Eilbert and Nguyen: 초경 전 난소꼬임
Abstract
Ovarian torsion is a common gynecologic emergency seen in women of all ages, mostly in reproductive women, resulting in ischemia and necrosis of the adnexal tissue. However, it is rare in premenarchal girls. This article reviews the limited published literature, and discusses special considerations about premenarchal ovarian torsion.
Key Words: Laparoscopy; Menarche; Ovarian Torsion; Pediatrics; Ultrasonography, Doppler, Color
Introduction
First described by Bland Sutton in 1890, ovarian torsion (OT) involves the twisting of the adnexa, including the fallopian tube or ovary 1). A torsion causes venous compression, leading to ovarian edema and enlargement. If torsion persists, arterial blood flow becomes compromised, resulting in ischemia and necrosis of the adnexal tissue. OT is the fifth most common gynecologic emergency, accounting for 2.7% of all emergency gynecologic surgeries 2). While most common in reproductive women, approximately 15% of OTs occur during infancy or childhood2). OT most commonly affects women aged 29-34 years, with an estimated incidence of 4.9 per 100,000 among women aged 1-20 years 3,4).
To date, the majority of publications describing OT in premenarchal girls have consisted of case reports and case series, primarily in the gynecologic and surgical literature 5-13). This narrative review provides a summary of OT in children with a focus on premenarchal OT.
Main subjects
1. Epidemiology and pathophysiology
While OT can occur in girls of any age, more than 50% of cases occur in those aged 9-14 years 12). OT was found to be the cause of 1.3% of all non-traumatic abdominal emergencies evaluated in a pediatric emergency department 14). Similarly to adults, the right ovary twists in 60% of children with OT while 40% occurring on the left 15). It has been postulated that the right-side dominance is due to the sigmoid colon occupying the pelvic space on the left, or the hypermobility of the distal ileum and cecum on the right 16). Asynchronous bilateral OTs in children have been reported 17).
Majority of the girls with OT are postmenarchal and subject to hormonal influences, predisposing them to developing an adnexal mass 7). The presence of such a mass increases the likelihood of torsion since a heavy ovary is more likely to twist on its pedicle. The most frequent adnexal masses found with pediatric OTs are benign cystic teratoma and hemorrhagic or follicular cyst 6,16,18). As with adults, the incidence of malignancy associated with OT in children is quite low, with some studies reporting a 0% incidence of associated malignancy 8,18,19).
Premenarchal OT is less likely to be associated with an ovarian mass than postmenarchal OT, with some studies reporting over 50% of premenarchal OTs occurring in the structurally normal ovaries 9,10). Possible factors associated with torsion of the normal ovary include an abnormally long ovarian suspensory ligament, increased venous congestion in the premenarchal period, previous gynecologic surgery, and abrupt changes in intraabdominal pressure from coughing or vomiting 9,12,16,20,21). Premenarchal functional ovarian cysts, which predispose to OT, occur most frequently during the first year of life and around the time of menarche 16,22). This is attributed to the lingering maternal hormones in the former period and the self-secreting hormones in the latter. These endocrinologic features explain the bimodal distribution of premenarchal OT, with the peak ages at infancy and at 12 years. 23).
2. Presentation
Abdominal pain, usually described as having abrupt onset in the lower abdomen, is the presenting symptom in over 90% of pediatric OT ( Table 1) 5,7-11,15,16,21,24,25). Vomiting is the next most common symptom, occurring in the majority of pediatric patients 5,7,9,15,16,21,24,26). Vomiting is more prominent in premenarchal girls than postmenarchal ones 9). Approximately half of the patients report having had similar symptoms, indicating a possible previous torsion and detorsion 26,27). Diagnosis of OTs in infants may be challenging in light of their nonverbal status. While not well-studied, most infantile OTs present with a groin mass and vomiting 28). The symptom duration prior to presentation is typically longer than 24 hours, with premenarchal girls often having a significantly longer duration than postmenarchal ones 5,7,9).
On physical examination, majority of the patients have abdominal tenderness, with peritoneal signs present in less than half of them 7,9,15,21). A palpable mass is present in up to 50%, and is more common in premenarchal girls 7,9,10,15,16,26). Fever is present in a minority, and is also more common in premenarchal girls 5,7,9,10,16,21).
