Diagnosis of Ovarian Torsion: Is It Time to Forget About Doppler?

Ovarian torsion: A retrospective case series at a tertiary care center emergency department

Ovarian torsion (OT) is a gynecological emergency that can have diverse clinical presentations makings its diagnosis especially challenging. Few studies exist in the literature describing the clinical presentation as well as the management of OT in the emergency department (ED). This study aims to describe the clinical presentation, physical examination, emergency management, radiographic and intraoperative findings, histopathology reports and the time-to-intervention metrics of OT cases presenting to the emergency room of our tertiary care center. Data was collected by a retrospective chart review of all OT cases that presented to our ED over a period of 1 year. A total of 20 cases were included in the final analysis. The incidence of OT in the ED was 157.4 per 100 000 visits of women in the reproductive age group. All patients were women of reproductive age, with a mean age of 27.3 years. A total of 15 patients (78.9%) presented within 24 hours of symptom onset. The most common presenting symptom was abdominal pain (95%, 19/20) with most localizing to the right lower quadrant (60%, 12/20), followed by nausea and vomiting (90%, 18/20). Almost all patients (95%, 19/20) required opioids for pain management. The majority (80%, 16/20) were diagnosed by ultrasound prior to surgery, whereas (20%, 4/20) went straight to surgery based on a high index of clinical suspicion. Among those who underwent ultrasound, ovarian cyst was present in (75%, 12/16) while (68.9%, 11/16) showed ovarian enlargement and (50%, 8/16) showed abnormal ovarian blood flow. All patients except one patient underwent operative management. Out of the 19 patients who underwent surgery, the majority of patients (94.7%, 18/19) had viable ovaries with the exception of 1 patient (5.3%) who required a salpingo-oophorectomy post ovarian detorsion. A total of 13 cases included histopathologic review of specimens out of which 6 (46.2%) had a mature cystic teratoma. The mean time from door to ultrasonography was 1.4 hours and from door to surgery was 11.4 hours. Our study provides valuable insights into the incidence, clinical presentation, physical examination, emergency management, ultrasonographic and intraoperative findings, histopathology reports as well as the time-to-intervention metrics of OT patients presenting to the ED.

Rapid, free-breathing non-contrast MRI for first-line imaging evaluation of ovarian torsion in the emergency department

BACKGROUND

Transabdominal ultrasound (US) is first-line imaging to evaluate ovaries in girls presenting to the emergency department (ED) with suspected ovarian torsion. Ovaries may be difficult to visualize sonographically; therefore, prompt diagnosis using US alone can be challenging. Rapid MRI as first-line imaging may help streamline patient throughput, especially with increasing MRI availability in the ED.

OBJECTIVE

To assess feasibility of rapid MRI for diagnosis of ovarian torsion.

MATERIALS AND METHODS

A retrospective, single-center IRB approved study of MRI performed in female pediatric patients presenting with abdominopelvic pain from August 2022 to January 2023. Imaging occurred according to one of three clinical pathways (US-first approach vs MRI-first approach vs US + MRI-second-line approach). A rapid three-sequence free-breathing MRI protocol was utilized. Frequency of ovarian torsion and secondary diagnoses was recorded. Length of MR scan time, time from ED arrival to time of diagnosis, and whether patient had US prior to MR exam were obtained. A historical cohort of patients with US only performed for assessment of ovarian torsion were evaluated for length of the US examination and time from ED arrival to time of diagnosis. Intervals were compared using the uncorrected Fisher's least significant difference and Turkey's multiple comparison tests.

RESULTS

A total of 140 MRI exams (mean age 14.6 years) and 248 historical US exams (mean age 13.5 years) were included. Of the patients with MRI, 41 (29%) patients were imaged with US + MRI and 99 (71%) imaged with MRI only; 4% (6/140) MR exams were suspicious for ovarian torsion, with one true positive case (1/6 TP) and 5 false positive cases (5/6 FP); 26.4% (37/140) of exams had secondary diagnoses. Median MRI scan time was 11.4 min (4.4) vs median historical US scan time was 24.1 min (19.7) (P<0.001). Median time from arrival in ED to MRI read was 242 (140). Median time from arrival in ED to US only read was 268 min (148). This was not a statistically significant difference when compared to the MRI only cohort.

