Sonographic diagnosis of ovarian torsion: accuracy and predictive factors

Isolated fallopian tube torsion: A systematic review of case reports

OBJECTIVE

To combine all literature describing cases of isolated fallopian tube torsion in adult non pregnant patients in a systematic manner, to optimize knowledge and practice both for diagnosis and management.

STUDY DESIGN

EMBASE and PubMed databases were searched for the terms 'tubal' OR 'fallopian tube' AND 'isolated' AND 'torsion' from the inception of these databases to July 5, 2023. All case reports or case series of adult patients (18 years or older) with isolated fallopian tube torsion were included. Exclusion criteria included: all other study types; cases involving children and adolescents (less than 18 years old); pregnant patients of all trimesters; tubo-ovarian torsion; studies not published in English; duplicates and those not available in text. Following the database search, two authors independently screened the studies and search results were subsequently reported in accordance with PRISMA guidelines. Data was extracted independently by two authors and analysed using Excel. All cases were assessed for bias using a modified version of the tool proposed by Murad et al. RESULTS: 92 unique articles enrolling 131 individual cases were included in this systematic review. Isolated fallopian tube torsion most commonly occurs during reproductive ages between 18 and 45 years. It is uncommon in postmenopausal women. The most common presenting symptoms include unilateral lower abdominal or pelvic pain along the affected side with nausea and vomiting. Risk factors can be intrinsic or extrinsic and can include conditions such as hydrosalpinx, sterilization, pelvic inflammatory disease or cysts. Ultrasound is the optimal imaging modality however Computed Tomography and Magnetic Resonance Imaging can also be used. Imaging in general has low sensitivity, however isolated fallopian tube torsion can be identified with appropriate expertise. The gold standard for isolated fallopian tube torsion management is laparoscopy and detorsion however currently, the most common intervention performed is salpingectomy.

CONCLUSIONS

Isolated fallopian tube torsion is a rare but important gynaecological emergency with significant fertility implications. This study summarizes the most common presentations, investigation findings and surgical interventions in patients with isolated fallopian tube torsion. This study also emphasizes the importance of clinicians maintaining a high degree of suspicion and low threshold for early laparoscopic intervention to retain fertility.

Isolated torsion of the utero-ovarian ligament

Key Clinical Message

Isolated utero-ovarian torsion poses a challenge to diagnosing adnexal torsion, as it may not present with imaging findings. Clinicians with high suspicion for torsion but lack of evidence on ultrasonography should proceed to diagnostic laparoscopy.

Abstract

Adnexal torsion occurs when the ovary rotates around its supporting ligaments, the infundibulopelvic and utero-ovarian (UO) ligaments, often causing disruption of blood supply. This pathology often presents with acute pelvic pain and is a gynecologic surgical emergency. Diagnosis is typically made with Doppler ultrasound, although dual blood supply to the ovary poses additional diagnostic challenges and sensitivity of this tool is debated. In this case study, we present a case of missed torsion due to isolated compromise of UO ligament.

Pregnancy-Associated Ovarian Torsion - a Single-Center Case-Control Study

The etiology of OT is largely unknown. Any predisposition to rotation of the infundibulopelvic ligament and utero-ovarian ligament should be considered a possible etiology. Information with respect to ovarian torsion (OT) among pregnant is underreported and based on small studies. We aim to compare characteristics of confirmed OT to laparoscopies performed for the indication of suspected OT, in which no OT was found among pregnant women. This is a retrospective case-control study. We included pregnant women who underwent laparoscopy for a suspected OT between March 2011 and August 2020. Pregnant women with confirmed OT (torsion group) were compared to those without (no torsion group). There were 169 women with suspected OT. OT was confirmed in 140 (82.8%) women. There was higher proportion of assisted reproductive technology (ART) gestation in the torsion group [76 (54.3%) vs. 5 (17.2%), p < 0.001]. The rate of pregnant approaching evaluation within 8 h of symptoms onset was higher in the torsion group [57 (40.7%) vs. 2 (6.9%), p < 0.001]. The mean visual analogue score (VAS) was higher in the torsion group (8.5 vs. 7.1, p = 0.002). The mean pulse was lower in the torsion group (79 vs. 88 bpm, p < 0.001). From sonographic characteristics examined, the following was higher in the torsion group; mean maximal size of the ovary (70 mm in the torsion group vs. 54 mm in the no torsion group, p = 0.011). In a multivariable logistic regression analysis, number of hours of symptoms was negatively associated with AT [aOR, 95% CI 0.95 (0.91-0.98)] and pulse was negatively associated with OT [aOR, 95% CI 0.78 (0.63-0.95)]. Among the 29 cases in which no OT was found during laparoscopy, the following findings were noted: 16 (55.2%) no abnormality at all, 5 (17.2%) functional ovarian cyst, 2 (6.9%) mature teratoma and 6 cases of peritoneal adhesions (20.7%). The time from pain onset to approaching evaluation and women's pulse should be considered and acknowledged in the evaluation of OT during pregnancy.

Scoring system for predicting ovarian necrosis in adnexal torsion using an ultra-short optimized MRI protocol

PURPOSE

To evaluate a MRI scoring system predicting haemorrhagic necrosis in adnexal torsion with intraoperative and/or histopathological correlation using an abbreviated and optimized MRI protocol.

METHODS

This retrospective observational study includes patients with adnexal torsion who underwent Magnetic Resonance Imaging(MRI) and surgery. T2 sequences were evaluated by three observers of varying experience for following findings: Hypo-intensity of ovarian stroma, around the follicle, cyst wall or ovarian capsule and the twisted pedicle. Hypo-intensities in the above and a thick cyst wall were considered as predictors of necrosis. A scoring system was created based on the number of positive findings. MRI was correlated with intraoperative and histopathological findings. Lesions showing haemorrhagic necrosis were considered true positives.

RESULTS

43 women with torsion were included. 74.4% were secondary to a lead point and 25.4% were without one. Hypointensity score of 2 or more had the highest diagnostic accuracy and inter-reader agreement in predicting necrosis (R1-sensitivity: 92%, specificity: 89%, positive predictive value (PPV): 92% and negative predictive value (NPV): 89%, R2-sensitivity: 92%, specificity: 94%, PPV: 96% and NPV: 90% and R3-sensitivity: 92%, specificity: 83%, PPV: 89% and NPV: 89%).

CONCLUSION

In patients with suspected adnexal torsion, optimized MRI using T2 weighted sequences will serve as a rapid and effective single imaging modality for diagnosing adnexal torsion and accurately predicting necrosis thereby triaging the patients for appropriate management.

