Conservative management of adnexal torsion in premenarchal girls

doi:10.1016/S1074-3804(00)80021-3

The Journal of the American Association of Gynecologic Laparoscopists

Volume 7, Issue 1, February 2000, Pages 121-124

https://doi.org/10.1016/S1074-3804(00)80021-3 Get rights and content

Abstract

Study Objective.

To evaluate treatment of premenarchal girls with torsion of the adnexa.

Design.

Retrospective review of medical records (Canadian Task Force classification II-2).

Setting.

Tertiary care, university-affiliated hospital.

Patients.

Eight premenarchal girls (age range 3–12 yrs) with twisted adnexa.

Intervention.

Laparoscopic detorsion and follow-up with B scan and Doppler ultrasound imaging.

Measurements and Main Results.

Duration of complaints ranged from 8 to 72 hours (mean 34.6 hrs) and the interval from admission to surgery ranged from 6 to 24 hours (mean 18.7 hrs). Four patients had torsion of normalappearing adnexa. The other four had ovarian neoplasms. Two had cystic mature teratomas (dermoid cysts) and one a serous cystadenoma that required additional operation. The fourth girl had a simple ovarian cyst that was aspirated laparoscopically. Seven girls (87%) had normal-appearing ovaries on follow-up ultrasound. In one patient, a small ovary was seen, with no intraovarian blood flow on color Doppler.

Conclusion.

Although the diagnosis of torsion of the adnexa in premenarchal girls is difficult and usually delayed, laparoscopic detorsion seems to be an effective adnexa-sparing approach. We suggest that laparoscopy should be the treatment of choice and that detorsion, rather than adnexectomy, be performed more often in these patients.