CONCLUSION

First-line MRI imaging for evaluation of ovarian torsion is a rapid and feasible imaging modality for female patients in the emergent setting.

Imaging of Acute Abdominopelvic Pain in Pregnancy and Puerperium-Part II: Non-Obstetric Complications

Emergency imaging in pregnancy and puerperium poses unique challenges both for clinicians and radiologists, requiring timely and accurate diagnosis. Delay in treatment may result in poor outcomes for both the patient and the foetus. Pregnant and puerperal patients may present in the emergency setting with acute abdominopelvic pain for various complications that can be broadly classified into obstetric and non-obstetric related diseases. Ultrasonography (US) is the primary diagnostic imaging test; however, it may be limited due to the patient's body habitus and the overlapping of bowel loops. Computed tomography (CT) carries exposure to ionising radiation to the foetus, but may be necessary in selected cases. Magnetic resonance imaging (MRI) is a valuable complement to US in the determination of the etiology of acute abdominal pain and can be used in most settings, allowing for the identification of a broad spectrum of pathologies with a limited protocol of sequences. In this second section, we review the common non-obstetric causes for acute abdominopelvic pain in pregnancy and post partum, offering a practical approach for diagnosis and pointing out the role of imaging methods (US, MRI, CT) with the respective imaging findings.

Can Natural Language Processing Improve Adnexal Torsion Predictions?

STUDY OBJECTIVE

To create a decision support tool based on machine learning algorithms and natural language processing (NLP) technology, to augment clinicians' ability to predict cases of suspected adnexal torsion.

DESIGN

Retrospective cohort study SETTING: Gynecology department, university-affiliated teaching medical center, 2014-2022.

PATIENTS

This study assessed risk-factors for adnexal torsion among women managed surgically for suspected adnexal torsion based on clinical and sonographic data.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The dataset included demographic, clinical, sonographic, and surgical information obtained from electronic medical records. NLP was used to extract insights from unstructured free text and unlock them for automated reasoning. The machine learning model was a CatBoost classifier that utilizes gradient boosting on decision trees. The study cohort included 433 women who met inclusion criteria and underwent laparoscopy. Among them, 320 (74%) had adnexal torsion diagnosed during laparoscopy, and 113 (26%) did not. The model developed improved prediction of adnexal torsion to 84%, with a recall of 95%. The model ranked several parameters as important for prediction. Age, difference in size between ovaries, and the size of each ovary were the most significant. The precision for the "no torsion" class was 77%, with a recall of 45%.

CONCLUSIONS

Using machine learning algorithms and NLP technology as a decision-support tool for the diagnosis of adnexal torsion is feasible. It improved true prediction of adnexal torsion to 84% and decreased cases of unnecessary laparoscopy.

Sonographic Predictors of Ovarian Torsion in Premenarchal Girls

STUDY OBJECTIVE

To identify preoperative transabdominal sonographic predictors of surgically-confirmed ovarian torsion (OT) in premenarchal girls.

METHODS

Retrospective case-control study of 32 premenarchal girls aged 0-12 undergoing surgery for OT (cases) or a non-torsed ovarian mass (controls) from 2006-2017 at a single academic center. Cases had ICD-9/10 codes for torsion of the ovary, adnexa, ovarian pedicle, or fallopian tube and surgically-confirmed OT; controls had codes for ovarian mass or cyst and surgically-confirmed absence of OT. Preoperative transabdominal ultrasounds were analyzed by three radiologists blinded to final diagnosis. Chi-square, Fisher's exact, and Student's t-test were used for statistical comparisons.

RESULTS

From 2016-2017, 32 patients presented with acute abdominal pain or symptoms concerning for ovarian mass requiring ultrasound imaging and subsequent diagnostic laparoscopy-24 (75.0%) had confirmed OT by laparoscopy; eight (25.0%) did not. Mean age in both groups was similar (7.3±2.9 years). Preoperative sonographic variables significantly associated with OT included presence of a simple cyst (20.8% vs 12.5%), ovarian heterogeneity (100% vs 12.5%), presence of peripheralized follicles (70.8% vs 0%), and asymmetry of color Doppler (75.0% vs 37.5%)-all p<0.05. Presence of free fluid, arterial color Doppler, and a whirlpool sign were not predictive of OT.