The "Double Ovary" Sign: A Unique Sonographic Observation in Isolated Fallopian Tube Torsion

Isolated fallopian tube torsion (IFTT) is a rare subset of adnexal torsion. Timely diagnosis of IFTT is essential for preservation of the fallopian tube. However, a pre-operative diagnosis is challenging due to nonspecific symptoms and findings on physical exam. In addition, ultrasound (US) is typically the initial imaging modality in this setting and adnexal torsion may not be considered when normal ovaries are seen. In this small case series, we introduce the "double ovary" sign, a unique observation on US characterized by two adjacent structures: the ovary and the twisted fallopian tube giving rise to an ovary-like, cystic structure. We present three cases in which IFTT was diagnosed preoperatively.

Diagnostic accuracy of ultrasound signs for detecting adnexal torsion: systematic review and meta-analysis

OBJECTIVE

To evaluate the diagnostic accuracy of different ultrasound signs for diagnosing adnexal torsion, using surgery as the reference standard.

METHODS

This was a systematic review and meta-analysis of studies published between January 1990 and November 2021 evaluating ovarian edema, adnexal mass, ovarian Doppler flow findings, the whirlpool sign and pelvic fluid as ultrasound signs (index tests) for detecting adnexal torsion, using surgical findings as the reference standard. The search for studies was performed in PubMed/MEDLINE, CINAHL, Scopus, The Cochrane Library, ClinicalTrials.gov and Web of Science databases. The Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) tool was used to evaluate the quality of the studies. Pooled sensitivity, specificity, and positive and negative likelihood ratios were calculated separately, and the post-test probability of adnexal torsion following a positive or negative test was also determined.

RESULTS

The search identified 1267 citations after excluding duplicates. Eighteen studies were ultimately included in the qualitative and quantitative syntheses. Eight studies (809 patients) analyzed the presence of ovarian edema, eight studies (1044 patients) analyzed the presence of an adnexal mass, 14 studies (1742 patients) analyzed ovarian Doppler flow, six studies (545 patients) analyzed the whirlpool sign and seven studies (981 patients) analyzed the presence of pelvic fluid as ultrasound signs of adnexal torsion. Overall, the quality of most studies was considered to be moderate or good. However, there was a high risk of bias in the patient-selection and index-text domains (with the exception of the whirlpool sign) in a significant proportion of studies. Pooled sensitivity, specificity, and positive and negative likelihood ratios of each ultrasound sign were 58%, 86%, 4.0 and 0.49 for ovarian edema, 69%, 46%, 1.3 and 0.67 for adnexal mass, 65%, 91%, 7.6 and 0.38 for the whirlpool sign, 53%, 95%, 11.0 and 0.49 for ovarian Doppler findings and 55%, 69%, 1.7 and 0.66 for pelvic fluid. Heterogeneity was high for all analyses.

CONCLUSIONS

The presence of an adnexal mass or pelvic fluid have poor diagnostic accuracy as ultrasound signs of adnexal torsion, while the presence of ovarian edema, the whirlpool sign and decreased or absent ovarian Doppler flow have good specificity but moderate sensitivity for detecting adnexal torsion. © 2022 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Pediatric and Adolescent Gynecologic Emergencies

Pediatric gynecology encompasses a wide range of topics from the maternal estrogen impact on the neonate, to the unique pathophysiology of the lack of estrogen on prepubescent females, and the independence and sexual maturation that occurs with adolescence. This article will review the impact of normal hormonal variations in children, unique pathophysiology of certain conditions in the prepubescent period, as well as common injuries and infections of the genitourinary system in children.

The Acute Female Nongravid Pelvis: A Review of Appropriate Clinical Applications of Sonography, Computed Tomography, and Magnetic Resonance Imaging

Objective:

The objective of this literature review was to provide a summary of the primary concerns in evaluating ovarian cysts and compare the diagnostic roles of each imaging technique, in an emergent setting.

Materials and Methods:

A literature review of the imaging evaluation of functional ovarian cysts, emergent complications, and relevant case studies was performed using peer-reviewed articles. The literature search was conducted using PubMed, The Wiley Online Library, and Google Scholar search engines.

Results:

Sonography, computed tomography (CT), and magnetic resonance imaging (MRI) demonstrate comparable accuracy in the diagnosis of functional ovarian cysts and ovarian torsion. While sonography is the preferred method of imaging the female pelvis, CT and MRI demonstrate similar diagnostic capabilities.

Conclusion:

Functional ovarian cyst rupture/hemorrhage and ovarian torsion can be accurately demonstrated using sonography, CT, and MRI.

Predictive Role of Neutrophil to Lymphocyte Ratio in Adnexal Torsion: A Systematic Review and Meta-Analysis

Introduction. The goal of this systematic review and meta-analysis was to consolidate the available data on the role of the neutrophil to lymphocyte ratio (NLR) in predicting adnexal torsion (AT), to help guide clinical decision-making and outcomes. Methods. We used Web of Science, PubMed, and Scopus to conduct a systematic search for relevant publications published before June 26, 2022. We reported standardized mean difference (SMD) with a 95% confidence interval (CI). Because a significant level of heterogeneity was found, we used the random-effects model to calculate pooled effects. We used the Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2) too for quality assessment. Results. Overall, 15 articles were included in the analysis. A random-effects model revealed that patients with AT had elevated levels of NLR compared to those with other adnexal masses ( $\text{SMD}=1.06$ , $95\%\text{CI}=0.67$ to 1.45, $p<0.001$ ). So, NLR had diagnostic value. In the subgroup analysis according to ethnicity, we found that Caucasian patients with AT had elevated levels of NLR compared to patients who were operated due to adnexal mass and reported as having a benign ovarian cyst, without torsion ( $\text{SMD}=1.12$ , $95\%\text{CI}=0.71$ to 1.54, $p<0.001$ ). However, in the case of East Asian patients, there was no difference between cases and controls ( $\text{SMD}=0.86$ , $95\%\text{CI}=-0.21$ to 1.94, $p=0.11$ ). The pooled sensitivity of NLR was 0.79 ( $95\%\text{CI}=0.72–0.85$ ), and the pooled specificity was 0.84 (95% CI, 0.74–0.91). Conclusion. In conclusion, there has been an interest in the use of NLR as a diagnostic marker for AT.

The double bladder sign: Challenges in early sonographic diagnosis of ovarian torsion

Ovarian torsion is an emergency whereby challenges in diagnosis may lead to delayed management. The morbidity associated with delayed diagnosis can be severe and includes loss of ovarian function. We present a case of a 24-year-old female who presented to the hospital with left lower quadrant abdominal pain with unremarkable physical examination. A transabdominal and transvaginal ultrasound were acquired and demonstrated a mildly enlarged left ovary and fallopian tube without other significant findings. However due to worsening pain and up trending inflammatory markers, diagnostic laparoscopy was performed and demonstrated a 12cm ovarian cyst, a necrotic left adnexal mass and a torsed left tubo-ovarian pedicle. These findings were not appreciated on the initial Doppler ultrasound acquired but retrospective analysis demonstrated a double bladder sign. Our case report aims to aid sonographers and physicians to promptly diagnose ovarian torsion through the “double bladder sign” and other salient ultrasonographic and clinical features.