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Ovarian torsion is a rare, frequently misdiagnosed condition that carries with it a high rate of morbidity.
This review highlights the pearls and pitfalls of ovarian torsion, including presentation, evaluation, and management in the emergency department (ED) based on current evidence.
Ovarian torsion is one of the most common gynecological surgical emergencies and occurs with complete or partial rotation of the ovary along the supporting ligaments, obstructing vascular flow. Several risk factors include the presence of an ovarian mass or cyst. The most common population affected includes reproductive aged women, though cases also occur in premenarchal females, pregnant women, and postmenopausal women. Abdominal or pelvic pain is common but is not always sudden in onset or severe. Nausea and vomiting occur in 70%. Ultrasound can assist with diagnosis, but a normal ultrasound examination cannot exclude the diagnosis. Computed tomography with intravenous contrast can assist with diagnosis. Treatment includes emergent gynecologic consultation for surgical detorsion, along with symptomatic therapy in the ED.
An understanding of ovarian torsion can assist emergency clinicians in diagnosing and managing this disease.
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To study features of isolated fallopian tube torsion (IFTT) to promote early diagnosis of this entity and describe options for management.
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All patients with surgically confirmed adnexal torsion or IFTT during the study period.
All of the patients underwent gynecological examination, imaging, and laparoscopy.
During this 3-year period, 64 patients underwent laparoscopy owing to confirmed torsion, of which 55 had adnexal torsion, and 9 had IFTT. Patients with IFTT tended to be younger (21.2 years ± 8.2 vs 29.1 years ± 11.9, p = .06) and had more fever on admission (p = .007). On ultrasound examination, isolated hydrosalpinx was demonstrated only in patients with IFTT (p <.001). During surgery, more para-ovarian cysts were observed in patients with IFTT (44.4% vs 10.9%, p = .01), whereas patients with adnexal torsion had more ovarian cysts (52.7% vs 0%, p = .003). The most common procedure was detorsion in both groups. Most patients that underwent detorsion of the tube had a normal ultrasound scan on follow-up examination.
IFTT is probably underdiagnosed. Its clinical presentation is more equivocal than adnexal torsion, and ovaries are usually of normal size on ultrasonography. Hydrosalpinx or para-ovarian cysts should raise suspicion toward IFTT. Detorsion of the tube is probably a valid management option, although further research with long-term follow-up analyzing tubal patency is necessary to define the optimal management for this condition.
Adnexal Torsion
2018, Journal of Pediatric and Adolescent Gynecology
Citation Excerpt :
The most frequently encountered lesions are mature cystic teratoma and follicular cysts.12,16–19 Torsion of a normal ovary is more prevalent in the prepubescent population.11,20–22 Overall, AT is reported more commonly on the right side than on the left.10,11,17,21,23
Adnexal torsion is an uncommon gynecologic disorder caused by the partial or complete rotation of the ovary and/or the fallopian tube on its vascular support. Delay in treatment can impact fertility adversely. The objective of this report is to provide clinical recommendations based on the latest evidence. Specifically we discuss epidemiology, clinical presentation, diagnostic approach and management of adnexal torsion in adolescents.
Pediatric Adnexal Torsion: Not Just a Postmenarchal Problem
2017, Journal of Emergency Medicine
Pediatric adnexal torsion is rare, can be challenging to recognize, and may result in ovarian loss.
We sought to identify and compare the defining characteristics of adnexal torsion in premenarchal and postmenarchal girls.
A retrospective cohort study was performed at a tertiary care children's hospital, including patients diagnosed postnatally with adnexal (ovarian or tubal) torsion between 1997 and 2013. Proportions were compared using relative risk regression.
Adnexal torsion was found in 59 premenarchal and 43 postmenarchal girls. Abdominal pain was the most common chief complaint (54%). History included reports of pain (96%), vomiting (67%), and fever (19%). Excluding 12 patients with isolated tubal torsion and 19 with a teratoma, there were no statistically significant differences in ovarian loss in premenarchal vs. postmenarchal girls (47% and 25% respectively; relative risk [RR] = 1.8 [95% confidence interval {CI} 0.9–3.8]), left- vs. right-sided torsion (47% and 32%; RR = 1.5 [95% CI 0.8–2.7]), pain duration ≤ 2 days vs. > 2 days (31% and 41%; RR = 0.8 [95% CI 0.4–1.5]; n = 64) and severe pain vs. mild to moderate (38% and 33%; RR = 1.1 [95% CI 0.7–1.5]; n = 56).
The diagnosis of pediatric adnexal torsion is difficult and often delayed. Pain and tenderness may not be isolated to a unilateral lower quadrant. Although traditionally considered a postmenarchal problem, in a pediatric academic emergency department adnexal torsion occurred with similar frequency in premenarchal and postmenarchal girls. The potential for organ salvage means that adnexal torsion should be considered in all females presenting with acute abdominal pain regardless of age or menstrual history.
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Current trends in the surgical treatment of pediatric ovarian torsion: We can do better
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Current literature strongly recommends ovarian preservation for pediatric patients with ovarian torsion. The purpose of this study was to evaluate national trends in the surgical management of pediatric ovarian torsion and to compare outcomes between pediatric surgeons (PED) and gynecologists (GYN).
We queried Pediatric Health Information System (PHIS) data from 2007 to 2011 for patients < 18 years old with a diagnosis of ovarian torsion who underwent a surgical procedure. Patients with malignant disease were excluded. Outcomes were compared between pediatric surgeons and gynecologists.
A total of 1151 patients were identified with a mean age of 10.7 ± 4.1 years with a bimodal distribution. Pediatric surgeons performed the majority of procedures (81%) and were more likely to use a laparoscopic approach (PED 27% vs. GYN 17%, p < .05). Pediatric surgeons were more likely to perform an oophorectomy (PED 38% vs. GYN 27%, p < .01), and more likely to administer antibiotics for this clean procedure (PED 61% vs. GYN 29%, p < .001). The overall reoperation rate was 5.1% and did not differ significantly by subspecialty (PED 4.4% vs. GYN 7.8%, p > .05).
These data demonstrate a significant opportunity for pediatric surgeons and gynecologists to improve ovarian salvage rates and to reduce unnecessary antibiotic utilization for children with ovarian torsion.

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¹: Presented at the 26th annual meeting of the American Association of Gynecologic Laparoscopists, Seattle, Washington, September 23–28, 1997.

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Original articleConservative management of adnexal torsion in premenarchal girls1

Abstract

Study Objective.

Design.

Setting.

Patients.

Intervention.

Measurements and Main Results.

Conclusion.

Pediatr Surg

Am J Obstret Gynecol

Pediatr Surg

Am J Obstet Gynecol

J Pediatr Surg

Original article
Conservative management of adnexal torsion in premenarchal girls1