Risk Factors, Symptoms, and Treatment of Ovarian Torsion

Original Article
Risk Factors, Symptoms, and Treatment of Ovarian Torsion
in Children: The Twelve-Year Experience of One Center
Ziv Tsafrir, MD*, Foad Azem, MD, Joseph Hasson, MD, Efrat Solomon, BSc, Benny Almog, MD,
Hagith Nagar, MD, Joseph B. Lessing, MD, and Ishai Levin, MD
From the Department of Gynecology (Drs. Tsafrir, Azem, Hasson, Lessing, Almog and Levin), Lis Maternity Hospital, and the Department of Pediatric Surgery
(Dr. Nagar and Ms. Soloman), Dana Children’s Hospital, Tel-Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel.
ABSTRACT Objective: To assess risk factors, clinical findings and mode of diagnosis and treatment in premenarchal children with
surgically verified ovarian torsion (OT).
Study Design: A retrospective case review (Canadian Task Force Classification II-2).
Setting: Teaching and research hospital, a tertiary center.
Patients: Premenarchal children with surgically verified OT.
Interventions: Patients underwent either laparoscopy or laparotomy.
Results: Twenty-two cases of OT in 20 premenarchal girls (median age 12 years) were identified. Three cases involved recurrent
torsion after detorsion without cystectomy. The main presenting symptoms were sudden pain and vomiting. Six patients underwent Doppler examinations, and all demonstrated an abnormal flow. Seventeen interventions were by laparoscopy. Conservative management, mainly detorsion with additional cyst drainage or cystectomy, was performed in 19 cases (86.4%).
Oophoropexy was performed in 3 cases (13.6%). Pathologic examination demonstrated 5 simple cysts and 1 dermoid cyst.
Conclusions: Ovarian torsion in premenarchal girls usually presents with intermittent abdominal pain and abdominal tenderness. Other signs and symptoms are nonspecific. When performed, Doppler imaging may assist in diagnosing ovarian torsion
in children. Detorsion followed by cystectomy may prevent recurrence. Journal of Minimally Invasive Gynecology (2012) 19,
29–33 Ó 2012 AAGL. All rights reserved.
Doppler; Ovarian torsion; Premenarchal treatment
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Ovarian torsion (OT) rarely occurs in childhood. Its
annual prevalence is estimated to be 4.9 per 100 000 females
aged 1 to 20 years [1]. Nevertheless, it should be considered
in the differential diagnosis of every young girl who presents
with acute abdominal or pelvic pain [2]. The symptoms and
signs of OT are nonspecific and can be related to other
The authors have no commercial, proprietary, or financial interest in the
products or companies described in this article.
The essence of the project was presented at the 13th World Congress On
Controversies In Obstetrics, Gynecology & Infertility, which was held in
Berlin, Germany, November 4-7, 2010.
Corresponding author: Ziv Tsafrir, MD, Lis Maternity Hospital, Tel Aviv
Sourasky Medical Center, 6 Weizman Street, Tel Aviv 64239, Israel.
E-mail: [email protected]
Submitted June 15, 2011. Accepted for publication August 19, 2011.
Available at www.sciencedirect.com and www.jmig.org
1553-4650/$ - see front matter Ó 2012 AAGL. All rights reserved.
clinical causes, for example, gynecologic, urologic, or gastrointestinal [3–5]. Abdominal ultrasonography (AUS) is
the modality of choice in the evaluation of the young
female pelvis, providing clear visualization of the pelvic
organs with no exposure to radiation, in addition to being
highly available [6]. The demonstration of an ovarian mass
or of ovarian enlargement by AUS in a child with abdominal
pain must raise the suspicion of OT. The Doppler flow has
also been recently studied for the purpose of assisting in
the diagnosis of OT, but the results on its accuracy in detecting pathology have not been consistent [6].
The preferred treatment in the event of a confirmed OT is
still a matter of debate as well. Ovarian vitality in the setting
of OT is dependent on the duration of time until the diagnosis
is established, before necrosis occurs. A growing number of
studies advocate conservative surgery (ie, mainly detorsion
with additional cyst drainage or cystectomy), but this
approach mainly applies to the adult population [7–13].