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.

Adnexal torsion: a review of diagnosis and management strategies

PURPOSE OF REVIEW

Adnexal torsion remains a diagnostic challenge heavily reliant on high clinical suspicion, with patient presentation and imaging used as adjuncts to aid in its diagnosis. This review summarizes diagnostic and management techniques of adnexal torsion to assist providers when encountering this surgical emergency.

RECENT FINDINGS

Common findings of adnexal torsion include abdominal pain, nausea, vomiting, and adnexal mass or ovarian enlargement. An elevated neutrophil to lymphocyte ratio may be useful for diagnosis. A 'whirlpool' sign, 'follicular ring' sign, enlarged/edematous ovary, and absent Doppler flow to the ovary are highly suggestive of adnexal torsion. Intraoperative visual diagnosis of ovarian death is highly inaccurate, with only 18-20% of ovaries necrotic on pathological examination. Necrotic appearing ovaries have been shown to have follicular activity on ultrasound one year postoperatively.

SUMMARY

Pelvic ultrasound remains the first-line imaging modality. In patients of reproductive age, we recommend performing detorsion with ovarian conservation, even in cases where the tissue appears necrotic, given poor intraoperative diagnostic rates of tissue death. Retention of ovarian function is also reliant on a timely diagnosis and intervention. We emphasize that the risk of ovarian damage/loss outweigh the risk of a diagnostic laparoscopy in patients of reproductive age.

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.

Ultrasonographic scoring system for the diagnosis of adnexal torsion

PURPOSE

To establish the utility of an ultrasonographic scoring system for the diagnosis of adnexal torsion.

METHODS

We retrospectively analyzing 358 adnexal torsion cases. Using Pearson's χ² test we determined whether ultrasonographic signs were significantly associated with adnexal torsion. Receiver operating characteristic curves were used to evaluate the diagnostic efficacy of the system. Ultimately by using binary logistic regression we established a precise and convenient scoring system.

RESULTS

The torsion score was based on five criteria that were identified to be independently associated with adnexal torsion: (1) abnormal position of the index adnexa (odds ratio [OR], 2.311); (2) presence of a mass or cyst (OR, 3.495); (3) unilateral ovarian enlargement (OR, 3.051); (4) vascular pedicle twisting (OR, 2.105); and (5) peripheral hypervascularity of the corpus luteum with ovarian edema(encapsulating cyst sign) (OR, 4.164).patients with torsion who scored 0, have a predicted diagnosis rate of 20.9%; patients whose scores were 1,2 have a predicted probability of 41.8% and 66.15%, respectively. For patients with torsion scores of 3, 4, and 5, predicted diagnosis rates were 84.16%, 93.52%, and 98.27%, respectively.

CONCLUSION

The ultrasonographic scoring system is feasible and precisely diagnoses adnexal torsion using ultrasound.

The “Black Pattern”, a Simplified Ultrasound Approach to Non-Traumatic Abdominal Emergencies

Background: A key issue in abdominal US is the assessment of fluid, which is usually anechoic, thus appearing “black”. Our approach focuses on searching for fluid in non-traumatic patients, providing a new, simplified method for point-of-care US (POCUS). Objective: Fluid assessment is based on a three-step analysis that we can thus summarize. 1. Look for black where it should not be. This means searching for effusions or collections. 2. Check if black is too much. This means evaluating anatomical landmarks where fluid should normally be present but may be abnormally abundant. 3. Look for black that is not clearly black. This means evaluating fluid aspects, whether wholly anechoic or not (suggesting heterogeneous or corpusculated fluid). Discussion: Using this simple method focused on US fluid presence and appearance should help clinicians to make a timely diagnosis. Although our simplified, systematic algorithm of POCUS may identify abnormalities; this usually entails a second-level imaging. An accurate knowledge of the physio–pathological and anatomical ultrasound bases remains essential in applying this algorithm. Conclusion: The black pattern approach in non -traumatic emergencies may be applied to a broad spectrum of abnormalities. It may represent a valuable aid for emergency physicians, especially if inexperienced, involved in a variety of non-traumatic scenarios. It may also be a simple and effective teaching aid for US beginners.

A clinical prediction model for adnexal torsion in pediatric and adolescent population

PURPOSE

To describe the clinical characteristics of children and adolescents that underwent diagnostic laparoscopy for suspected adnexal torsion (AT), and to develop a prediction model for preoperative detection of AT among young women.

METHODS

A retrospective cohort study. We included all girls ≤18 years old with clinically suspected AT who underwent a diagnostic laparoscopy between 3/2011 and 6/2020. We compared patients with AT to those without AT and constructed a prediction model.

RESULTS

Overall, 120 children and adolescents with suspected AT were included in the study. Of those, AT was identified in 83 (69.2%). In a multivariate analysis, the following risk factors were independently associated with AT and included in the prediction model: absence of right lower quadrant tenderness upon examination [adjusted odds ratio (aOR) (95% Confidence interval (CI)) 3.23 (1.23-8.47), p = 0.017], platelets level >240 K [aOR (95% CI) 3.15 (1.19-8.36), p = 0.021], and neutrophils level >5.4 [aOR (95% CI) 2.71 (1.02-7.52), p = 0.046]. The rate of AT was 12.5% in cases without risk factors for AT, 56.7% with one, 68.8% with two, and 94.1% with three risk factors present, respectively.

CONCLUSIONS

We have identified preoperative indicators independently associated with surgically confirmed AT in a large cohort of young women. Level of evidence- III.

Accurate Diagnosis of Adnexal Torsion-Not Only for Expert Sonographers: A Retrospective Cohort Analysis

OBJECTIVES

The aim of the study was to evaluate the clinical and sonographic parameters associated with a correct or incorrect diagnosis of adnexal torsion made by resident/attending physicians who are not expert sonographers.

METHODS

A retrospective study design included women who presented to the Emergency Department (ED) of a tertiary medical center between 2010 and 2019 with acute lower abdominal pain, who were subsequently diagnosed laparoscopically with adnexal torsion. Women who were correctly diagnosed in the ED by an obstetrician-gynecologist who was not an expert sonographer were compared for clinical and sonographic parameters with women who were initially incorrectly diagnosed and underwent a second ultrasound examination by an expert sonographer following admission.

RESULTS

Of 118 women with surgically proven adnexal torsion, 76 were correctly diagnosed in the ED and 42 were initially incorrectly diagnosed. The correctly diagnosed group was characterized by a significantly shorter mean time from admission to surgery, higher rate of vomiting, shorter duration of abdominal pain, and higher rate of prior torsion (P < .05). Physicians who made the correct diagnosis utilized more sonographic parameters than those who did not, namely ovarian size, ovarian edema, and Doppler flow. The correctly diagnosed group had a higher rate of bluish-black (ischemic) adnexa at laparoscopy, but a higher rate of recovery following detorsion.

