Patient Presentation
An 18-year-old female came to the emergency department with an 18 hour history of sudden onset of right lower quadrant pain. She had a sharp pain that was now fairly constant. She said she felt like it was in her lower abdomen and into her right pelvis. She said she hadn't felt well for a couple hours before that and had had some nausea and emesis before the pain. She continued to be nauseous and had intermittent emesis that was non-bilious and non-bloody since then. She denied any fever, chills, dysuria, or diarrhea. She denied being sexually active with her last menstruation 2.5 weeks previously. She denied any vaginal symptoms. She had eaten the same food as her college roommates who were all well. The past medical history was non-contributory.
The pertinent physical exam showed slightly elevated blood pressure and heart rate that were attributed to pain and anxiety. She was afebrile. Her abdominal examination was positive for tenderness without guarding on the right lower quadrant towards the pelvis. There was no pain along the liver either. There was no obvious hepatosplenomegaly, suprapubic or costovertebral angle tenderness. The rest of her examination was normal.
A working diagnosis of probably appendicitis versus ovarian torsion was considered. The laboratory evaluation showed she was not pregnant, her white blood cell count was 11.5 without a significant left shift, and her urinalysis was normal as was the rest of her metabolic panels.
The radiologic evaluation of ultrasound showed an enlarged right ovary with a large follicular cyst and decreased blood flow in the pedicle. There was a normal amount of peritoneal fluid noted.
The diagnosis of ovarian torsion was made. The findings were confirmed during surgery when she underwent detorsion and resection of the follicular cyst. The patient's clinical course 3 months later found that the ovary had returned to normal size and there were no abnormal anatomical structures.
Figure 138 -
Sagittal grayscale US of the right ovary (above) shows the right ovary to be enlarged and to contain a large central hypoechoic cyst. The right ovary was 4 times larger in size than the normal left ovary. Sagittal spectral doppler US of the right ovary (below) shows arterial flow to be present in the right ovary, but the amount of arterial flow in the right ovary was relatively decreased when compared to the arterial flow to the left ovary.
Discussion
Ovarian torsion (OT) is defined as a partial or complete twisting rotation around the central vascular pedicle, infundibulopelvic ligament and the tubo-ovarian ligament. It is a difficult diagnosis to make and a rare occurrence with an estimated incidence of 4.9 : 100,000 in the US. It can occur at any age (including fetus and newborn) but is most common in 20-40 year old females. A common presentation for OT is abdominal pain or pelvic pain both of which are common. Other symptoms may include nausea, emesis and fever in 1-7% of patients with fever more common in the pediatric age group. Signs can include abdominal tenderness (66-91%) and a palpable mass (17-36%). As these are common and non-specific signs and symptoms, the diagnosis is sometimes delayed (20-69%) and delay occurs more often in prepubertal girls. Pelvic ultrasound is the imaging test of choice and findings can include an enlarged ovary (at least 3-4 time the contralateral ovary in size), thickened ovarian walls and/or displaced follicles, follicular cysts located peripherally in the ovary, "whirlpool sign" of a twisted pedicle, free fluid in the pelvis, along with some less common changes. On Doppler ultrasound arterial blood flow may or may not be seen.
Conservative surgical treatment with detorsion of the ovary is the primary treatment. Removal of a cyst or mass may also occur if one is identified as being the cause of the torsion. and some patients also undergo oophoropexy where the ovary is fixed to the one of the abdominal/pelvic sidewalls with or without plication of the utero-ovarian ligaments. Overall outcomes are good. Most ovaries (90%) return to normal size on ultrasound 3 months after treatment and development of ovarian follicles is 52-96%. Long-term fertility for pediatric patients is unknown but in adults has occurred. Only 5-18% of the time does OT recur (can be same or other side) and can recur even after oophoropexy. Interestingly there is worse outcome for a "normal" ovary that undergoes torsion than with one that has an identified mass as the cause of torsion.
A review of abdominal pain can be found here.
A review of pelvic pain can be found here.
A review of causes of peritoneal fluid can be found here.
Learning Point
Causes of OT include normal ovarian tissue, ovarian cysts, benign neoplasms, malignant neoplasms (very rare), and loose/lax/"extra" tissue in the supporting ovarian structures. Multicystic ovarian torsion is associated with primary hypothyroidism. If neoplasms are the cause they are usually benign including teratoma, cystadenoma, dermoid and fibromas. Note that ovarian cysts for all women (not only those with OT) are quite common with 10% being often quoted.
Questions for Further Discussion
1. How is endometriosis diagnosed? A review can be found here
2. What causes emesis? A review can be found here
3. How is pelvic inflammatory disease diagnosed?
Related Cases
To Learn More
To view pediatric review articles on this topic from the past year check PubMed.
Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.
Information prescriptions for patients can be found at MedlinePlus for this topic: Ovarian Disorders
To view current news articles on this topic check Google News.
To view images related to this topic check Google Images.
To view videos related to this topic check YouTube Videos.
Dasgupta R, Renaud E, Goldin AB, et al. Ovarian torsion in pediatric and adolescent patients: A systematic review. Journal of Pediatric Surgery. 2018;53(7):1387-1391. doi:10.1016/j.jpedsurg.2017.10.053
Tielli A, Scala A, Alison M, et al. Ovarian torsion: diagnosis, surgery, and fertility preservation in the pediatric population. Eur J Pediatr. 2022;181(4):1405-1411. doi:10.1007/s00431-021-04352-0
Sims MJ, Price AB, Hirsig LE, Collins HR, Hill JG, Titus MO. Pediatric Ovarian Torsion: Should You Go With the Flow? Pediatr Emerg Care. 2022;38(6):e1332-e1335. doi:10.1097/PEC.0000000000002679
Author
Donna M. D'Alessandro, MD
Professor of Pediatrics, University of Iowa
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