The presentation of OT in children frequently mimics other more common surgical emergencies, such as appendicitis and intussusception 28-30). Not surprisingly, many diagnoses of OT in children are made during surgery for a possible appendicitis 31).
3. Evaluation
Serum white blood cell count has little value in the evaluation of possible OT in children, and is elevated in 38%-82% of cases 8,16). In contrast, a C-reactive protein concentration higher than 5 mg/L was found to have an odds ratio of 12.3 32). Approximately one-third of girls diagnosed with OT may undergo multiple imaging modalities before the diagnosis is made 33). This is possibly driven by the fact that only approximately half of physicians suspect gynecologic diseases as the first presumptive diagnosis in cases of proven pediatric OT 30). This percentage drops to one third in premenarchal girls 30). Compared with postmenarchal girls, premenarchal girls with OT are more likely to obtain a delayed diagnosis, with a study reporting the delay in 38% of premenarchal girls compared with 20% in postmenarchal ones 12).
Doppler ultrasonography (US) has a reported 80% sensitivity and an 85%-95% specificity for adult OT 34). For pediatric OT, the imaging modality has a 79% sensitivity and a 92% specificity 35). Computed tomography has reported a 90%-100% sensitivity and an 85%-90% specificity, but it has a disadvantage of radiation exposure 34,36). For this reason, US is considered the imaging modality of choice 15,36-39). Magnetic resonance imaging has an 81% sensitivity and a 91% specificity, and has the advantage of no radiation exposure like US 37). However, the use of magnetic resonance imaging is limited by availability and the frequent need for sedation in younger patients.
For sonographic diagnosis of OT, morphologic features are more important than the absence of arterial flow on Doppler images. Although transvaginal US is ideal for sonographic diagnosis, in reality, only transabdominal US is performed in most pediatric cases. The most common finding is an asymmetrically edematous ovary with an increased volume typically 3-4 times that of the contralateral ovary 40). Irregular ovarian wall thickening and free fluid in the pelvis may also be seen 40,41). In pediatric OT, an absence of Doppler flow is seen only in 38%-75% of cases 8-10,33,42,43). This is likely due to the dual blood supply to the ovary from the ovarian and uterine arteries. Authors in both the pediatric and adult literature have concluded that Doppler flow alone cannot be relied on to diagnose or exclude the diagnosis of OT 41,45).
4. Treatment
Laparoscopic surgery is considered the best diagnostic and therapeutic modality for pediatric OT 35). In 29%-80% of pediatric OTs, the diagnosis is suspected before surgery 7,8,18,27). Premenarchal girls are significantly less likely to have a preoperative diagnosis of OT than postmenarchal ones 7). Surgical management of pediatric OT has changed recently, with a shift from oophorectomy to ovarian detorsion with or without oophoropexy 8,43,46,47). An ovarian salvage rate of 27%-99% in children has been reported with this more conservative approach 48). Specifically in premenarchal girls, a 100% ovarian salvage rate was reported 49).
Conclusion
Pediatric OT is rare, particularly prior to the menarche. Unlike postmenarchal OT, premenarchal OT frequently involves the structurally normal ovaries. The peak incidences of premenarchal OT are in infancy and just prior to menarche. Abdominal pain is the most common presenting symptom. Vomiting and palpable masses are often present, particularly in premenarchal girls. Pediatric OT is frequently misdiagnosed preoperatively as appendicitis. US is the imaging modality of choice, with an enlarged, edematous ovary commonly seen. An absence of Doppler flow is not universally present in pediatric OT. Laparoscopic surgery is considered the diagnostic and therapeutic modality of choice for pediatric OT.
Conflicts of interest
No potential conflicts of interest relevant to this article were reported.
Notes
Funding sources
No funding source relevant to this article was reported.
Table 1.