CONCLUSIONS

Physicians in the ED should be alerted to the need to address some basic sonographic features when adnexal torsion is suspected. The diagnostic accuracy of adnexal torsion can be improved by utilizing simple sonographic markers, even in the ED setting.

Risk Factors Associated with Adnexal Torsion after Hysterectomy

STUDY OBJECTIVE

To identify preoperative and intraoperative risk factors for adnexal torsion after hysterectomy, and to estimate the incidence of the disease in the modern-day era of laparoscopic surgery.

DESIGN

Retrospective nested case-control study.

SETTING

Large urban medical system.

PATIENTS

Eighty-nine female patients ages 17 to 51.

INTERVENTIONS

Patients underwent ovarian-sparing hysterectomy.

MEASUREMENTS AND MAIN RESULTS

The estimated incidence of ovarian torsion after hysterectomy was 0.5% (46/8538 ovarian-sparing hysterectomies). The following variables were found to be associated with adnexal torsion after hysterectomy in an adjusted logistic regression: laparoscopic or laparoscopic-assisted approach to hysterectomy vs any other approach (odds ratio [OR], 3.36; 95% confidence interval [CI], 0.86-13.23); younger age at the time of hysterectomy (17-40 years) vs older age (41-51 years) (OR, 3.45; 95% CI, 1.33-8.97); and a gynecologic history significant for endometriosis (OR, 4.07; 95% CI, 1.04-15.88).

CONCLUSION

There is an association between laparoscopic approach to hysterectomy, younger age at time of hysterectomy, and a history of endometriosis with subsequent risk of adnexal torsion. Providers should have a heightened index of suspicion for adnexal torsion after hysterectomy in patients presenting with acute-onset abdominal pain who underwent laparoscopic hysterectomy at a younger age.

A validated predictive model for adnexal torsion pre-operative diagnosis

PURPOSE

To develop a simple predictive model for pre-operative diagnosis of adnexal torsion (AT).

METHODS

A retrospective cohort study with a retrospective validation, including 669 separate episodes of women who underwent laparoscopy due to a suspected AT between January 2011 and June 2020. We compared the pre-operative characteristics between women with surgically confirmed AT and those without.

RESULTS

The derivation cohort included 615 episodes of suspected AT. AT was surgically confirmed in 445 episodes (72%). The retrospectively collected validation cohort included 54 episodes, with 31 (57.4%) surgically confirmed AT. In a multivariate regression analysis, vomiting, neutrophils to lymphocytes ratio > 3.5 and sonographic finding of enlarged ovary were independently associated with AT [OR 95% CI 2.78 (1.21-6.36), 3.15 (1.42-6.97) and 2.80 (1.33-5.88), respectively]. In the derivation cohort, the PPV for AT diagnosis was 69.7%, 84.5% and 93.1% if 1, 2 and 3 risk factors were present, respectively. Retrospective validation analysis underlined a PPV of 67.6%, 82.6 and 66.6% for 1, 2 and 3 risk factors, respectively.

CONCLUSION

We have developed and validated a simple predictive model for pre-operative diagnosis of AT, based on three parameters. Our model may assist clinicians while evaluating patients with suspected AT and improve pre-operative diagnosis.

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.

Ovarian Torsion in Adolescents with and without ovarian mass: A Cross-sectional Study

STUDY OBJECTIVE

The aim of this study was to compare the characteristics of adolescents with and without adnexal mass who were diagnosed with ovarian torsion (OT).

DESIGN

Retrospective cross-sectional study.

SETTING

Gynecology Department at Tepecik Education and Reseach Hospital, Izmir, Turkey.

PARTICIPANTS

Adolescent girls who received surgery for OT between March 2012 and October 2020 in our institution.

INTERVENTIONS AND MAIN OUTCOME MEASURES

The patients were divided into 2 groups according to the presence or absence of an ovarian mass and compared. Demographic and clinical characteristics, imaging findings, surgery, and pathology reports of the patients were obtained. Differences in initial symptoms, ultrasound findings, the diagnostic process, and the degree of torsion in patients with and without ovarian mass.

RESULTS

Seventy-six patients were diagnosed with OT. Of the 76 patients, 41/76 (53.9%) had an ovarian mass (OTwM), and 35/76 (46.1%) had no pathology (OTnP). The admission to surgery interval was longer in the OTnP group (P = .03). Ultrasound findings of ovarian edema and the appearance of free fluid were significant in the OTnP group (P = .001). The largest dimension of the nontorsion ovary in the OTnP group was greater than in the OTwM group (P = .03). In addition, it was found that torsion more than 360° was more common in the OTnP group than in the OTwM group (24/35, 68.5% vs 41/18, 43.9%; P = .03).

CONCLUSION

In symptomatic adolescents without an ovarian mass, the presence of follicle peripheralization suggesting ovarian edema on ultrasound and the presence of free fluid in the abdomen are important in terms of suspicion of torsion for clinicians. In addition, the degree of torsion was increased in these patients.

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.

Surgically confirmed adnexal torsion during pregnancy: Does the trimester make a difference?

AIM

To investigate the clinical and the sonographic characteristics of adnexal torsion (AT) during pregnancy and to underline differences in AT manifestation between pregnancy trimesters.

METHODS

This is a retrospective cohort study in a tertiary medical center. The study included all pregnant women with surgically confirmed AT between March 2011 and April 2020. The patients were divided into three groups according to pregnancy trimesters, and the clinical and sonographic characteristics were compared between the groups.

RESULTS

The study cohort included 140 cases of AT. Ninety-nine (70.7%) of the cases occurred during the 1st trimester, and 31 (22.1%) and 10 (7.1%) occurred during the 2nd and the 3rd trimesters, respectively. Conception by assisted-reproductive technologies (ART), nausea, and finding of enlarged ovary on ultrasound scan were all more common among patients in the 1st trimester group as compared to the 3rd trimester group (p = 0.001, 0.015, and 0.024, respectively). The mean time from admission to surgery was significantly shorter in the 1st trimester group as compared to late pregnancy (p = 0.001). The majority of cases were right-sided. There was a significant difference in the organs involved in every trimester of pregnancy-ovary only, ovary and fallopian tube, and fallopian tube only (p = 0.023).

CONCLUSIONS

Most AT cases during pregnancy occurred during the 1st trimester. Conception by ART and enlarged ovary on ultrasound scan were also more common in AT cases during early pregnancy. Time from admission to surgery was longer as pregnancy progressed and organs involved differed between trimesters. Understanding the difference in manifestation of AT in every trimester might improve the preoperative evaluation of AT in pregnancy.