CONCLUSION

In premenarchal patients, while certain variables on transabdominal sonography predicted surgically-confirmed OT, only the presence of peripheralized follicles was unique to girls with OT. The decision to proceed with diagnostic laparoscopy for suspected OT can be aided by these specific sonographic findings but should ultimately be based on high clinical suspicion.

Adnexal torsion in pregnancy: A systematic review of case reports and case series

OBJECTIVES

This study aimed to investigate clinical presentations, surgical procedures and findings, complications, and predisposing factors of adnexal torsion in pregnant women.

METHODS

We searched PubMed/Medline, Embase, and Web of Science from January 2000 to March 2022. All case reports and case series with full-text English language reporting adnexal torsion in pregnant women were included. Medical history, clinical presentations, surgical procedures and findings, complications related to adnexal torsion, and predisposing factors were independently extracted by two investigators.

RESULTS

A total of 182 articles reporting 662 pregnant women with adnexal torsion were included. Most of the adnexal torsions occurred during the first trimester (54.63%), while others occurred during the second (26.36%) and third (19.00%) trimesters. The most common symptom of adnexal torsion was sudden-onset pain (80.60%). Enlargement of the adnexa was the most prevalent ultrasound finding in a twisted adnexa (95.20%). Additionally, about half of the patients had decreased blood flow in Doppler ultrasound (53.80%). Laparoscopic surgery was the favorite option (56.88%), while cystectomy and detorsion were the most commonly performed procedure (29.06%). Expectant management was reported in only 2.99% of the patients. In addition, the most common complications were preterm labor (27.58%) and emergent cesarean sections (25.28%).

CONCLUSIONS

Clinicians should think of adnexal torsion when pregnant women complain of sudden-onset pain. Then, using ultrasound, adnexal enlargement or masses should be explored seriously. They should take invasive and urgent therapy to preserve ovaries and prevent complications.

Added value of gadolinium-based contrast agents for magnetic resonance evaluation of adnexal torsion in girls

PURPOSE

Ultrasound is the first-line imaging modality to evaluate adnexa in girls with clinical suspicion of torsion. Patients with equivocal ultrasound findings can undergo MRI for better delineation of adnexal pathology. Here, we assess the utility of intravenous contrast in MRI evaluation of adnexal torsion in children.

METHODS

Two pediatric radiologists (R1, R2) retrospectively reviewed 198 pelvic MRI exams in 172 girls (median age 15 years). Each MRI was reviewed twice. The first review included pre-contrast images only. A second review, at least 1 month later, included both pre- and post-contrast images. Readers concluded if findings were suspicious for torsion or not. Readers' findings were compared to each other's and to surgical and MRI reports and clinical course.

RESULTS

198 MRI exams yielded 354 evaluable ovaries. Surgical and pathological reports were available for 47 patients. 11 patients had adnexal torsion. Both readers accurately diagnosed acutely torsed ovaries during pre- and post-contrast reviews (n = 4). However, readers disagreed on torsed paraovarian cysts (n = 4) and chronically/intermittently torsed ovaries (n = 3). In 21 non-torsed ovaries that had lesions, one or both readers concluded that there were pre-contrast features of torsion. In this set with ovarian lesions, contrast helped readers to correctly conclude no torsion (R1 = 8, R2 = 6) more commonly than to incorrectly conclude torsion (1 each), improving post-contrast specificity for each reader.

CONCLUSIONS

Post-contrast sequences did not provide additional benefit in evaluating acutely torsed ovaries but helped in excluding torsion in patients with adnexal lesions. Therefore, contrast administration should be individualized, potentially reserved only for those with abnormal ultrasound or pre-contrast images.

Twisting Ovaries: Three Cases of Ovarian Torsion

Ovarian torsion is a medical emergency that should be considered for every female presenting with abdominal pain. This series consists of three cases of females of varying ages presenting with abdominal pain who were all ultimately diagnosed with ovarian torsion. It highlights the variability in presentation, physical examination, and other factors related to the diagnosis.

