Ovarian torsion is an infrequent diagnosis in the pediatric age group. The clinical picture is nonspecific, and children cannot always articulate their symptoms, which often makes the diagnosis a challenge. However, early recognition and prompt management yield significant reduction in morbidity and an increased likelihood of ovarian salvage. Emergency physicians must always consider this differential in pediatric and adolescent females presenting with abdominal pain. We offer an evidence-based approach to the diagnosis and management of ovarian torsion in the pediatric population.

Epidemiology

Incidence

Adnexal torsion occurs primarily in the child-bearing age group, but it is not uncommon in premenarchal girls. According to Shalev et al. (1985), gonadal torsion is of particular concern in perimenarchal girls. The actual incidence of ovarian torsion in children is not well defined and varies in recent literature. Studies have found an estimated incidence of 4.9 per 100,000 among females 1-20 years old¹ and a diagnosis in up to 2.7% of cases presenting with acute abdominal pain.² In one 16-year study, excluding neonates, the mean age was found to be 12.5 years, ranging from 8 to 16 years old.³ However, other similar studies have shown the mean age to be around 9.5 years old.⁴

Morbidity

Delay and misdiagnosis of adnexal torsion is common and may result in loss of the ovary, fallopian tube, or both.⁵ An incidental finding of an isolated absence of an ovary or fallopian tube may be the result of an undiagnosed previous adnexal torsion.⁵ Early diagnosis of ovarian torsion is paramount and will reduce the risk of complications and increase the probability of ovarian preservation. Diagnostic laparoscopy is the gold standard for diagnosing ovarian torsion. Current reports show an 80%-90% rate of ovarian salvage with early surgical intervention.⁶

Pathophysiology

Ovarian torsion occurs secondary to the abnormal twisting of the involved ovary on its ligamentous support. Torsion of the ovarian blood supply will result in venous congestion, hemorrhage, and eventually ischemia. Prolonged ischemia of the ovary or other adnexal structures can lead to necrosis, resulting in loss of ovarian function or infection and peritonitis.⁷

The anatomy is such that the right side is more frequently affected than the left. In pediatric patients, ovarian torsion can be caused by a variety of anatomic mechanisms. Most studies have found approximately 50% of ovarian torsion in pediatric patients to involve adnexal cysts, teratomas, or other benign masses, including polycystic ovaries.^6,8 Most data suggest that the risk is higher for cysts larger than 4-5 cm, but there have been case reports of cysts less than 5 cm causing symptoms.^10-12 Another risk for ovarian torsion is a malignant tumor; however, there is only a 1.8% malignancy rate reported in the literature.¹³ Thus, it is important to note that a large number of cases of adnexal torsion may occur with anatomically normal ovaries.