Adnexal Torsion Predictive Tool Maintains Applicability in a Heterogeneous Pediatric Population

STUDY OBJECTIVE

A previously published scoring system showed promise in identifying adnexal torsion in adolescents. However, published patients were homogeneously Caucasian/White. We sought to assess whether this scoring system was generalizable to a more diverse population that is predominantly African American and overweight.

DESIGN

Retrospective chart review.

SETTING

Tertiary academic hospital.

PARTICIPANTS

Female patients 0-21 years of age undergoing surgery for suspected ovarian torsion from 2010 to 2019.

INTERVENTIONS

Records were reviewed for patients, including laboratory studies, imaging, surgery, and pathology. Significance was determined for clinical and imaging findings, and retrospective composite scores were calculated for each participant as suggested by the scoring system.

MAIN OUTCOME MEASURES

Determination of whether the previously published composite score was predictive of pediatric adnexal torsion in our population.

RESULTS

A total of 57 cases of suspected torsion were included. Approximately 60% of patients were African American, 10% Hispanic, and 30% Caucasian/White. The average body mass index (BMI) across ethnicities was 29. Our findings significantly correlated with previously published predictors for all components. The presence of nausea/vomiting, leukocytosis, ovarian volume and ratio were found to be significant. The post hoc calculated composite score was applied to our cohort, and more than 90% of confirmed torsion would have been identified.

CONCLUSION

Our study suggests that a previously published composite score assessing torsion can successfully be used to predict torsion in a more diverse setting than the original study population, potentially accelerating surgical management of patients with the condition.

CT Imaging in Predicting Ovarian Torsion: Report of Two Cases, With and Without Infarction

Ovarian torsion is one of the common abdominal and gynecologic surgical emergencies with serious morbidity in the form of ovarian infarct or necrosis. Various imaging modalities like USG, CT, and MRI have been used in the evaluation of ovarian torsion. Two middle-aged females presented with lower abdominal pain. Imaging showed an ovarian cystic lesion in the first patient and thickened and twisted ovarian pedicle or ‘helical swirling’ sign in the second. Intraoperatively, the first case turned out to be a 180* twist with mild ovarian edema and the second showed more than 720* torsion with ovarian infarction. The CT findings of twisted pedicle with pericystic fat stranding might be predictive of hemorrhagic infarction in cases of torsion.

Diagnostic value of the sonographic whirlpool sign in the diagnosis of ovarian torsion: A systematic review and meta-analysis

In this review, we investigated the diagnostic value of the sonographic "whirlpool sign" in identifying ovarian torsion. This was done by performing a search in PubMed, Scopus, Embase, Web of Science, CINAHL, and Google scholar. Additional search for the grey literature was made in EThOS.bl.uk, explore.bl.uk, opengrey.eu, greylit.org, and clinicaltrials.org. A total of eight studies were included in this meta-analysis. Sensitivity and specificity of whirlpool sign were extracted from the studies and computed into the Metadisc statistical software for pooled analysis. The whirlpool sign showed a high sensitivity and specificity for the diagnosis of ovarian torsion.

Pregnancy outcomes following laparoscopy for suspected adnexal torsion during pregnancy

OBJECTIVE

To evaluate pregnancy outcomes of women with surgically confirmed adnexal torsion (AT) as compared to those in whom AT was ruled out.

METHODS

A retrospective cohort study in a tertiary medical center. All pregnant women who underwent diagnostic laparoscopy due to suspected AT between 3/2011 and 4/2020 were included. We compared maternal, delivery and neonatal outcomes of both groups. We further compared women with confirmed AT to a control group of women who did not undergo laparoscopy during pregnancy.

RESULTS

During the study period, 112 women met the inclusion criteria. AT was confirmed in 93 cases (83.0%). Baseline characteristics did not differ between groups, excluding the rate of previous AT [5.4% in the torsion vs. 26.3% in the no-torsion group, odds ratio (OR) 0.15, 95% confidence interval (CI) 0.04-0.62, p = .004], and nulliparity rate (57.0% in the torsion vs. 31.6% in the no-torsion group, OR 2.41, 95%CI 1.004-8.21, p = .043). Pregnancies conceived by assisted reproductive technology were more common in the AT group compared to the no-AT group (46.2% vs. 10.5%, OR 7.21, 95%CI 1.59-33.45, p = .002). Miscarriage and stillbirth rates, gestational age at delivery, delivery characteristics and neonatal outcomes were favorable and did not differ between groups. Outcomes of pregnancies with confirmed AT did not differ from a control group of women who did not undergo laparoscopy during pregnancy.

CONCLUSION

Pregnancy outcomes among women who underwent laparoscopy for a suspected AT during pregnancy were reassuring, irrespective of the surgical findings and gestational week. Outcomes did not differ when compared to pregnant women who did not undergo laparoscopy.

SYNOPSIS

Maternal, fetal and neonatal outcomes among women who underwent laparoscopy for suspected adnexal torsion during pregnancy are reassuring, irrespective of the surgical findings and gestational week.

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.

The Flipped Ovary Sign in Ovarian Torsion

The diagnosis of ovarian torsion is challenging and relies mostly on morphologic findings. Occasionally, women or children with acute pelvic pain who have undergone an initial ultrasound (US) evaluation with results interpreted as negative for ovarian torsion will return with recurrent or increasing pain, prompting an US reevaluation. The flipped ovary sign refers to a demonstrable change in the orientation of the ovary on follow-up US examinations, recognized by changing positions of ovarian landmarks established by follicles, cysts, or masses. This sign is valuable for identifying ovarian torsion in these patients, even in the absence of classic morphologic or Doppler features of ovarian torsion.

Preoperative CT image-based assessment for estimating risk of ovarian torsion in women with ovarian lesions and pelvic pain

PURPOSE

To define and weight the preoperative CT findings for ovarian torsion and to develop an integrated nomogram for estimating the probability of ovarian torsion in women with ovarian lesion and pelvic pain.

METHODS

This retrospective study included 218 women with surgically resected ovarian lesions who underwent preoperative contrast-enhanced CT for pelvic pain from January 2014 to February 2019. Significant imaging findings for torsion were extracted using regression analyses and a regression coefficient-based nomogram was constructed. The diagnostic performance with sensitivity, specificity, and accuracy of the significant imaging findings and the nomogram were assessed.

RESULTS

A total of 255 ovarian lesions (123 lesions with torsion and 132 lesions without torsion) were evaluated. Multivariable regression analysis showed that whirl sign (odds ratio [OR] 11.000; p < 0.001), tubal thickening (OR 4.621; p = 0.001), unusual location of ovarian lesion (OR 2.712; p = 0.020), and hemorrhagic component within adnexal lesion (OR 2.537; p = 0.028) were independent significant parameters predicting ovarian torsion. Tubal thickening showed the highest sensitivity (91.1%) and whirl sign showed the highest specificity (94.7%). When probabilities of ovarian torsion of 0.5 or more in the nomogram were diagnosed as ovarian torsion, sensitivity, specificity, and accuracy of the nomogram were 78.1%, 91.7%, and 85.1%, respectively.