Clinical and ultrasound features of dermoid-associated adnexal torsion

PURPOSE

To determine the clinical and ultrasound features of dermoid-associated adnexal torsion.

METHODS

Forty-four patients with at least one dermoid and ultrasound ≤ 30 days of surgery were retrospectively reviewed by three radiologists. Ultrasound and clinical findings were compared to intra-operative findings using Fisher's exact test or Mann-Whitney test with p < 0.05 to determine statistical significance.Please check and confirm that the authors and their respective affiliations have been correctly identified and amend if necessary.Correct. No edit RESULTS: Twenty patients had torsion, while 24 patients did not. Patients with dermoid-associated torsion were more likely to present to emergency department (ED) (100% vs 13%; p < 0.001) and have acute unilateral pelvic pain (100% vs 42%; p < 0.001). On ultrasound, patients with torsion had larger dermoids (median largest dimension 9.0 cm (IQR 7.7-11.1) vs 6.0 cm (IQR 4.4-7.5); p < 0.001), displaced dermoid anterior or superior to the uterus (59% vs 21%; p = 0.016), and ipsilateral adnexal fluid (41% vs 4%; p = 0.003). Displaced dermoid and ipsilateral adnexal fluid had substantial (kappa = 0.72) and moderate inter-rater agreement (kappa = 0.49), respectively. The combination of ED presentation and each statistically significant ultrasound feature (dermoid size ≥ 5.0 cm, displaced dermoid, and ipsilateral adnexal fluid) yielded high specificity and positive predictive value (ranging from 93-100% to 92-100%, respectively). The combination of ED presentation and dermoid size ≥ 5.0 cm yielded the highest sensitivity, negative predicative value, and accuracy (100%, 100%, and 96%, respectively).Please check and confirm whether the edit made to the article title is in order.Looks great. No edits. Thank you!

CONCLUSION

Although the diagnosis of adnexal torsion in the presence of an ovarian dermoid is traditionally challenging, the combination of ED presentation and ultrasound features increase diagnostic confidence of dermoid-associated adnexal torsion.

Diagnosis and Management of Pediatric Ovarian Torsion in the Emergency Department: Current Insights

Ovarian torsion is defined as twisting of the ovary around an axis consisting of its vascular pedicle, the infundibulopelvic ligament and the tubo-ovarian ligament, and can occur in females of any age. Torsion can be a result of ovarian mass causing asymmetry and subsequent torsion, or can be spontaneous. While ovarian torsion is a surgical emergency, early diagnosis and treatment can preserve ovarian viability even if necrosis is seen operatively. Presentation classically involves sudden onset severe abdominal pain and vomiting but diagnostic delay can follow subtler presentations. Diagnosis is most commonly based on sonographic findings, but advanced imaging such as CT or MRI may be required if sonography is not diagnostic. Treatment is surgical, with ovarian preservation preferred in almost all cases. In this review, I present the most recent evidence on epidemiology, diagnosis, and management of pediatric ovarian torsion, with a focus on point-of-care ultrasound for the emergency care provider.

Transvaginal US vs. CT in non-pregnant premenopausal women presenting to the ED: clinical impact of the second examination when both are performed

Objective

To determine the clinical impact of the second examination when both CT and TVUS are obtained in the same ED visit for acute pelvic/lower abdominal symptoms in non-pregnant premenopausal women.

Methods

200 consecutive non-pregnant premenopausal women (mean age, 31.8 years; range, 18–49 years) who underwent both ED-based TVUS and abdominopelvic CT evaluation for acute symptoms over a 12 month period were included; 107 women had TVUS first, followed by CT; 93 women had CT first. All relevant clinical, radiologic, and pathologic findings were reviewed to establish a final diagnosis. Any additional clinical impact provided by the second imaging test was assessed by two experienced abdominal radiologists.

