Pediatric Adnexal Torsion: Not Just a Postmenarchal Problem

Key clinical predictors in the diagnosis of ovarian torsion in children

OBJECTIVE

Ovarian torsion (OT) represents a severe gynecological emergency in female pediatric patients, necessitating immediate surgical intervention to prevent ovarian ischemia and preserve fertility. Prompt diagnosis is, therefore, paramount. This retrospective study set out to assess the utility of combined clinical, ultrasound, and laboratory features in diagnosing OT.

METHODS

The authors included 326 female pediatric patients aged under 14 years who underwent surgical confirmation of OT over a five-year period. Logistic regression analysis was employed to pinpoint factors linked with OT, and the authors compared clinical presentation, laboratory results, and ultrasound characteristics between patients with OT (OT group) and without OT (N-OT group). The authors conducted receiver operating characteristic (ROC) curve analysis to gauge the predictive capacity of the combined features.

RESULTS

Among 326, OT was confirmed in 24.23 % (79 cases) of the patients. The OT group had a higher incidence of prenatal ovarian masses than the N-OT (22 cases versus 7 cases) (p < 0.0001). Similarly, the authors observed significant differences in the presence of lower abdominal pain, suspected torsion on transabdominal ultrasound, and a high neutrophil-lymphocyte ratio (NLR > 3) between the OT and non-OT groups (p ˂ 0.05). Furthermore, when these parameters were combined, the resulting area under the curve (AUC) was 0.868, demonstrating their potential utility in OT diagnosis.

CONCLUSION

This study demonstrates a prediction model integrating clinical, laboratory, and ultrasound findings that can support the preoperative diagnosis of ovarian torsion, thereby enhancing diagnostic precision and improving patient management. Future prospective studies should concentrate on developing clinical predictive models for OT in pediatric patients.

Ovarian Torsion and Its Remediation in a Three-Year-Old Girl

Ovarian torsion is a rare, emergent occurrence seen in the premenarchal population. If detected promptly, ovarian torsion can be treated via detorsion. We present a case of a three-year-old girl whose ovary spontaneously torsed and was corrected via ovarian detorsion. The patient presented with sudden-onset abdominal pain and emesis; a transabdominal ultrasound with Doppler was performed, which led to the diagnosis of ovarian torsion. The patient was directly taken into surgery for correction, after which she quickly recovered and was subsequently discharged. The choice of ovarian detorsion to protect fertility in pediatric patients is supported by this case and by the related literature. The key to safeguarding fertility in these patients lies in rapid detection, which remains a challenge in the pediatric population. By raising widespread awareness of the use of Doppler ultrasound as well as symptom presentation, the protection of fertility in cases of pediatric ovarian torsion can be improved.

Ovarian torsion in the pediatric population: predictive factors for ovarian-sparing surgery-an international retrospective multicenter study and a systematic review

STUDY OBJECTIVE

Ovarian torsion (OT) in pediatric age is a challenging condition to diagnose and treat. To date, there is still no clear consensus about its management. Our aim was to assess some possible associated factors that can help surgeons in decision-making.

DESIGN

We conducted a retrospective multicentric study of pediatric OT surgically treated between 2010 and 2020 in six Italian and German institutions, comparing our findings with a literature review of the last 10 years (2010-2020).

PARTICIPANTS

Patients aged 0-18 years with a diagnosis of OT intraoperatively confirmed and surgically treated at the involved institutions.

RESULTS

Ninety-seven patients with a mean age at diagnosis of 8.37 years were enrolled in the study. Severe abdominal pain was present in 82 patients (84.5%). Eighty children (82.5%) presented an enlarged ovary with an US diameter > 5 cm and only 32 (40%) of them underwent conservative surgery. A laparoscopic approach was performed in 60 cases (61.9%) although in 15 (15.5%) conversion to open surgery was deemed necessary. A functional cyst was present in 49 patients (50.5%) while 11 children (11.3%) suffered from OT on a normal ovary.

CONCLUSIONS

Our results showed that a post-menarchal age (p = .001), a pre-operative US ovarian size < 5 cm, (p = .001), the presence of severe abdominal pain (p = .002), a laparoscopic approach (p < .001), and the presence of a functional cyst (p = .002) were significantly associated with conservative surgery.