CONCLUSION

The whirl sign, tubal thickening, unusual location of ovarian lesion, and hemorrhagic component within adnexal lesion, and an integrated nomogram derived from these significant findings can be useful for predicting ovarian torsion.

Diagnostic value of the neutrophil-to-lymphocyte and platelet-to-lymphocyte ratios in adnexal torsion cases

AIM

To evaluate if the neutrophil-to-lymphocyte ratio (NLR) and the platelet-to-lymphocyte ratio (PLR) could be used to diagnose adnexal torsion.

METHODS

A retrospective study reviewed medical records of women who underwent surgery due to an adnexal mass between January 2012 and December 2017 at a tertiary referral center in Turkey. According to the surgical findings, the women were divided into a torsion group and a control group. NLR and PLR were compared between women who had adnexal torsion and those who did not.

RESULTS

A total of 201 women were included in the study: 67 in the torsion group and 134 in the control group. Mean WBC count (9584.0 ± 3080.8 vs. 6678.2 ± 1886.1 h/mm³ ), mean NLR (5.9 ± 4.3 vs. 2.1 ± 0.8), and mean PLR (210.5 ± 132.7 vs. 147.9 ± 48.7) were higher in the torsion group than in the control group (p < 0.001). According to the ROC curve analyses, the optimal cut-off value for NLR and PLR were 2.51 (sensitivity, 72%; specificity, 78%) and 154.4 (sensitivity, 61%; specificity, 64%) in the diagnosis of adnexal torsion, respectively.

CONCLUSION

NLR and PLR have been found useful hematological markers for the diagnosis of adnexal torsion. NLR and PLR could be helpful in cases, which is difficult to make a definitive diagnosis with patients' symptom and the ultrasonographic examination.

Pearls and Pitfalls in Imaging of Pelvic Adnexal Torsion: Seven Tips to Tell It's Twisted

Pelvic adnexal torsion is a collective term referring to twisting of an ovary, fallopian tube, or paraovarian cyst on its axis with varying degrees of vascular compromise. Although it is the fifth most common gynecologic emergency, the diagnosis is challenging and often missed due to symptoms, physical examination findings, and imaging features that are nonspecific. Delay in salvage surgery may lead to ovarian or tubal loss, dysfunction, and infertility. The tips shared herein are based on the authors' observations of key clinical and imaging features of torsion, with the intent of heightening radiologists' index of suspicion and diagnostic accuracy in a clear and memorable fashion. Clinically, severe acute pain with a known adnexal mass or of severity to elicit nausea or vomiting should raise concern. At imaging, features of ovarian edema are key to the diagnosis, including asymmetric ovarian enlargement, peripheralized follicles, adjacent free fluid, and foci of stromal hemorrhage. The converse finding of symmetric nonenlarged ovaries in a normal location with any imaging modality has a high negative predictive value for torsion, obviating the need for additional imaging. The whirlpool sign (twisted vascular pedicle), abnormal ovarian location, and uterine tilting are additional key imaging manifestations. The presence of color Doppler flow or contrast enhancement only suggests that an ovary is still viable and should not be used to exclude the diagnosis of torsion. In cases of isolated tubal or paraovarian cyst torsion, the ovaries may appear normal; therefore, recognition of this entity along with appreciation of several key imaging findings may assist with this difficult diagnosis. An invited commentary by Dighe is available online. Online supplemental material is available for this article. ^©RSNA, 2021.

Factors Associated with Torsion in Pediatric Patients with Ovarian Masses

BACKGROUND

Management of ovarian torsion has evolved toward ovarian preservation regardless of ovarian appearance during surgery. However, patients with torsion and an ovarian neoplasm undergo a disproportionately high rate of oophorectomy. Our objectives were to identify factors associated with ovarian torsion among females with an ovarian mass and to determine if torsion is associated with malignancy.

METHODS

A retrospective review of females aged 2-21 y who underwent an operation for an ovarian cyst or neoplasm between 2010 and 2016 at 10 children's hospitals was performed. Multivariate logistic regression was used to assess factors associated with torsion. Imaging data were assessed for sensitivity, specificity, and predictive value in identifying ovarian torsion.

RESULTS

Of 814 girls with an ovarian neoplasm, 180 (22%) had torsion. In risk-adjusted analyses, patients with a younger age, mass size >5 cm, abdominal pain, and vomiting had an increased likelihood of torsion (P < 0.01 for all). Patients with a mass >5 cm had two times the odds of torsion (odds ratio: 2.1; confidence interval: 1.2, 3.6). Imaging was not reliable at identifying torsion (sensitivity 34%, positive predictive value 49%) or excluding torsion (specificity 72%, negative predictive value 87%). The rates of malignancy were lower in those with an ovarian mass and torsion than those without torsion (10% versus 17%, P = 0.01). Among the 180 girls with torsion and a mass, 48% underwent oophorectomy of which 14% (n = 12) had a malignancy.

CONCLUSIONS

In females with an ovarian neoplasm, torsion is not associated with an increased risk of malignancy and ovarian preservation should be considered.

Adnexal Torsion: Review of Radiologic Appearances

Adnexal torsion is the twisting of the ovary, and often of the fallopian tube, on its ligamental supports, resulting in vascular compromise and ovarian infarction. The definitive management is surgical detorsion, and prompt diagnosis facilitates preservation of the ovary, which is particularly important because this condition predominantly affects premenopausal women. The majority of patients present with severe acute pain, vomiting, and a surgical abdomen, and the diagnosis is often made clinically with corroborative US. However, the symptoms of adnexal torsion can be variable and nonspecific, making an early diagnosis challenging unless this condition is clinically suspected. When adnexal torsion is not clinically suspected, CT or MRI may be performed. Imaging has an important role in identifying adnexal torsion and accelerating definitive treatment, particularly in cases in which the diagnosis is not an early consideration. Several imaging features are characteristic of adnexal torsion and can be seen to varying degrees across different modalities: a massive, edematous ovary migrated to the midline; peripherally displaced ovarian follicles resembling a string of pearls; a benign ovarian lesion acting as a lead mass; surrounding inflammatory change or free fluid; and the uterus pulled toward the side of the affected ovary. Hemorrhage and absence of internal flow or enhancement are suggestive of ovarian infarction. Pertinent conditions to consider in the differential diagnosis are a ruptured hemorrhagic ovarian cyst, massive ovarian edema, ovarian hyperstimulation, and a degenerating leiomyoma. Online supplemental material is available for this article. ^©RSNA, 2021.