Results

Initial TVUS was interpreted as normal (n = 63) or mentioned incidental findings (n = 11) in 69% (74/107); subsequent CT established a non-gynecologic GI/GU etiology in 25 (34%). For 37% (34/93) of CT exams interpreted as normal, TVUS added no new information. In 32 cases (34%), TVUS further excluded ovarian torsion/adnexal pathology when initial CT was indeterminate/equivocal. Overall, CT following TVUS provided a key new or alternative diagnosis in 26% (28/107), whereas TVUS after CT provided a relevant new/alternative diagnosis in only 1/93 cases (p < 0.001). In nine cases (8%), CT confirmed a positive US diagnosis but detected relevant additional diagnostic information.

Conclusion

CT following negative TVUS frequently identified a non-gynecologic cause of acute pelvic or lower abdominal symptoms in non-pregnant premenopausal women, whereas the main benefit of TVUS after CT was more confident exclusion of ovarian torsion.

Graphical abstract

Supplementary Information

The online version contains supplementary material available at 10.1007/s00261-022-03504-6.

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.

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.

Adnexal Torsion: A Retrospective Analysis From a Tertiary Care Teaching Hospital in Northern India

Background Adnexal torsion is an acute gynecological emergency presenting with acute abdomen which can be missed owing to non-specific symptoms. Among reproductive-age women, conservative surgery is preferred. The present study was a retrospective analysis of adnexal torsion cases reported to a tertiary care teaching hospital in Northern India. The purpose of the study was to describe the demography, clinical features, diagnostic and treatment modalities, and prognosis of adnexal torsion cases. Methods Surgically proven adnexal torsion case records were retrieved and data were entered in an excel sheet from a period of two and half years from January 2018 to June 2020. Results There were 28 cases with an age range of 7-85 years (median age 24 years) with lower abdominal pain and nausea/vomiting symptoms. The majority were in the reproductive age group (71.4%). A Colour Doppler was done which detected 75% (12/16) of the ovarian torsion cases. The size of the adnexal torsion was 5-10 cm in 60.7% with right-sided torsion seen in 57.14%. Detorsion and salpingo-oophorectomy was done in 14 (50%) and 11 (39.2%) cases, respectively. Histopathological examination revealed hemorrhagic/necrotic infarcts (54.2%) and dermoid cysts (33.3%). Conclusions Owing to non-specific symptoms, adnexal torsion is diagnosed with strong clinical suspicion as routine ultrasonography diagnosed only 7.1% in the present study. Conservative surgery is preferred in the reproductive age group.

Approach to Abdominal Imaging in 2022

Abdominal pain represents 5% to 7% of all emergency department presentations. Many patients require imaging for diagnosis, and choosing the appropriate imaging modality is a crucial decision point. Modern medicine offers a fantastic array of options including abdominal radiograph, computed tomography, MRI, and ultrasonography, but the plethora of alternatives can be paralyzing. This article introduces the commonly available modalities, discusses the advantages and disadvantages, and presents current recommendations for commonly diagnosed conditions.

Predictive Value of Single or Combined Ultrasound Signs in the Diagnosis of Ovarian Torsion

OBJECTIVES

To determine predictive values of isolated and combined ultrasound signs in the diagnosis of adnexal torsion.

METHODS

This work was a retrospective study of 129 adult female patients who underwent an ultrasound examination followed by a definitive surgical procedure within a 24-hour period to determine whether adnexal torsion was present.

RESULTS

The positive predictive value (PPV) of the ultrasound diagnosis of adnexal torsion was 82.2%. The statistically significant ultrasound signs in multivariate logistic regression with single-predictor analyses were relative enlargement of the ovary, an abnormal adnexal position, a twisted vascular pedicle, and the follicular edema "ring sign." Possible combinations of these ultrasound criteria showed high specificities (74%-100%), high PPVs (93%-100%), and lower sensitivities (29%-71%) and negative predictive values (24%-35%). Any combination that included a twisted vascular pedicle or the follicular ring sign as one of the signs had high odds ratios and positive likelihood ratios.

CONCLUSIONS

Ultrasound has a high PPV as a first-choice imaging modality in the diagnosis of adnexal torsion. The combinations of the following 4 statistically significant ultrasound signs, consisting of an abnormal position, relative enlargement of the index ovary, a twisted vascular pedicle, and the follicular edema ring sign, substantially narrow the imaging differential diagnosis in such cases. The presence of vascular pedicle twisting and the follicular ring sign was highly associated with a positive ovarian torsion diagnosis, with 100% specificity.