Frequency of manifestations with pediatric ovarian torsion
Variable |
Frequency, % |
Symptoms |
|
Abdominal pain |
90-100 |
Vomiting |
33-82 |
Anorexia |
53 |
Urinary symptoms |
8-14 |
Diarrhea |
8 |
Signs |
|
Abdominal tenderness |
61-95 |
Palpable mass |
8-50 |
Peritoneal signs |
27-47 |
Fever |
4-22 |
Abdominal distension |
10 |
References
1. Bland Sutton J. Salpingitis and some of its effects. Lancet 1890;136:1206–9.
2. Hibbard LT. Adnexal torsion. Am J Obstet Gynecol 1985;152:456–61.
3. Bridwell RE, Koyfman A, Long B. High risk and low prevalence diseases: ovarian torsion. Am J Emerg Med 2022;56:145–50.
5. Pansky M, Abargil A, Dreazen E, Golan A, Bukovsky I, Herman A. Conservative management of adnexal torsion in premenarchal girls. J Am Assoc Gynecol Laparosc 2000;7:121–4.
6. Wang JH, Wu DH, Jin H, Wu YZ. Predominant etiology of adnexal torsion and ovarian outcome after detorsion in premenarchal girls. Eur J Pediatr Surg 2010;20:298–301.
7. Ashwal E, Hiersch L, Krissi H, Eitan R, Less S, Wiznitzer A, et al. Characteristics and management of ovarian torsion in premenarchal compared with postmenarchal patients. Obstet Gynecol 2015;126:514–20.
8. Ashwal E, Krissi H, Hiersch L, Less S, Eitan R, Peled Y. Presentation, diagnosis, and treatment of ovarian torsion in premenarchal girls. J Pediatr Adolesc Gynecol 2015;28:526–9.
10. Schuh AM, Klein EJ, Allred RJ, Christensen A, Brown JC. Pediatric adnexal torsion: not just a postmenarchal problem. J Emerg Med 2017;52:169–75.
11. Tasset J, Rosen MW, Bell S, Smith YR, Quint EH. Ovarian torsion in premenarchal girls. J Pediatr Adolesc Gynecol 2019;32:254–8.
12. Prieto JM, Kling KM, Ignacio RC, Bickler SW, Fairbanks TJ, Saenz NC, et al. Premenarchal patients present differently: a twist on the typical patient presenting with ovarian torsion. J Pediatr Surg 2019;54:2614–6.
14. Tseng YC, Lee MS, Chang YJ, Wu HP. Acute abdomen in pediatric patients admitted to the pediatric emergency department. Pediatr Neonatol 2008;49:126–34.
15. Rey-Bellet Gasser C, Gehri M, Joseph JM, Pauchard JY. Is it ovarian torsion? A systematic literature review and evaluation of prediction signs. Pediatr Emerg Care 2016;32:256–61.
16. Kokoska ER, Keller MS, Weber TR. Acute ovarian torsion in children. Am J Surg 2000;180:462–5.
18. Cass DL. Ovarian torsion. Semin Pediatr Surg 2005;14:86–92.
19. Beaunoyer M, Chapdelaine J, Bouchard S, Ouimet A. Asynchronous bilateral ovarian torsion. J Pediatr Surg 2004;39:746–9.
20. Shust NM, Hendricksen DK. Ovarian torsion: an unusual cause of abdominal pain in a young girl. Am J Emerg Med 1995;13:307–9.
21. Tsafrir Z, Azem F, Hasson J, Solomon E, Almog B, Nagar H, et al. Risk factors, symptoms, and treatment of ovarian torsion in children: the twelve-year experience of one center. J Minim Invasive Gynecol 2012;19:29–33.
22. Hoey BA, Stawicki SP, Hoff WS, Veeramasuneni RK, Kovich H, Grossman MD. Ovarian torsion associated with appendicitis in a 5-year-old girl: a case report and review of the literature. J Pediatr Surg 2005;40:e17–20.
23. Oltmann SC, Fischer A, Barber R, Huang R, Hicks B, Garcia N. Cannot exclude torsion--a 15-year review. J Pediatr Surg 2009;44:1212–7.
24. Rossi BV, Ference EH, Zurakowski D, Scholz S, Feins NR, Chow JS, et al. The clinical presentation and surgical management of adnexal torsion in the pediatric and adolescent population. J Pediatr Adolesc Gynecol 2012;25:109–13.
