Although ovarian torsion is rare in children, it is frequently misdiagnosed in the broad differential diagnosis of its major presenting symptom: abdominal pain. In addition to the pain that ovarian torsion causes, when left untreated, ovarian torsion represents a significant threat to the future fertility of girls. This review looks at the evidence on diagnosing ovarian torsion, focusing particularly on diagnostic imaging modalities and the major guideline recommendations to effectively differentiate ovarian torsion from the many other possible causes of abdominal pain in the pediatric female. Literature regarding the relevance of symptom duration in the prediction of ovarian salvageability is discussed as well as recurrence, complications, and conservative operative management. A combination of findings from the history, the physical examination, and ultrasound imaging will guide emergency clinicians in prompt and effective surgical referrals for ovarian torsion, offering patients the best hope to avoid morbidity.
In the middle of a busy shift, you go in to see a 13-year-old female who has presented with 3 hours of constant, “cramping” right lower quadrant pain that awoke her from sleep. Since the onset of pain, she has had 10 episodes of emesis. She denies any sexual activity, and her last menstrual period was approximately 3 weeks prior. Her vital signs are appropriate for her age, and she is in moderate distress secondary to pain. Her physical examination is unremarkable except for tenderness to palpation in the right lower quadrant and suprapubic area. Although your first thought is that this patient has appendicitis, you want to make sure that you do not miss the possibility of ovarian torsion. You wonder how often ovarian torsion occurs in children and how you should proceed in the diagnostic work-up of this patient. You order basic blood work and a urinalysis, but what will you do if they are normal? Should you order a CT or an ultrasound, or should you just call the surgeon? You remember one of your partners recently had a young patient who presented similarly. She had several days of worsening symptoms, and in the ED her ultrasound showed a complex pelvic mass. Gynecology took the patient to the operating room and discovered that she had an ovarian teratoma that had torsed. The ovary was removed because it appeared necrotic. You wonder: if this patient has torsion, does the duration of her symptoms have any prognostic value? You remind yourself to ask the gynecologist if an ovary that appears ischemic at the time of surgery should be removed, and if there is any risk if it is detorsed and left in place.
Abdominal pain is one of the most frequently encountered complaints in pediatric emergency medicine, and the emergency clinician must determine who among these patients may have serious pathology and needs further evaluation or management. Ovarian torsion is one of the “cannot miss” diagnoses that presents with abdominal pain, and it must be considered in every case of abdominal pain in a female patient. Nonetheless, ovarian torsion in the pediatric patient is an uncommon event and is frequently a challenging diagnosis to make. Clinicians who care for children in the acute setting can avoid missing this diagnosis by being aware of the symptoms and the diagnostic findings and by maintaining vigilance for ovarian torsion. This issue of Pediatric Emergency Medicine Practice focuses on the evaluation and management of the patient with suspected ovarian torsion, using the best available evidence from the literature.
Ovid MEDLINE® was searched, through PubMed, for articles published since 1970. Keywords were torsion and adnexal or ovarian. Over 1300 results were retrieved, and titles and abstracts were reviewed for relevance. Papers focusing on torsion during fertility treatment or in pregnant patients and antenatal torsion were specifically excluded. More than 130 papers focusing on pediatric patients were included in this review. Nothing of relevance was found in a search of the Cochrane Database of Systematic Reviews, while a search of the National Guideline Clearinghouse (http://www.guidelines.gov) resulted in 3 relevant documents from the American College of Radiology.1-3 (See Table 1.)
The literature on history and physical examination findings is based predominantly on older, retrospective case series, with some recent additions. The majority of the literature on diagnostic imaging for ovarian torsion has been published in the last 20 years, with emphasis on ultrasonography and Doppler techniques. Since the primary challenge for the emergency clinician is making the diagnosis of ovarian torsion, a significant portion of this article will be devoted to reviewing the literature on diagnostic imaging. Unfortunately, much of this is based on retrospective case series, with very few prospective studies and no randomized trials. Recently, there has been some investigation into biomarkers for ovarian torsion, although the sample sizes are small or use animal models and, therefore, have limited applicability for the emergency clinician.
Other notable contributions to the recent literature deal with operative strategies, specifically with regard to ovarian conservation and functional outcome. There are some larger case series and a few prospective studies, although there is, again, an absence of any randomized trials. Although much has been written about the diagnosis and treatment of ovarian torsion, we are limited by an overwhelming preponderance of anecdotal and retrospective data, so there is little true evidence to support much of current practice.
Although gynecologic causes of abdominal pain are uncommon in children, ovarian torsion can occur at any age. The differential diagnosis for any patient with concerning symptoms needs to include ovarian torsion, regardless of age. Even premenarchal patients need a pelvic ultrasound, which can be done transabdominally.
Ovarian cysts are known to predispose patients to ovarian torsion, especially when intermediate in size (eg, 5 cm). A patient with a previous
history of an ovarian cyst and acute pelvic pain must be evaluated for ovarian torsion, and repeat ultrasound is indicated.
Ovarian torsion is frequently misdiagnosed as acute appendicitis because there is significant overlap between the clinical presentations of these 2 disorders. Before making the clinical diagnosis of appendicitis in a female, ovarian torsion should first be excluded with a pelvic ultrasound.
torsion, and it may actually be present in as many as two-thirds of patients with ovarian torsion. Abnormal venous flow may be more sensitive than lack of arterial flow, but it is not always reported. The ultrasound diagnosis of ovarian torsion is usually made on the basis of a combination of findings, none of which have high sensitivity individually.
diagnostic modality and should be considered in patients without a clear diagnosis after imaging.
Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report.
To help the reader judge the strength of each reference, pertinent information about the study, such as the type of study and the number of patients in the study will be included in bold type following the references, where available. The most informative references cited in this paper, as determined by the author, will be noted by an asterisk (*) next to the number of the reference.
Eric R. Schmitt; Marianne Gausche-Hill
July 1, 2012