Moreover, although laparoscopy followed by a detorsion
procedure is the usual approach for treating these cases, the
apprehension of overlooking malignancy continues to be
a matter of concern [14,15]. The necessity of performing
an oophoropexy is also a point of contention [16,17].
Several recent reports focused on OT in the pediatric population [5,6,15]; however, they did not stratify for
premenarchal girls. The aim of this study was to delineate
risk factors, symptoms, signs, and mode of treatment in
premenarchal girls diagnosed as having OT.
Materials and Methods
We conducted a chart review of all cases of children with
surgically verified OT who were treated in our institution
From January 1997 through January 2008. The institutional
ethics committee approved this retrospective study. Only
premenarchal girls were selected for study. The medical
records were evaluated for patients’ age, medical and gynecologic history, presenting symptoms and signs, physical
examination findings, laboratory results and imaging studies. We calculated the duration of symptoms until admission
to the emergency department (ED), the interval between ED
admission to undergoing AUS, and the time period between
ED admission and transport to the operating room. Data on
the type of surgical approach used to visualize the ovary, surgical findings, surgical procedure for treatment of the OT,
pathologic results, postoperative complications, and whether
the index OT was a recurrence of a prior one were analyzed.
Statistical Analysis
The c2 test or the Fischer exact test was used to compare
categorical variables as appropriate, and the t test was used
to compare means of continuous variables. Distribution
was reported as means and SDs for normally distributed
data and as medians for nonparametric data. Statistical analysis was performed with SPSS statistical software (IBM
Corp., Armonk, New York).
A total of 22 cases of OT in 20 premenarchal patients
were identified. Their median age was 12 years (range
3 months to 16 years). The index OT was a recurrence of
a previous one in 3 cases. The presenting symptom of
abdominal pain was of abrupt onset in 17 of 22 cases, but
all patients complained of intermittent pain, which was
localized mostly to the lower abdomen. Vomiting during
the painful episode was present as well (Table 1).
The median time interval from pain onset to ER admission was 15 hours. Physical examination revealed abdominal
tenderness in all but 1 case. There were positive peritoneal
signs in 6 cases. High fever (.38.0 C, orally) was measured
in 2 cases, and leukocytes (.11 ! 103/mL) were elevated in
Journal of Minimally Invasive Gynecology, Vol 19, No 1, January/February 2012
Table 1
Signs and symptoms of ovarian torsion (20 patients, 22 cases)
Abdominal pain
Abrupt onset
Gradual onset
Location of abdominal pain
Abdominal tenderness
Peritoneal signs
Fever R38 C
WBCC .11 000/mL
No. (%) of cases
17 (77.3%)
5 (22.7%)
9 (40.9%)
3 (13.7%)
5 (22.7%)
4 (18.2%)
1 (4.5%)
13 (59%)
21 (95%)
6 (27.3%)
2 (9%)
8 (36%)
LLQ 5 Left lower quadrant; LA 5 lower abdomen; RLQ 5 right lower
quadrant; WBCC 5 white blood cell count.
8 cases (36%). AUS with a full bladder had been performed
in 20 cases and demonstrated enlarged ovaries (5–10 cm) in
8 cases and normal-sized ovaries with or without signs of
edema in 8 and 4 cases, respectively. There was only
1 case of free fluid in the pelvis and no cases of complex
cysts or abnormal mass.
Doppler flow studies were performed in 6 cases, and the
absence of blood flow to the affected ovary was demonstrated in all of them. Computed tomography examination
was performed in 1 patient; however, this did not add any
diagnostic information. The median time from ED admission to AUS imaging was 3.5 hours.
The surgical approach to the affected ovary was laparoscopy in 17 cases, laparotomy in 3, and laparoscopy that converted to laparotomy in 2. Torsion was more common on the
right side (68.2% vs 31.8% on the left side). The median number of adnexal twisting was 2 (range 1–6). The ovary was not
enlarged in 13 cases (59.1%), whereas it was enlarged with or
without a cyst (5–10 cm) in 5 cases (22.7%). The other 4 cases
involved a paraovarian cyst. The median time interval from
the ED to the operating room was 5.75 hours.