26. Schultz LR, Newton WA Jr, Clatworthy HW Jr. Torsion of previously normal tube and ovary in children. N Engl J Med 1963;268:343–6.
27. Emonts M, Doornewaard H, Admiraal JC. Adnexal torsion in very young girls: diagnostic pitfalls. Eur J Obstet Gynecol Reprod Biol 2004;1116:207–10.
28. Mordehai J, Mares AJ, Barki Y, Finaly R, Meizner I. Torsion of uterine adnexa in neonates and children: a report of 20 cases. J Pediatr Surg 1991;26:1195–9.
29. Smith CJ, Bey T, Emil S, Wichelhaus C, Lotfipour S. Ovarian teratoma with torsion masquerading as intussusception in 4-year-old child. West J Emerg Med 2008;9:228–31.
30. Chang YJ, Yan DC, Kong MS, Wu CT, Chao HC, Luo CC, et al. Adnexal torsion in children. Pediatr Emerg Care 2008;24:534–7.
31. Schmitt ER, Ngai SS, Gausche-Hill M, Renslo R. Twist and shout! Pediatric ovarian torsion clinical update and case discussion. Pediatr Emerg Care 2013;29:518–23.
32. Bolli P, Schädelin S, Holland-Cunz S, Zimmermann P. Ovarian torsion in children: development of a predictive score. Medicine (Baltimore) 2017;96:e8299.
33. Piper HG, Oltmann SC, Xu L, Adusumilli S, Fischer AC. Ovarian torsion: diagnosis of inclusion mandates earlier intervention. J Pediatr Surg 2012;47:2071–6.
34. Swenson DW, Lourenco AP, Beaudoin FL, Grand DJ, Killelea AG, McGregor AJ. Ovarian torsion: Case-control study comparing the sensitivity and specificity of ultrasonography and computed tomography for diagnosis in the emergency department. Eur J Radiol 2014;83:733–8.
35. Naiditch JA, Barsness KA. The positive and negative predictive value of transabdominal color Doppler ultrasound for diagnosing ovarian torsion in pediatric patients. J Pediatr Surg 2013;48:1283–7.
36. Bronstein ME, Pandya S, Snyder CW, Shi Q, Muensterer OJ. A meta-analysis of B-mode ultrasound, Doppler ultrasound, and computed tomography to diagnose pediatric ovarian torsion. Eur J Pediatr Surg 2015;25:82–6.
39. Scheier E, Balla U. Pediatric ovarian torsion on point-of-care ultrasound: a case series. Pediatr Emerg Care 2022;38:e1159–63.
41. Melcer Y, Maymon R, Pekar-Zlotin M, Pansky M, Smorgick N. Clinical and sonographic predictors of adnexal torsion in pediatric and adolescent patients. J Pediatr Surg 2018;53:1396–8.
43. Spinelli C, Buti I, Pucci V, Liserre J, Alberti E, Nencini L, et al. Adnexal torsion in children and adolescents: new trends to conservative surgical approach -- our experience and review of literature. Gynecol Endocrinol 2013;29:54–8.
44. Grunau GL, Harris A, Buckley J, Todd NJ. Diagnosis of ovarian torsion: is it time to forget about Doppler? J Obstet Gynaecol Can 2018;40:871–5.
45. Childress KJ, Dietrich JE. Pediatric ovarian torsion. Surg Clin North Am 2017;97:209–21.
46. Aziz D, Davis V, Allen L, Langer JC. Ovarian torsion in children: is oophorectomy necessary? J Pediatr Surg 2004;39:750–3.
47. Dasgupta R, Renaud E, Goldin AB, Baird R, Cameron DB, Arnold MA, et al. Ovarian torsion in pediatric and adolescent patients: a systematic review. J Pediatr Surg 2018;53:1387–91.
48. Appelbaum H, Abraham C, Choi-Rosen J, Ackerman M. Key clinical predictors in the early diagnosis of adnexal torsion in children. J Pediatr Adolesc Gynecol 2013;26:167–70.
49. Yildiz A, Erginel B, Akin M, Karadag CA, Sever N, Tanik C, et al. A retrospective review of the adnexal outcome after detorsion in premenarchal girls. Afr J Paediatr Surg 2014;11:304–7.
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