Proposed mechanisms that may increase risk of ovarian torsion in a normal ovary include:

• Disproportionately elongated utero-ovarian ligament that allows excessive ovarian movements.
• Jarring movements of a relatively large ovary in a small infant.^14,15
• Associated Müllerian anomalies.

Presentation

The diagnosis of adnexal torsion in young girls presents a diagnostic challenge because the presenting signs and symptoms of ovarian torsion are nonspecific and may mimic constipation, gastroenteritis, mesenteric adenitis, appendicitis, renal colic, pelvic inflammatory disease, ectopic pregnancy, and hemorrhagic or ruptured ovarian cysts.

The most common presenting symptoms are abdominal pain, nausea, and vomiting. Classically, the pain is acute in onset and colicky in nature. The most common physical exam findings in children with ovarian torsion are tenderness, adnexal fullness or mass, and fever. However, up to 50% of pediatric patients with ovarian torsion may have variable symptoms or lack specific physical exam findings altogether, with 30% having only mild pain and 30% with no pain. Peritoneal findings are infrequent, and the absence of rebound or guarding does not correlate with the severity of compromise to ovarian vascular supply. When evaluating infants and younger children, it is often helpful to perform an abdominal exam while distracting them or even when they are sleeping so as to differentiate abdominal tenderness from crying because of fear of the practitioner. Even with the appropriate symptoms, physical exam findings can also be very subtle and quite variable. Accordingly, a high index of suspicion for adnexal torsion is imperative in any girl presenting with lower abdominal pain.

When compared with patients with acute appendicitis, the only occasionally helpful exam finding in these patients was the palpation of an abdominal mass. Yet studies show that such a finding is reported in fewer than 10% of torsion cases. Researchers have yet to find statistically distinguishing variables, thus making ovarian torsion a diagnostic challenge for even the more experienced clinicians.^16,17,19