The modes of therapeutic management are summarized in
Table 2. Conservative management, mainly detorsion with
additional cyst drainage or cystectomy, was the standard of
care in most cases (19/22; 86.4%). Oophorectomy was performed because of 1 case each of excessive bleeding, a necrotic
ovary, and a large dermoid cyst. Oophoropexy by plication of
the ovarian ligament was performed in 3 cases, 2 of which
were recurrences and 1 that was a prophylactic oophoropexy
after contralateral oophorectomy. We had 3 cases of recurrent
OT, 2 of which occurred after detorsion, and 1 after detorsion
and cyst drainage. After surgery, 1 patient had bacteremia that
was successfully treated with antibiotics.
Tsafrir et al.
Risk Factors, Symptoms, and Treatment of Ovarian Torsion in Children
Table 2
Modes of treatment (20 patients, 22 cases)
No. (%) of cases
Detorsion and drainage/fenestration
Detorsion and cystectomy
Detorsion and fixation*
Ovarian resection
8 (36.4%)
6 (27.3%)
3 (13.6%)
3 (13.6%)
2 (9.1%)
1 (4.5%)
* One case involved unilateral adnexectomy followed by fixation of the
contralateral ovary.
The pathologic study reports included simple cysts in
5 cases and 1 mature cystic teratoma (dermoid cyst). No
other obvious pathologic findings were documented. The
median hospital stay was 3 days.
This retrospective chart study was conducted on a homogeneous group of premenarchal patients, unlike previous
studies that included heterogeneous populations of neonates,
premenarchal girls, adolescents, and young adults aged up to
20 years [5,6,15]. Our selection enabled us to clearly identify
clinical aspects of OT and to help raise the level of awareness
of diagnosticians who treat this specific patient population.
The lack of specificity of signs and symptoms complicates the diagnosis of OT. Similar to other studies [2,3,7],
we did not identify risk factors or symptom(s) that
correlated well with an existing OT. Fever or elevated
white blood cell count was present in only a few of our
patients, and most of them had a normal-sized ovary. Anders
et al [4], Beaunoyer et al [9], and Muehlstedt et al [18] also
demonstrated normal-sized ovaries in 55%, 49%, and 46%
of their cases, respectively. The incidence of OT without
any underlying abnormality, however, appears to be more
frequent in premenarchal girls compared with adolescents
in whom it is usually correlated to the presence of a functional cyst [19]. We did not have any cases of malignant
masses, unlike other reports of higher neoplastic cyst rates
(benign or malignant) in premenarchal girls [1]. Also, 59%
(13/20) of our patients did not have any underlying ovarian
disease. Cases of OT of the normal-appearing adnexa seem
to occur more frequently in premenarchal girls (15%–50%
of cases) [20]. Several theories have been proposed to explain the presence of OT when there is no adnexal enlargement or mass [7,17]. One is excessive mobility of the
adnexa caused by an abnormally long oviduct,
mesosalpinx, and mesovarium or hyperlaxity of those
ligaments; other explanations are attributed to adnexal
venous congestion that may follow premenarchal activity
or jarring movement of the body [7,17].
The use of AUS scans in the diagnosis of OT was demonstrated to have low specificity [2]. The search for a better
modality of imaging in the diagnosis of OT led to the
suggestion of Doppler-flow studies used to evaluate compromise in arterial or venous blood flow to the affected ovary. Its
role as a predictor of torsion, however, has elicited similar
controversy [6,7,17,21]. Servaes et al [6] demonstrated either arterial or venous blood flow in 64% of their patients.
Similarly, Stark and Siegel [21] noted blood flow in 10 of
15 patients. In contrast, 9 of 10 patients who underwent
Doppler imaging by Celik et al [17] had decreased or absent
blood flow, and we demonstrated an absence of flow in all 6
of our patients who underwent Doppler studies.