Ovarian torsion: can we save the ovary?

OBJECTIVE

The purpose of this study is to evaluate the correlation between visually appearing ovarian necrosis and necrosis in histopathology in patients with ovarian torsion; and to identify predictive factors of ovarian necrosis.

METHODS

This is a retrospective study. All women admitted to the hospital with a diagnosis of suspected ovarian torsion from January 2014 to December 2018 were recruited. Forty-two patients with a confirmed diagnosis of ovarian torsion were finally included. Correlation analysis was done between visual judgement of ovarian necrosis and necrosis in histopathology. Chi-square was performed to analyze dependence between time from pain onset to surgery, ovarian size in ultrasound, Doppler flow, and histopathological analysis.

RESULTS

Thirty-one ovaries were visually judged as necrotic. Only five of them (16%) had histopathologically confirmed necrosis, 20 (64.5%) had hemorrhage or congestion, and 6 (19%) had normal ovarian tissue, p = 0.349. Development of ovarian necrosis showed to be dependent on time from onset of pain to surgery. All patients with necrotic ovaries in histopathology underwent surgery after 24 h of pain onset, while there was no necrosis in those who had surgery before 24 h. (p =  < 0.05). There was no relationship between ovarian size measured by ultrasound and necrosis (p = 0.265), as well as color flow in ultrasound and necrosis (p = 0.388).

CONCLUSION

Visual assessment of ovarian necrosis intraoperatively is not a good predictor of real necrosis in histopathology. To preserve the ovary, surgical management should not be delayed.

Is color Doppler ultrasonography reliable in diagnosing adnexal torsion? A large cohort analysis

INTRODUCTION

Color Doppler ultrasonography (CDU) is widely used to diagnose adnexal torsion (AT). However, its validity remains questionable due to its low sensitivity. Our study aimed to evaluate the accuracy of CDU for the preoperative diagnosis of AT.

MATERIAL AND METHODS

The electronic medical records of patients who were taken to the operating room with the diagnosis of suspected AT were reviewed. Patients having surgically/pathologically-proven AT were compared with patients who were found to have a different pathology at the time of surgery. CDU validity was assessed using a 2 × 2 table and compared with a diagnostic model that consists of the Doppler findings, patient's age, and previous surgical history.

RESULTS

AT was diagnosed correctly in 74.6% of cases. Absent Doppler flow was seen in only 18.6% of cases. Although its specificity and positive predictive value were high, CDU had very low sensitivity and negative predictive value. The combined diagnostic model exceeded CDU alone in terms of diagnostic accuracy.

CONCLUSIONS

The use of CDU alone is not a reliable modality to exclude AT. Absent Doppler flow is a sign of ovarian necrosis. Clinical correlation between CDU findings and the patient's symptoms makes the diagnosis of AT more timely and accurate.

Ovarian volume ratio is a reliable predictor of ovarian torsion in girls without an adnexal mass

PURPOSE

The aims of this study were to identify ultrasound-based predictors of ovarian torsion in girls without an adnexal mass and establish a set of normal values for ovarian volume ratio (OVR).

METHODS

A retrospective review was performed of all premenarchal patients ≥3 years of age with a normal pelvic ultrasound between January 2016 and January 2019. A comparison group of premenarchal girls presenting between 2011 and 2019 with torsion in the absence of an adnexal mass was utilized.

RESULTS

Five-hundred and four premenarchal girls underwent pelvic ultrasound evaluation with a normal examination. The mean OVR was 1.6 ± 0.7 (range 1.0-6.5). OVR did not vary with age (r = -0.06) as compared to ovarian width which increased steadily with age (r = 0.53, p < 0.001). OVR was increased in girls with torsion (7.6 vs 1.4, p < 0.0001), and by receiver operating characteristic (ROC) analysis a cutoff value of >2.5 demonstrated the best diagnostic accuracy of any predictive variable (sensitivity 100%, specificity 94%, AUC 0.991, p < 0.001).

CONCLUSIONS

OVR is an excellent predictor of ovarian torsion in premenarchal girls without an adnexal mass. Unlike ovarian width, OVR does not increase with age, and a cutoff OVR > 2.5 demonstrates high sensitivity and specificity for identifying ovarian torsion in this population.