Characteristics and Risk Factors for Ischemic Ovary Torsion in Children

Identifying ischemic ovary as a complication of ovary torsion (OT) is a significant challenge in children. This study identified risk factors for ischemic OT among pediatric OT patients to prevent delayed treatment. This retrospective study included pediatric inpatients who underwent operation for OT over 20 years. We employed multivariable logistic regression to find the risk factors associated with ischemic OT. Among the 118 patients included in this study, 78 (66.1%) had ischemic OT. Patients with ischemic OT tended to be younger; had more frequent vomiting; and had elevated White blood cell (WBC), C-Reactive protein (CRP), and segments in comparison with non-ischemic OT patients. Multivariable regression showed increased odds of ischemic ovary torsion, associated with higher WBC (12.3 × 10³/mm³ vs. 8.7 × 10³/mm³, p < 0.001), CRP (50.4 mg/L vs. 8.4 mg/L, p < 0.001), and vomiting (55.1% vs. 25%, p = 0.002) than in non-ischemic patients. A receiver-operating characteristic (ROC) analysis indicated that patients with vomiting, leukocytosis, or CRP ≧ 40 mg/L were more likely to have ischemic OT (sensitivity, 92%; specificity, 54%; PPV, 79.6; NPV, 78.9%). Ischemic OT is common among pediatric OT patients. The presence of potential risk factors of vomiting, leukocytosis, and CRP more significant than 40 mg/L may assist clinicians in ensuring an expedited surgical treatment.

Multimodality imaging review for suspected ovarian torsion cases in children

OBJECTIVES

Ovarian torsion (OT), although rare, can be described as a complete or partial twist of the ovary with impairment of blood flow. Although occurring at any age, it is more common in children and during pregnancy. Presenting symptoms are non-specific but include either persistent or intermittent acute abdominal pain, making early diagnosis difficult. Delayed diagnosis is associated with an increased need for oophorectomy. The aim of this literature review is to establish the safest and most efficacious imaging strategy for OT by comparing and contrasting evidence for current imaging modalities found in the literature.

KEY FINDINGS

Characteristically, OT can be identified through a combination of findings some of which includes an enlarged ovary, multiple follicles at the periphery and a "whirlpool" sign. Currently, ultrasound is the preferred primary imaging modality; although computed tomography (CT) and magnetic resonance imaging (MRI) may also be used when findings are equivocal; with MRI being the safer option.

CONCLUSION

Ultimately, while it is true that ovarian torsion is not a common cause of acute abdominal pain in children, it should always be considered in the differential diagnosis. Prior to selecting an imaging modality; the clinical presentation, age group, possible radiation dose and availability of the modality needs to be considered to ensure the appropriate imaging strategy.

IMPLICATIONS FOR PRACTICE

With new tools such as scoring systems, B-flow imaging (BFI), diffusion-weighted imaging (DWI) and susceptibility-weighted imaging (SWI) currently being explored for possible use in the future, early diagnosis of OT may be attainable. Thus, reducing the likelihood of adverse complications and consequently the need for oophorectomy.

Imaging in pediatric ovarian tumors

The spectrum of ovarian tumors in the pediatric population differs significantly from that in adults. Germ cell tumors are the predominant class of ovarian tumors in children, whereas epithelial tumors are the most common in adults. Ultrasonography is the modality of choice for the initial evaluation of pediatric ovarian tumors. Determining the diagnosis based on imaging may prove difficult, and combining the imaging findings with the clinical scenario is very helpful in reaching a differential diagnosis during clinical practice. We will discuss the spectrum of ovarian neoplasms in the pediatric population and describe their clinical, pathologic, and imaging characteristics. A few unique entities related to ovarian tumors, such as growing teratoma syndrome, anti-N-methyl-D-aspartate receptor encephalitis, and hereditary ovarian tumor syndromes, are also discussed. In addition, we will review several entities that may mimic ovarian neoplasms as well as their distinct imaging features.

Adnexal Torsion in Pediatric Age: Does Bolli's Score Work? Report of Two Cases

Adnexal torsion is a surgical emergency requiring early diagnosis in order to avoid demolitive surgery. Adnexal torsion's diagnosis could be very difficult in pediatric patients because children cannot explain symptoms accurately. Furthermore reproductive organs lie high in abdomen, causing unclear examinations findings. For reducing diagnostic mistakes or delay clinical and hematological criteria could be useful. No radiological criteria (CT or MRI) should be taken in count because of the costs and the required time. By combining clinical presentation in patients with OT three useful diagnostic variables have been identified: age, duration of pain, vomiting. Presence of vomiting, short duration of abdominal pain and high CRP levels have great predictive value for the diagnosis of adnexal torsion. In those patients an exploratory laparoscopy should be performed without any doubt and/or delay. These data may aid physicians in the evaluation of abdominal pain in premenarchal girls.