Laparoscopic procedures are superior to open surgery in
several aspects: the incisions are smaller, blood loss and
analgesic requirements are less, and postoperative recovery
is quicker. The advantages of laparoscopy in the diagnosis
and treatment of pelvic masses in gynecology are well established [5,14,22,23], and it was the preferred surgical
approach in our series as well. Three cases of laparotomy
were performed for the following indications: a 3-monthold with signs of peritoneal irritation, a 12-year-old with
a large dermoid cyst, and an 11-year-old with an uncertain
presurgical diagnosis.
In accordance with other reports [6,7,11,24], OT occurred
more frequently on the right side in the patients of our study
group, with a ratio of about 7:3. This tendency has been
attributed to the presence of the sigmoid colon on the left
side, which may help to prevent left-sided torsion [6].
Darrell et al [7] speculated that this difference may result
from undiagnosed events of OT on the left side, because
the increased suspicion of appendicitis may lead to a more
thorough investigation. We are inclined to agree with their
line of thought.
There has been a growing trend toward a more conservative approach in the treatment of OT over the past decade.
Previous reports of successful conservative laparoscopic
interventions in premenarchal patients [25], as well as negligible cases of cancer and data presented below all favor
the conservative approach. The advocates for a radical
approach (ie, resection of an ischemic-appearing ovary or
fallopian tube) raise several arguments against performing
detorsion: (1) a black-bluish adnexa signifies an irreversible
process of ischemia and necrosis; (2) untwisting of a torsed
ovary might dislodge a thrombus/embolus from pelvic veins,
causing a thromboembolic event/complication; (3) the concern of malignancy associated with torsed ovaries [7,9].
Mounting evidence in the literature has refuted the first
argument, claiming that the gross appearance of a twisted
hemorrhagic adnexa does not imply that it is nonviable
[15,18,26,27]. For example, Galinier et al [15] found viable
ovarian parenchyma on surgical specimens among 7 of
11 cases in which black-bluish ovaries were detorsed and
removed, and Muehlstedt et al [18] came to similar conclusions. With regard to thrombotic/embolic risks, a thorough
review of the literature since 1900 found only 2 cases of
pulmonary embolism associated with OT after laparotomy
and adnexal resection, and there have been no reported
events of thromboembolism after detorsion [28]. The third
argument about the possibility of leaving a malignancy in
situ, however, is disturbing. The reported malignancy rate
for ovarian masses in the pediatric population is 10%, and
several series demonstrated that the incidence of malignancy
specifically associated with torsion is actually much lower
(up to 2%) [5,9–11]. Notably, Sommerville et al [29] found
that benign ovarian neoplasms had a 12.9-fold increased risk
of undergoing adnexal torsion compared with malignant
ones (p , .001). The authors explained this finding by the
tendency of malignant neoplasms to cause inflammation
and adhesions to surrounding structures, paradoxically
preventing torsion.
The presence of an ovarian mass should trigger meticulous clinical assessment to rule out the possibility of malignancy. That in-depth approach includes the exclusion of
clinical symptoms and signs of malignancy (mainly menstrual disturbances, pubertal precocity, virilization, ascites,
or other signs of metastatic spread) in conjunction with
morphologic characterization of the mass by AUS and
Doppler flow studies, followed by measurement of tumor
markers. These measures ought to reduce the risk of overlooking the presence of a malignancy during a detorsion
procedure. Indeed, there has been no report of such a disturbing scenario thus far.
Time plays an important role in the effort to conserve the
involved adnexa. Rousseau et al [11] reported an inverse
relationship between the time interval from admission to
diagnosis and to performing conservative surgery. Contrary
to other studies [11,15], conservative treatment was the
preferred approach for most of our cases (86.4%). Our
ability to safely choose conservative management can be
partially attributed to a very short interval between
admission to the ER and intraoperative diagnosis and
treatment. The average time interval from the onset of pain
to surgery in our patients was 54.5 hours (median interval
20.75 hours). It is perhaps this relatively short interval that
aided us in the decision to perform conservative surgery, in
accordance with the data presented by Rousseau et al [11].
We had 3 cases where radical surgery was performed.
