Diagnosing And Managing Ovarian And Adnexal Torsion In Children

Table of Contents

 

1. Abstract
2. Case Presentations
3. Introduction
4. Critical Appraisal Of The Literature
5. Epidemiology, Etiology, And Pathophysiology
6. Differential Diagnosis
7. Prehospital Care
8. Emergency Department Evaluation
   1. History
   2. Physical Examination
9. Diagnostic Studies
   1. Laboratory Testing
   2. Plain Radiography
   3. Pelvic Ultrasound
   4. Computed Tomography And Magnetic Resonance Imaging
   5. Accuracy Of Diagnostic Imaging
10. Treatment
    1. Traditional Management
    2. Conservative Treatment With Detorsion And Ovarian Salvage
       1. Viability Of The Torsed Ovary
11. Special Circumstances
12. Controversies And Cutting Edge
13. Disposition
14. Summary
15. Risk Management Pitfalls For Ovarian Torsion In Children
16. Cost-Effective Strategies For Managing Ovarian Torsion In The Emergency Department
17. Case Conclusion
18. Clinical Pathway For Management Of Ovarian Torsion In Children
19. Tables and Figures
    1. Table 1. American College Of Radiology Guidelines On Imaging In Suspected Ovarian Torsion
    2. Table 2. Differential Diagnosis For Abdominal Pain In The Pediatric Female
    3. Table 3. Possible Ultrasound Findings In Ovarian Torsion
    4. Figure 1. Abdominal X-Ray Showing Calcification In The Right Pelvis
    5. Figure 2. Congested Ovary And Cyst With The Twisted Pedicle Clearly Visible
    6. Figure 3. Ultrasound Image Showing Portions Of An Enlarged Right Ovary
    7. Figure 4. Doppler Ultrasound Image Of Right Ovary
20. References

Abstract

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.

Case Presentations

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.

Introduction

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.

Critical Appraisal Of 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.

Risk Management Pitfalls For Ovarian Torsion In Children

1. “The patient was only 6 years old; I didn’t consider a gynecologic cause for her pain.”

   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.

2. “Since the patient was previously found to have an ovarian cyst, I didn’t think we needed to reimage her.”

   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.

3. “She had right lower quadrant pain with vomiting, a low-grade fever, and was tender on examination. It sounded like a classic case of appendicitis, so I called the surgeon. I was surprised when they called from the operating room to tell me that her ovary was torsed.”

   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.

4. “She told me that the pain had been coming and going and that she’d had similar episodes of pain previously, so I didn’t think it was anything serious.” Many patients with ovarian torsion will report previous episodes of similar pain. Intermittent torsion has been well-described, and patients can have spontaneous detorsion and may not seek medical attention until they have an episode that is prolonged or more severe than they havepreviously experienced. A history of prior pain should actually raise your suspicion for ovarian torsion and trigger further investigation.
5. “She seemed to be in a fair amount of pain, but she didn’t have any tenderness on examination. I discharged her, and when she came back the next day, my partner diagnosed her with ovarian torsion.” The hallmark of ovarian torsion is abdominal pain; all other symptoms and findings can be variable. A patient with ovarian torsion may not have a significant amount of tenderness on examination, but it may be possible to palpate a pelvic mass when there is a large cyst or teratoma predisposing to the torsion. The clinical history should be enough to raise the suspicion of ovarian torsion even in the absence of physical findings, and further evaluation with ultrasound is indicated, especially in the patient with ongoing pain.
6. “She had an elevated CRP and her WBC count was up, so I ordered a CT to look for appendicitis. I wasn’t expecting the radiologist to call and tell me that the scan showed she had a pelvic mass.” Elevated WBC and CRP are nonspecific and may be seen in many different causes of abdominal pain, including ovarian torsion. Although they are statistically higher in appendicitis than in ovarian torsion, they are not useful in differentiating the etiology in an individual patient. Ultrasound should always be considered in the pediatric female with lower abdominal pain, since it is noninvasive, does not expose the patient to radiation, and has reasonable diagnostic accuracy for appendicitis as well as other causes of pain.
7. “I ordered the ultrasound, but the ovary had Doppler flow, so I thought the ovary couldn’t be torsed.” Doppler flow is not sensitive to exclude ovarian

   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.

8. “The ultrasound showed a significant ovarian enlargement, but it was bilateral, so I didn’t think it could be torsion.” Ovarian enlargement in ovarian torsion is a common finding and likely has the highest sensitivity of the various possible ultrasound abnormalities. Bilateral torsion is rare, but not unheard of. Any concerning ultrasound findings in the setting of a suspicious clinical history should trigger a consultation with gynecology. Diagnostic laparoscopy is the definitive

   diagnostic modality and should be considered in patients without a clear diagnosis after imaging.

9. “The ovary didn’t have flow on the ultrasound, and my patient had been having pain constantly for 3 days. It was the middle of the night and I figured that, after this much time, there was no chance of saving the ovary, so I waited until the morning to call the gynecologist.” Duration of symptoms has not been correlated with irreversible ischemia in ovarian torsion, and should not be used as a prognostic factor. Many patients have had their ovary salvaged even after multiple days of symptoms. With a definitive ultrasound diagnosis, the gynecologist should be called immediately and the patient prepared for the operating room, even if she has had prolonged symptoms.
10. “After the ultrasound showed ovarian torsion, I went to talk to the patient and her family and tell them the plan. They asked me what would happen, so I told them that she’d need to have her ovary removed.” Although ovarian torsion has traditionally been treated with oophorectomy, recent studies have shown very good outcomes after detorsion and ovarian conservation. While this approach has not yet gained universal acceptance, an increasing number of patients are having their ovary salvaged, and this is likely to become the future standard of care.

Tables and Figures

References

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.

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