Analysis of the risk of ovarian torsion in 49 consecutive pediatric patients treated at a single institution

Purpose

An early diagnosis of ovarian torsion is sometimes difficult due to variable clinical symptoms and non-specific imaging findings. We retrospectively reviewed patients with pediatric ovarian masses manifesting torsion.

Methods

Fifty-eight ovarian masses (55 episodes) in 49 non-neonatal patients treated from April 1984 to March 2017 were retrospectively analyzed. The Mann-Whitney U test and Fisher’s exact test were used for the statistical analysis.

Results

The median age of these 55 episodes was 10.5 years old (range 1.0–23.0). Thirty-three patients presented with abdominal pain. Forty-five tumors and 13 cystic masses were resected and diagnosed pathologically (50 benign and 8 malignant). Torsion was identified in 15 cases (25.9%) at operation. The torsion masses were all benign, and 8 ovaries (53.3%) were successfully preserved. Comparing the torsion cases with the non-torsion cases, only the white cell count was significantly higher in the torsion cases (p=0.0133) and in the patients presented with abdominal pain (p=0.0068). The duration of abdominal pain was significantly shorter in ovary preserved cases than in oophorectomy cases.

Conclusion

The white blood cell may be a helpful indicator of the presence of torsion as well as the need for surgery.

Ovarian Torsion in Premenarchal Girls

STUDY OBJECTIVE

To investigate characteristics that differentiate premenarchal girls with ovarian torsion (OT) from those without OT at the time of surgery.

DESIGN

Retrospective chart review of 36 premenarchal girls who underwent 42 surgeries for either OT (n = 33) or a nontorsed ovarian mass (n = 9) from 2006 to 2017.

SETTING

Large, tertiary care academic institution.

PARTICIPANTS

We included patients aged 0-12 years with International Classification of Diseases, Ninth Revision codes for torsion of the ovary, adnexa, ovarian pedicle, or fallopian tube. Controls had International Classification of Diseases, Ninth Revision codes for ovarian mass or cyst, who also underwent surgery and did not have OT.

INTERVENTIONS

Records were reviewed for patient characteristics including laboratory and imaging studies, surgical intervention, and pathologic diagnosis. Fischer exact test and the nonparametric Mann-Whitney U test were used for statistical analysis.

MAIN OUTCOME MEASURES

Characteristics predictive of OT in premenarchal girls.

RESULTS

Twenty-nine premenarchal patients were diagnosed with 33 episodes of OT. Nine patients underwent surgery for ovarian masses but did not have OT. All patients with OT reported abdominal pain (compared with 55.6% without OT; P < .001) and most had nausea and/or emesis (81.8% vs 33.3%; P < .009). Ultrasound findings of ovarian enlargement and decreased Doppler flow were significant in the OT group (P < .083, P < .009). There were 2 cases of malignancy in each group.

CONCLUSION

Patients with OT had significantly more nausea, emesis, and abdominal pain compared with those without OT. Additionally, 2 of 4 malignancies were found in patients with OT, indicating that malignancy should still be considered with large, complex masses.

Isolated tubal torsion: A rare cause of acute abdomen in childhood

Isolated fallopian tube torsion is a rare cause of acute abdomen mostly seen in women of reproductive age. It is often diagnosed during surgery. In this study we aimed to present a case of isolated fallopian tube torsion in a child. An 11-year-old girl presented with abdominal pain. With the help of radiological evaluation we diagnosed. It should be kept in mind that even if ovarian blood flow is normal in girls with abdominal pain, it may be an isolated tubular torsion and requires immediate intervention.

Isolated tubal torsion: Successful preoperative diagnosis of five cases using ultrasound and management with laparoscopy

Our aim was to evaluate the presentation and diagnostic evaluation of patients with isolated tubal torsion and to evaluate the surgical approach to these patients. We also aimed to define the ultrasonographic diagnostic criteria. Five patients with isolated tubal torsion who were admitted to our gynecology department between January 2014 and January 2017 were evaluated and included in this study. All cases were diagnosed through ultrasonographic imaging alone. The preoperative findings of the patients were similar to those described in the literature. No further imaging modality was used for diagnosis and all patients were managed with laparoscopy. The clinical findings and ultrasonographic findings were consistent with literature. It may be difficult to preoperatively diagnose isolated tubal torsion, which is a rare clinical entity. Evaluation of these patients by an experienced sonographer and knowledge of the ultrasonographic findings of isolated tubal torsion may have vital preventive measures.