Oophorectomy was performed in a 12-year-old with a functional cyst complicated by severe ovarian bleeding; oophorectomy in a 3-month-old admitted 150 hours after onset
of pain caused by irreversible necrosis (pathologic report
of hemorrhagic necrosis); and partial oophorectomy in
a 12-year-old admitted 101 hours after the onset of pain
caused by a dermoid cyst.
There were 3 cases of recurrent OT in our series, 2 after
detorsion alone and 1 after detorsion and cyst drainage. The
first recurrence was in an 11-year-old patient 20 months after
a detorsion procedure of a normal-appearing ovary. The
recurrence was due to a 6-cm cyst that was removed.
Oophoropexy was performed by plication of uteroovarian ligament. The second case of recurrence was in a 14-year-old
Journal of Minimally Invasive Gynecology, Vol 19, No 1, January/February 2012
patient. The first episode was treated in another hospital and
data regarding this event was not available. The recurrence
was due to a 6-cm hemorrhagic cyst that was drained. The
third recurrence was in a 14-year-old patient 22 months after
the first event of torsion of a normal appearing ovary. The
recurrence was due to an enlarged ovary without a cyst.
Oophoropexy was carried out. The precise risk of recurrent
ipsilateral or asynchronous contralateral OT is not known,
but it is estimated as being between 2% to 5% [9,18,30,31].
Beaunoyer et al [9] estimated that the risk of recurrence
was 11.4% in OT without ovarian disease. Rousseau et al
[11] reported that 3 of 19 cases treated by detorsion had retorsion, all of which occurred after incomplete removal of the
cyst. They concluded that simple puncture or resection of
the upper pole of the cysts must be avoided and that the cysts
should undergo total resection in order to avoid recurrence.
As mentioned earlier, all recurrences in our series occurred
after detorsion only or cyst drainage, and none after detorsion
combined with cystectomy.
The role of oophoropexy in the treatment of children with
OT is debatable. Some authors have raised concerns of
anatomic alterations decreasing future fertility [32]. There
has been no evidence of this sequela in the literature thus far.
The general consensus is that the clinical situations that
justify the performance of an oophoropexy are postresection
of 1 ovary because of torsion, bilateral OT, recurrent OT, and
OT without any ovarian disease or a loose or redundant
mesosalpinx [7,11,16, 20,33]. Pansky et al [20] suggested
performing oophoropexy in cases of OT in postmenarchal
patients with normal appearing ovaries. They describe
a relatively high recurrence rate (60%!) if during the primary
surgery the adnexa appeared normal [20]. In our series,
oophoropexy was performed in 3 cases, 2 after recurrence
and 1 after adnexectomy to prevent contralateral OT.
Our study has several limitations. It has the drawbacks
inherent to any retrospective analysis. Because we located
and analyzed only charts of premenarchal girls with OT,
we could not deduce rates of occurrence of this condition
in young patients presenting with acute abdominal pain.
Other nongynecologic cases, as well as cases of OT that
we overlooked, were not included in our series.
Doppler flow studies were performed in only 6 of our
patients. We found a high degree of correlation between abnormal Doppler studies and OT; however, our decision to intervene was clinical rather than based on imaging. Also,
Doppler studies were carried out in our ultrasound unit and
so were not available during off-hours. The high degree of
correlation suggests that further studies should be carried
out to define the role of this modality in premenarchal girls.
A high index of suspicion of OT is cardinal in the evaluation and management of lower abdominal pain in premenarchal patients. The main signs and symptoms of OT are
an abrupt onset of lower intermittent abdominal pain and
Tsafrir et al.
Risk Factors, Symptoms, and Treatment of Ovarian Torsion in Children
vomiting. A normal-sized ovary on AUS does not rule out
the diagnosis of OT, because a substantial portion of premenarchal patients with OT have no underlying adnexal
disease. We contend that the high rate of salvaged ovary
(86%) in our current series can be attributable to the short
interval between ER admission to diagnosis with the aid of
Doppler studies and prompt surgical treatment. A laparoscopic approach to detorsion and conservative surgery
should be the treatment of choice. The benefit of ovarian
fixation in this age group remains to be established.
We thank Esther Eshkol for editorial assistance.
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