National Adolescent Health Month!

May is National Adolescent Health Month! This month provides an opportunity to spotlight the care of children, who have unique needs as compared to adult patients. To celebrate National Adolescent Health Month, the AAGL Pediatric & Adolescent Gynecology (PAG) SIG presents this review on adnexal torsion in children and adolescents, highlighting important differences in the workup and treatment of our youngest patients to promote healthy reproductive outcomes throughout the lifespan. 

Adnexal Torsion in the Pediatric & Adolescent Patient:
Evaluation and Management

Evaluation of Pediatric and Adolescent Patients:

Children and adolescents with adnexal torsion typically present with acute abdominal pain.  Notably, torsion pain may be intermittent (hours/days of pain with intermittent hours of decreased or minimal pain), which risks missed diagnosis.¹ Vomiting usually accompanies pain and lack of vomiting may be a negative predictor of torsion. In one study of pediatric torsion, 83% of pre-menarchal patients and 100% of post-menarchal patients with surgically-confirmed torsion reported vomiting.² Neonates may present with non-specific symptoms such as inconsolability or feeding intolerance.¹ Abdominal exam should assess for palpable masses and evidence of peritoneal signs. Pelvic exams are not required to diagnose torsion and are not typically performed in pediatric patients.

Imaging:

First-line imaging is transabdominal pelvic ultrasound.^3,4 Transabdominal ultrasound requires a full bladder for best views of uterine and adnexal structures; however, larger cysts/masses may be seen without a full bladder, and a full bladder may be difficult to facilitate in patients with developmental delay or young children. MRI is preferred over CT for second-line imaging to avoid radiation. Pediatric and adolescent patients are more likely to have torsion in the absence of an ovarian cyst (up to 46%) which may result in significant volume differences (often at least 2.5x difference) between the ovaries.⁵ Adolescents are also more likely to have a paratubal cyst or isolated tubal torsion compared to adults,³ in which case ovaries may appear normal on imaging, but an adnexal cyst or hydrosalpinx is still usually seen. Imaging, including the presence of arterial and venous flow on doppler ultrasound, cannot definitively diagnose or exclude torsion.^3,6

Laboratory Evaluation:

Mild leukocytosis may be present. If malignancy is suspected, serum tumor markers should be ordered; even if urgent surgery is performed, tumor markers may be followed for surveillance. For young patients, suggested markers are: B-HCG, alpha-fetoprotein (AFP), lactate dehydrogenase (LDH), inhibin A and B, and Ca-125.⁷

Surgical Management:

Typical management involves urgent laparoscopic de-torsion. If a cyst is present, cystectomy can be performed or deferred until an interval procedure if distortion from edema makes cystectomy difficult. Even “necrotic” appearing ovaries often retain function.¹ Concerns regarding increased infection or venous thromboembolism rates, if necrotic tissue is de-torsed and left in situ have not been substantiated.¹ Concern for malignancy is often cited as a cause for oophorectomy, as at least 10% of pediatric ovarian masses are malignant, but studies indicate low rates (< 2% in one study) of malignancy among pediatric patients with torsion.⁸ If the etiology of the mass is unclear, de-torsion and further workup with MRI and tumor markers may prevent unnecessary oophorectomy. Oophorectomy is rarely indicated for adnexal masses in the pediatric patient unless tumor markers or imaging suggest high-risk of malignancy. Oophoropexy is controversial as recurrence rates are high and may best be reserved for patients at highest risk of recurrence or ovarian loss, such as those with torsion of a normal ovary, bilateral torsion, recurrent torsion, or prior oophorectomy.⁹

References:

1. Childress KJ, Dietrich JE. Pediatric Ovarian Torsion. Surg Clin North Am. 2017;97(1):209-221. doi:10.1016/j.suc.2016.08.008
2. Schwartz BI, Huppert JS, Chen C, Huang B, Reed JL. Creation of a Composite Score to Predict Adnexal Torsion in Children and Adolescents. J Pediatr Adolesc Gynecol. 2018;31(2):132-137. doi:10.1016/j.jpag.2017.08.007
3. Adnexal Torsion in Adolescents: ACOG Committee Opinion No, 783. Obstet Gynecol. 2019;134(2):e56-e63. doi:10.1097/AOG.0000000000003373
4. Wattar B, Rimmer M, Rogozinska E, Macmillian M, Khan KS, Al Wattar BH. Accuracy of imaging modalities for adnexal torsion: a systematic review and meta-analysis. BJOG. 2021;128(1):37-44. doi:10.1111/1471-0528.16371
5. Hartman SJ, Prieto JM, Naheedy JH, et al. Ovarian volume ratio is a reliable predictor of ovarian torsion in girls without an adnexal mass. J Pediatr Surg. 2021;56(1):180-182. doi:10.1016/j.jpedsurg.2020.09.031
6. Ssi-Yan-Kai G, Rivain AL, Trichot C, et al. What every radiologist should know about adnexal torsion. Emerg Radiol. 2018;25(1):51-59. doi:10.1007/s10140-017-1549-8
7. Lawrence AE, Fallat ME, Hewitt G, et al. Understanding the Value of Tumor Markers in Pediatric Ovarian Neoplasms. J Pediatr Surg. 2020;55(1):122-125. doi:10.1016/j.jpedsurg.2019.09.062
8. Oltmann SC, Fischer A, Barber R, Huang R, Hicks B, Garcia N. Pediatric ovarian malignancy presenting as ovarian torsion: incidence and relevance. J Pediatr Surg. 2010;45(1):135-139. doi:10.1016/j.jpedsurg.2009.10.021
9. Comeau IM, Hubner N, Kives SL, Allen LM. Rates and Technique for Oophoropexy in Pediatric Ovarian Torsion: A Single-Institution Case Series. J Pediatr Adolesc Gynecol. 2017;30(3):418-421. doi:10.1016/j.jpag.2016.11.006