Contrast-enhanced ultrasound of the small organs in children

In pediatric and adult populations, intravenous contrast-enhanced ultrasound (CEUS) remains off-label for imaging of organs other than the liver and heart. This limited scope inhibits potential benefits of the new modality from a more widespread utilization. Yet, CEUS is potentially useful for imaging small organs such as the thyroid gland, lymph nodes, testes, ovaries and uterus, with all having locations and vasculature favorable for this type of examination. In the adult population, the utility of CEUS has been demonstrated in a growing number of studies for the evaluation of these small organs. The aim of this article is to present a review of pediatric CEUS of the thyroid gland, lymph nodes, testes, ovaries and uterus as well as to draw from the adult literature indications for possible applications in children.

Variations in the management of adolescent adnexal torsion at a single institution and the creation of a unified care pathway

PURPOSE

Adnexal torsion is a gynecologic emergency, requiring intervention for tissue preservation. At our institution, torsion is managed by pediatric surgeons or gynecologists. We evaluated differences between specialties to streamline evaluation for children with gynecological emergencies, develop a clinical pathway, and prevent care delays.

METHODS

A retrospective review of adolescents undergoing intervention for adnexal torsion from 2004-2018 was performed. Differences in time to intervention, operation duration, the procedure performed, and length of stay (LOS) between the specialties were analyzed.

RESULTS

Eighty-six patients underwent 94 operations for presumed adnexal torsion with 87 positive cases. Pediatric surgeons performed 60 operations and 34 cases were performed by gynecologists. Preservation of fertility was the goal in both cohorts and the rate of oophoropexy, cystectomy, and oophorectomy were similar between the cohorts (p = 0.14, p = 1.0, p = 0.39, respectively). There was no difference in intra-operative time (p = 0.69). LOS was shorter in the gynecology cohort (median 1 day [1-2] vs. 2 days [2-3], p > 0.001).

CONCLUSIONS

Adnexal torsion is a time-sensitive diagnosis requiring prompt intervention for ovarian or fallopian tube preservation. A multidisciplinary institutional care pathway should be developed and implemented.

Prediction of Adnexal Torsion by Ultrasound in Women with Acute Abdominal Pain

PURPOSE

 To investigate the accuracy of ultrasound in the diagnosis of adnexal torsion.

MATERIALS AND METHODS

 Retrospective cohort analysis of 322 women, presenting to a tertiary medical center with acute abdominal pain, who underwent gynecological examination, sonographic evaluation and laparoscopic surgery, between 2010 and 2016. Findings for adnexal torsion were compared among three groups: positive sonographic findings consistent with surgically confirmed adnexal torsion (true positive, n = 228); negative sonographic findings inconsistent with surgically confirmed adnexal torsion (false negative, n = 42); and positive sonographic findings inconsistent with a surgical diagnosis other than adnexal torsion (false positive, n = 52). Outcome measures were sensitivity and positive predictive value of ultrasound, and its specific features, for the diagnosis of adnexal torsion.

RESULTS

 The sensitivity of ultrasound for adnexal torsion diagnosis was 84.4 %, and the positive predictive value was 81.4 %. Edematous ovary and/or tube, as well as positive whirlpool sign had the highest sensitivity and positive predictive value. The false-negative group had the highest frequency of ovarian cysts (p = 0.0086) and the lowest frequency of ovarian edema (p < 0.0001). The false-positive group had the lowest proportion of pregnant women (p = 0.0022). Significantly more women in the true-positive group had a prior event of adnexal torsion (p = 0.026).

CONCLUSION

 Ultrasound examination is highly accurate in the diagnosis of adnexal torsion. Clinicians should be aware of the presence of demographic and clinical characteristics that may positively or negatively affect sonographic diagnostic accuracy.

Imaging in gynecological disease (20): clinical and ultrasound characteristics of adnexal torsion

OBJECTIVES

To describe the clinical and ultrasound characteristics of adnexal torsion.

METHODS

This was a retrospective study. From the operative records of the eight participating gynecological ultrasound centers, we identified patients with a surgically confirmed diagnosis of adnexal torsion, defined as surgical evidence of ovarian pedicle, paraovarian cyst and/or Fallopian tube twisted on its own axis, who had undergone preoperative ultrasound examination by an experienced examiner, between 2008 and 2018. Only cases with at least two available ultrasound images and/or videoclips (one grayscale and one with Doppler evaluation) were included. Clinical, ultrasound, surgical and histological information was retrieved from each patient's medical record and entered into an Excel file by the principal investigator at each center. In addition, two authors reviewed all available ultrasound images and videoclips of the twisted adnexa, with regard to the presence of four predefined ultrasound features reported to be characteristic of adnexal torsion: (1) ovarian stromal edema with or without peripherally displaced antral follicles, (2) the follicular ring sign, (3) the whirlpool sign and (4) absence of vascularization in the twisted organ.

RESULTS

A total of 315 cases of adnexal torsion were identified. The median age of the patients was 30 (range, 1-88) years. Most patients were premenopausal (284/314; 90.4%) and presented with acute or subacute pelvic pain (305/315; 96.8%). The surgical approach was laparoscopic in 239/312 (76.6%) patients and conservative surgery (untwisting with or without excision of a lesion) was performed in 149/315 (47.3%) cases. According to the original ultrasound reports, the median largest diameter of the twisted organ was 83 (range, 30-349) mm. Free fluid in the pouch of Douglas was detected in 196/275 (71.3%) patients. Ovarian stromal edema with or without peripherally displaced antral follicles was reported in the original ultrasound report in 167/241 (69.3%) patients, the whirlpool sign in 178/226 (78.8%) patients, absent color Doppler signals in the twisted organ in 119/269 (44.2%) patients and the follicular ring sign in 51/134 (38.1%) patients. On retrospective review of images and videoclips, ovarian stromal edema with or without peripherally displaced antral follicles (201/254; 79.1%) and the whirlpool sign (139/153; 90.8%) were the most commonly detected features of adnexal torsion.

CONCLUSION

Most patients with surgically confirmed adnexal torsion are of reproductive age and present with acute or subacute pain. Common ultrasound signs are an enlarged adnexa, the whirlpool sign, ovarian stromal edema with or without peripherally displaced antral follicles and free fluid in the pelvis. The follicular ring sign and absence of Doppler signals in the twisted organ are slightly less common signs. Recognizing ultrasound signs of adnexal torsion is important so that the correct treatment, i.e. surgery without delay, can be offered. Copyright © 2020 ISUOG. Published by John Wiley & Sons Ltd.