TYPE OF STUDY

Study of diagnostic test.

LEVEL OF EVIDENCE

Level III.

Imaging right lower quadrant pain: Not always appendicitis

Although acute appendicitis (AA) is one of the commonest causes of right lower quadrant abdominal pain (RLQP), there are numerous other conditions in the abdomen and pelvis that can simulate the clinical presentation of AA for which imaging is essential in detection. We discuss the approach to evaluation of patients presenting with acute onset RLQP and the choice of various imaging modalities that can be utilized. Although CT remains the workhorse in evaluation, US and MRI, given lack of radiation, play an important ancillary role, particularly in the pediatric and pregnant patients. We present a spectrum of conditions presenting with RLQP which we have classified systematically ranging from conditions affecting the bowel, mesentery/omentum/peritoneum, vasculature, urinary and reproductive systems to give the reader a checklist of conditions to consider when evaluating a case of RLQP.

Abdominal Pain in a Young Female Adolescent: Point-of-Care Ultrasound Added Value

An adolescent female patient presented to the emergency department with diffuse, severe lower abdominal pain and vomiting. The initial suspected diagnosis was appendicitis. Point-of-care ultrasound did not visualize the appendix but demonstrated a suspected left ovarian torsion, which was confirmed by radiology-performed ultrasound. The clinical presentation, in combination with images obtained via point-of-care ultrasound, helped to expedite gynecology consultation and immediate surgery.

Ovarian torsion and laparoscopy in the paediatric and adolescent population

A 9-year-old girl attended the emergency department with right-sided abdominal pain and vomiting. Due to history and following examination, an ultrasound was requested which demonstrated a large complex midline mass. The most likely diagnosis was ovarian torsion, for which the patient underwent laparoscopy, detorsion and ovarian cystectomy. Histology revealed a mature cystic teratoma. Although less common than in the adult population, it is important to consider ovarian torsion in children and adolescents. Presentation is usually with pain accompanied by vomiting and fever, although these symptoms are not always present. Current management is organ-sparing, with laparoscopy±cystectomy. We discuss the adaptations for this procedure with regard to the paediatric and adolescent population. Differences in the anatomy and physiology must lead to consideration for alterations in surgical technique and positioning to ensure the safest and best quality care for these young patients.

Premenarchal patients present differently: A twist on the typical patient presenting with ovarian torsion

BACKGROUND/PURPOSE

The aim of this study was to characterize differences between pre- and postmenarchal females with ovarian torsion.

METHODS

A single-center review was conducted of all nonneonatal pediatric patients with ovarian torsion from 2011 to 2018. Clinical data were compared between pre- and postmenarchal patients.

RESULTS

One hundred and twenty-seven patients were identified, and 25% were premenarchal. Premenarchal patients were more likely to have a delay in diagnosis (38% vs 20%, p = 0.042), develop ovarian necrosis (34% vs 17%, p = 0.036), and present without an associated adnexal mass (44% vs 0%, p < 0.001). All patients without a mass (n = 14) were premenarchal and presented with ovarian asymmetry. Patients without an associated mass underwent oophoropexy in the majority of cases. There were no differences in postoperative complication or recurrence rates between groups.

CONCLUSION

Premenarchal females with ovarian torsion can present differently than females postmenarche and often have a delay in diagnosis. Premenarchal females are more likely to undergo torsion without an associated adnexal mass and are at higher risk for ovarian necrosis. Oophoropexy is an appropriate treatment in the absence of an adnexal mass. A high-index of suspicion for ovarian torsion should be maintained for premenarchal females presenting with abdominal pain and an otherwise negative workup.

TYPE OF STUDY

Retrospective comparative study.

LEVEL OF EVIDENCE

Level III.

Gynecologic Ultrasound Evaluation of the Nongravid Woman with Pelvic Pain

Pelvic pain is a common condition. Many underlying gynecologic and nongynecologic conditions can contribute to this symptom. Pelvic ultrasound using comprehensive 2-dimensional interactive imaging techniques as well as color Doppler and 3-dimensional imaging optimizes the detection of inciting etiologies.