checked on a regular basis using ultrasound.

Ovarian torsion: CT findings in a child

The computed tomography (CT) findings of ovarian torsion in a 10-year-old girl are presented. The CT scan was the first cross-sectional imaging examination performed in this patient, who presented with suspected acute appendicitis. Analogous to the sonographic diagnosis of ovarian torsion, the imaging findings may be pathognomonic on CT and should be prospectively recognized for prompt diagnosis.

[Emergency ultrasound diagnosis of ovarian torsion in children : nine case reports]

OBJECTIVE

To report the ultrasonographic aspects of ovarian torsion in nine pediatric cases.

PATIENTS AND METHODS

The age range was from 16 months to 14 years. The patients presented with a variety of symptoms, including pain in the site of torsion. Ultrasonography was performed in all patients, and color Doppler studies in four.

RESULTS

Ultrasonography showed a cystic mass in six patients, a solid mass with peripheral cysts in two patients and an adnexal cyst in one patient. Color Doppler revealed absence of flow in three patients. The patients were treated by coeliosurgery.

CONCLUSION

Ovarian torsion is a serious gynecologic emergency. Torsion is rare during childhood and has a non-specific clinical presentation. Ultrasound and Doppler are the imaging study of choice. The ovarian salvage was attributable to the combination of delay in patient presentation and surgical delay.

Third place winner. Three-year-old female with intermittent ovarian torsion

We report an atypical case of ovarian torsion, an uncommon cause of abdominal pain in a very young girl. She presented with intermittent episodes of groin and thigh pain over a 10-week period. The child had minimal objective findings at the time of each evaluation. Despite the delay in diagnosis, the ovary was preserved. Despite its rarity, ovarian torsion must be considered in the differential diagnosis of abdominal pain in young girls.

Sudden death in an infant resulting from torsion of the uterine adnexa

A 2-month-old infant girl died suddenly as a result of torsion of the uterine adnexa. The infant was found unresponsive in bed and was pronounced dead shortly after her arrival at a hospital. There were no antecedent signs of illness. At autopsy, the right ovary and right fallopian tube were twisted and were dark purple, swollen, and necrotic. The right ovary was enlarged by a follicle cyst 4 cm in diameter, which likely precipitated the torsion. The mechanism of death was unclear but may have resulted from the release of cytokines produced in response to necrotic adnexal tissue. Fatal uterine adnexal torsion has been reported rarely in infants; in all those cases there were antecedent symptoms. Torsion of the uterine adnexa should be included in the differential diagnosis of sudden death in infancy.

Torsion of a normal ovary in a post-pubertal female: unenhanced helical CT appearance

This case report presents the CT features of torsion of normal adnexa in an adult woman. Unenhanced helical CT, initially performed for clinically suspected acute ureterolithiasis, established the diagnosis.

Acute ovarian torsion in children

BACKGROUND

Acute ovarian torsion (OT) is an uncommon cause of abdominal pain in children and is frequently confused with other conditions.

METHODS

We reviewed the records (1983 to 1999) of all children treated for acute OT at our children's hospital.

RESULTS

Mean child age (n = 51) was 12.5 +/- 0.3 years. Children presented with either right-sided (n = 29) or left-sided (n = 22) pain. Diagnosis of OT was confirmed preoperatively by ultrasound (73%) or computed tomography (CT) scan (10%) while nine children (17%) with right-sided pain underwent surgery for presumed appendicitis. Despite a relatively short time from diagnosis to surgery, all 51 children required salpingooophorectomy. Contralateral biopsy was performed in 29% and 57% had an appendectomy. Younger children more commonly had either a mature cystic teratoma or torsion with no underlying abnormality as an etiology compared with OT in older children that was more likely to result from either a follicular or corpus luteal cyst. Pathologic examination of the contralateral ovary and appendix was normal in all children who underwent biopsy and appendectomy.

CONCLUSION

Ultrasonography with color doppler is helpful for differentiating acute OT from appendicitis. Although the twisted ovary can rarely be salvaged, the etiology is usually benign. Preoperative serum markers and contralateral ovary biopsy may be unnecessary.

The use of laparoscopy in the management of adnexal pathologies in children

BACKGROUND

The authors' experience of using laparoscopy in the management of 23 girls (mean age: 8.9 years; range: 3 months-15 years) with various adnexal pathologies over a 3-year period is reviewed.

METHODS

Of the 23 patients, seven were evaluated for congenital gonadal pathologies, 15 presented with abdominal pain and one patient had an antenatally diagnosed adnexal mass. Detailed laparoscopic examination of the pelvic cavity and laparoscopic gonadectomy were successfully performed in all seven patients with congenital gonadal pathologies: mosaic Turner's syndrome (n = 2), gonadal dysgenesis (n = 3) and testicular feminization syndrome (n = 2). Of 15 patients presenting with abdominal pain, 11 had an adnexal mass, two had acute appendicitis and two had pelvic inflammatory disease.

RESULTS

Laparoscopic excision of the adnexal masses were successfully performed in 10 of 11 patients. Conversion to open surgery was required in one patient with a huge teratoma. Laparoscopic appendicectomy was successfully performed in both patients with acute appendicitis while diagnostic laparoscopy was the only procedure required in the two patients with pelvic inflammatory disease. Laparoscopy in the infant with an antenatally diagnosed adnexal mass confirmed this to be an omental cyst, which was successfully excised. All patients recovered without complications and good cosmetic result was universally achieved.

CONCLUSION

Laparoscopy is safe and effective in both diagnosis and treatment of adnexal pathologies in children.

Sonography of the neonatal genitourinary tract

Ultrasound has become the modality of choice for the evaluation of the neonatal genitourinary tract. High frequency linear, vector, and curved array transducers (7 MHz, 5 MHz, 12 MHz) and portability of the equipment make a rapid bedside evaluation with exquisite anatomic detail possible. A major advantage of sonography over other modalities is real time observation and circumvention of sedation.