Sigmoid cancer mimicking ovarian echotexture on transvaginal ultrasound: Case report with literature review

Ultrasound is a first line imaging modality for the evaluation of female pelvic pain. Pelvic pain constitutes one of the most common reasons for presentation to the emergency department with increasing use of point of care ultrasound. Infrequently, point of care or formal ultrasound evaluation may lead to misdiagnosis of extraovarian disease. This can have serious consequences, especially if an extraovarian malignancy is mistaken for a normal ovary or an ovary with a benign process. We present a case of a 41-year-old female who presented to the emergency department for a chief complaint of pelvic pain and vaginal bleeding. Transvaginal ultrasound demonstrated a left adnexal mass, later characterized as a sigmoid colon cancer on MRI and pathology, simulating ovarian echotexture with peripheral hypoechoic components resembling follicles. This article will review the literature of various cases of extraovarian pathology misidentified as ovarian processes and highlight the importance of considering these extraovarian mimickers to prevent potential morbidity and mortality of a missed diagnosis.

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.

Accuracy of imaging modalities for adnexal torsion: a systematic review and meta-analysis

BACKGROUND

Adnexal torsion (AT), a serious gynaecological emergency, often presents with non-specific symptoms leading to delayed diagnosis.

OBJECTIVE

To compare the test accuracy of ultrasound, computed tomography (CT) and magnetic resonance imaging (MRI) to diagnose AT.

SEARCH STRATEGY

We searched EMBASE, MEDLINE and Cochrane CENTRAL until December 2019.

SELECTION CRITERIA

Studies reporting on the accuracy of any imaging modality (Index Test) in female patients (paediatric and adult) suspected of AT compared with surgical diagnosis and/or standard clinical/radiological follow-up period until resolution of symptoms (Reference Standard).

DATA COLLECTION AND ANALYSIS

We assessed study quality using QUADAS-2. We conducted test accuracy meta-analysis using a univariate model or a hierarchical model.

MAIN RESULTS

We screened 3836 citations, included 18 studies (1654 women, 665 cases), and included 15 in the meta-analyses. Ultrasound pooled sensitivity (n = 12, 1187 women) was 0.79 (95% CI 0.63-0.92) and specificity was 0.76 (95% CI 0.54-0.93), with negative and positive likelihood ratios of 0.29 (95% CI 0.13-0.66) and 4.35 (95% CI 2.03-9.32), respectively. Using Doppler with ultrasound (n = 7, 845 women) yielded similar sensitivity (0.80, 95% CI 0.67-0.93) and specificity (0.88, 95% CI 0.72-1.00). For MRI (n = 3, 99 women), the pooled sensitivity was 0.81 (95% CI 0.63-0.91) and specificity was 0.91 (95% CI 0.80-0.96). A meta-analysis for CT was not possible with two case-control studies and one cohort study (n = 3, 232 women). Its sensitivity range was 0.74-0.95 and specificity was 0.80-0.90.

CONCLUSIONS

Ultrasound has good performance as a first-line diagnostic test for suspected AT. Magnetic resonance imaging could offer improved specificity to investigate complex ovarian morphology, but more evidence is needed.

TWEETABLE ABSTRACT

To investigate adnexal torsion, ultrasound is a good first-line diagnostic test with a pooled sensitivity of 0.79 and specificity of 0.76.

Added value of MRI for the diagnosis of adnexal torsion in children and adolescents after inconclusive ultrasound examination

PURPOSE

The purpose of this study was to assess the performance of magnetic resonance imaging (MRI) in children and adolescents with suspected adnexal torsion (AT) after inconclusive initial ultrasound examination.

MATERIALS AND METHODS

Twenty-eight girls with a mean age of 12±4 (SD) years (range: 1 month to 18years) were included. All had clinically suspected AT and inconclusive initial ultrasound findings followed by pelvic MRI as a second-line imaging modality. The final diagnosis was obtained by surgery or follow-up. Two radiologists blinded to the clinical, ultrasound and surgical data, retrospectively and independently reviewed MRI examinations. Clinical and MRI features associated with AT were searched for using univariate analyses.

RESULT

Among the 28 patients, 10/28 patients (36%) had AT and 22/28 (79%) had an ovarian or tubal mass. AT was associated with an age<13years (OR: 10.7; 95% CI: 1.3-148.2) (P=0.022) and a whirlpool sign at MRI (OR: 61.0; median unbiased estimate, 7.2) (P<0.0001). When a mass was present, the best quantitative MRI criteria for AT were mass volume and ovary-corrected volume≥30cm³ (κ=0.72 and 0.61, respectively), mass axis length≥5cm (κ=0.90), and mass surface area≥14 cm² (κ=0.58), with moderate to almost perfect interobserver agreement. The overall sensitivity, specificity and accuracy of MRI for the diagnosis of AT were 100% (10/10; 95% CI: 69-100), 94% (17/18; 95% CI: 73-100) and 96% (27/28; 95% CI: 82-100) respectively, with perfect interobserver agreement (κ=1).

CONCLUSION

In pediatric patients with suspected AT and inconclusive initial ultrasound examination, a strategy including MRI as a second-line imaging modality should be considered if MRI does not delay a potential surgery.

Comparison of ovarian torsion between pregnant and non-pregnant women at reproductive ages: sonographic and pathological findings

Background

Differences in the ultrasonographic features and histological diagnosis of ovarian torsion in pregnant and non-pregnant women have not been defined. A better characterization of these features may help improve the accuracy of preoperative diagnosis. The present study aimed to compare the clinical characteristics, sonographic findings, operative procedures, and histological spectrum of ovarian torsion in pregnant and non-pregnant women.

Methods

This was a retrospective investigation of female patients at reproductive age with ovarian torsion between January 2010 and May 2017. Each patient received a detailed preoperative ultrasound, and the diagnosis was confirmed by surgery. The clinical characteristics, ultrasonic features, operative procedures, and histological diagnosis of ovarian torsion were retrieved from medical records and were compared in non-pregnant and pregnant patients according to the method of conception.

Results

The overall preoperative ultrasonic detection rate of ovarian torsion was 0.84, which was significantly different between pregnant and non-pregnant women. The presence of ovarian edema and abnormal adnexal positions also differed between pregnant and non-pregnant women. The ultrasonic features were not significantly different between the two pregnant sub-groups. The most common histologic diagnoses in the pregnant group and the non-pregnant group were a normal ovary and teratoma, respectively. The incidence of ovarian neoplasm was significantly lower in pregnant women. There were significant differences in the surgical procedures between the groups based on neoplastic or non-neoplastic lesions.

Conclusions

Ovarian edema, absence/decreased blood flow in the ovary, and the whirlpool sign were reliable ultrasonic markers for ovarian torsion at reproductive ages. The preoperative ultrasonic detection rate of ovarian torsion was higher in pregnant women, and ovarian edema was more common. The clinical features of ovarian torsion in pregnant women were similar, independent of the method of conception. In women with ovarian torsion, the incidence of non-neoplastic lesions was more frequent in pregnant women, whereas neoplastic lesions were more common in non-pregnant women. Ultrasonography provides useful parameters for the preclinical diagnosis of ovarian torsion to improve patient management.