Therefore, MRI and CT should be reserved for those cases where ovarian pathology is highly suspected but ultrasound is equivocal.^19-22

CT scanning can be used to reveal an enlarged right adnexa with thickened tubular structure indicative of twisted vascular pedicle (image 1) and a enlarged, engorged midline right ovary with surrounding free fluid (image 2).

Another CT scan revealed a simple-appearing cyst that is actually an edematous vacuole in a torted ovary. Note the loss of follicles and loss of normal-appearing parenchyma in this scan (image 3), compared with a normal ovary (image 4).

MRI demonstrated an enlarged and edematous left ovary in an ectopic location (midline), with numerous peripheral follicles and free fluid in the pelvis (image 5).

Consultation

Upon recognition of signs and symptoms of suspected ovarian torsion, an expeditious consultation with a pediatric gynecologist (where available) or pediatric surgeon should be done during the early stages of the evaluation in order to facilitate swift management in a young girl with a suspected diagnosis of adnexal torsion.¹⁹

Management

Surgery

The mainstay of treatment is diagnostic laporoscopy with detorsion of the ovary. Historically, oophorectomy was the standard treatment of the torsed ovary. However, more recent publications have reevaluated ovarian preservation with favorable results. Detorsion is now recommended in lieu of oophorectomy, and there is little evidence of accompanying increases in morbidity as once believed.⁶

Urgent surgical evaluation must be emphasized. Better outcomes have been shown if surgical intervention occurs within 36 hours of ovarian torsion.^20,21

Oophoropexy is also widely debated in the literature, and there are no trials evaluating its efficacy. Oophoropexy can be offered as an option to prevent castration in cases of repeat ovarian torsion or in cases of bilateral adnexal torsion.^22,23

Conclusion

Ovarian torsion in the pediatric patient is an infrequent but important finding carrying potential for high morbidity if missed. The examination is often misleading, and 30% of patients have no pain on presentation but an otherwise suggestive history.