Pediatric emergency medicine trisk 2143 2143
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a suspicion of malignancy, which is rare. Recent case series demonstrate
increasing surgical conservation rate as evidence of the rarity of complications
and good clinical outcomes with the conservative approach. Detorsion without
cystectomy, ovarian biopsy, or oophoropexy is generally recommended to avoid
long-term effects on fertility. Concerns about the appearance of the ovary have
previously influenced surgical decisions, but multiple studies have shown that the
intraoperative appearance of the ovary does not predict ovarian viability and that
conservative therapy is not associated with increased morbidity or poor outcomes.
Torsion involving normal-appearing ovaries has been associated with an
increased risk of ipsilateral recurrence in both pre- and postmenarcheal females,
while torsion due to pathology (such as functional ovarian cysts) is not.
Clinical Considerations
Clinical Recognition
Torsion can occur in both pre- and postmenarcheal girls and may involve normal
ovaries or adnexal containing pathology, like ovarian or paraovarian cysts.
Adnexal torsion can be a difficult diagnosis to make, given that the clinical
picture can overlap with other more common abdominal diagnoses, such as
appendicitis. Most patients with adnexal torsion will present with acute onset of
lower abdominal or pelvic pain; the location of the pain can vary in younger
children, as the ovaries can be located higher in the abdomen than in adult
women, but symptoms are almost universally unilateral. Additional symptoms
may include nausea, vomiting, fever, and symptoms referable to the urinary tract.
Many patients report constant pain, although the pain can be intermittent.
Clinical Assessment
Female patients presenting with acute onset of abdominal pain should be assessed
with a complete history, physical examination, and pregnancy risk assessment for
postmenarcheal patients, which can start to narrow the broad differential
diagnosis. Because studies suggest that right-sided adnexal torsion is more
common than left-sided, many patients will need to be evaluated concurrently for
adnexal torsion and appendicitis. Additional diagnoses to consider include
nephrolithiasis, mesenteric adenitis, intussusception (in the younger patient),
pregnancy (including ectopic pregnancy in the older patient), and urinary tract
infection, to name several. Most patients present with 24 hours or more of severe,
intermittent, and nonradiating pain, and commonly report nausea, vomiting, and
abdominal tenderness on examination. While laboratory studies can assist in the
diagnosis of other entities causing abdominal pain, when there is high suspicion
