Diagnosis and Management of Adnexal Torsion in Adolescents
Learning Objectives and CME/Disclosure Information
This activity is intended for healthcare providers delivering care to women and their families.
After completing this activity, the participant should be better able to:
1. Discuss the role of imaging when making the diagnosis of ovarian torsion in an adolescent 2. Explain the reasoning for untwisting a torted ovary that is black and/or blue, rather than performing oophorectomy
Estimated time to complete activity: 0.25 hours
Susan J. Gross, MD, FRCSC, FACOG, FACMG
President and CEO, The ObG Project
Disclosure of Conflicts of Interest
Postgraduate Institute for Medicine (PIM) requires instructors, planners, managers and other individuals who are in a position to control the content of this activity to disclose any real or apparent conflict of interest (COI) they may have as related to the content of this activity. All identified COI are thoroughly vetted and resolved according to PIM policy. PIM is committed to providing its learners with high quality CME activities and related materials that promote improvements or quality in healthcare and not a specific proprietary business interest of a commercial interest.
Faculty: Susan J. Gross, MD, receives consulting fees from Cradle Genomics, and has financial interest in The ObG Project, Inc.
Planners and Managers: The PIM planners and managers, Trace Hutchison, PharmD, Samantha Mattiucci, PharmD, CHCP, Judi Smelker-Mitchek, MBA, MSN, RN, and Jan Schultz, MSN, RN, CHCP have nothing to disclose.
Method of Participation and Request for Credit
Fees for participating and receiving CME credit for this activity are as posted on The ObG Project website. During the period from 1/15/2020 through 07/15/2022, participants must read the learning objectives and faculty disclosures and study the educational activity.
If you wish to receive acknowledgment for completing this activity, please complete the post-test and evaluation. Upon registering and successfully completing the post-test with a score of 100% and the activity evaluation, your certificate will be made available immediately.
For Pharmacists: Upon successfully completing the post-test with a score of 100% and the activity evaluation form, transcript information will be sent to the NABP CPE Monitor Service within 4 weeks.
Joint Accreditation Statement
In support of improving patient care, this activity has been planned and implemented by the Postgraduate Institute for Medicine and The ObG Project. Postgraduate Institute for Medicine is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.
Physician Continuing Medical Education
Postgraduate Institute for Medicine designates this enduring material for a maximum of 0.25 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Continuing Nursing Education
The maximum number of hours awarded for this Continuing Nursing Education activity is 0.2 contact hours.
Adnexal torsion in adolescents is a complex clinical problem
given the need for ovarian preservation in this age group. It is a surgical
diagnosis and while imaging modalities may be helpful in the diagnosis,
clinical judgement is paramount. ACOG (2019) released a committee opinion
regarding torsion in this population, to aid in diagnosis and management.
Symptoms: Generally non-specific and may include
Intermittent | Nonradiating
Associated nausea and vomiting
Adnexal mass may or may not be present
Bimanual exam unnecessary and unlikely tolerated
in this population
No single lab test is specific for torsion
Labs will likely be part of the workup given
broad differential for abdominal pain in adolescents
The following tests are not helpful for diagnostic purposes: Leukocytosis | Pyuria | CRP |
Transabdominal Ultrasound (modality of choice)
Key sonographic findings include
Unilateral ovarian enlargement | Ovarian edema | Free fluid around an ovary | Ovary appears heterogeneous | Multiple peripheral follicles
Whirlpool sign: a coiled vascular pedicle – images appear in the ‘Learn More – Primary Sources’ opinion below | requires expertise and operator dependent
Note: The presence of Doppler arterial flow does not rule out torsion | “When torsed, all ovaries are enlarged” | TV ultrasound not required, especially as this approach may not be well tolerated in children and adolescents
Findings suggestive of torsion are similar to ultrasound such as unilateral ovarian enlargement
Findings specific to CT include ‘fat stranding’ – a sign of abdominal inflammation caused by the change in fat density as the tissue becomes increasingly edematous
Findings suggestive of torsion are similar to ultrasound such as unilateral ovarian enlargement
Other MRI findings may include: Deviation of uterus toward torsed side (may also be seen with CT) | Multiple peripheral follicles | Decreased ovarian enhancement post-contrast
Note: If CT or MRI are done first and are suspicious for torsion, do not delay surgery while waiting for ultrasound
Adnexal torsion, especially in this age group, is a surgical diagnosis and the clinical signs may be non-specific. Ultrasound is the imaging modality of choice which should show an enlarged ovary. Oophorectomy should be reserved for ovaries that are necrotic and falling apart. Otherwise untwist the ovary and monitor. Because recurrence is unlikely and data is limited, oophoropexy to prevent recurrence is not recommended.
Management of Suspected Torsion
Therapeutic and diagnostic laparoscopy is the procedure of choice
Untwist ovary as soon as possible even if black and blue color – avoid oophorectomy
Dual blood supply (ovarian artery and uterine-ovarian artery) and collaterals makes the ovary resilient to ischemic injury
There is no known maximal amount of time at which point irreversible ischemia has occurred
Cystectomy is unnecessary and may cause additional trauma | Drainage of large cysts may be an option based on clinical judgment at the time of surgery
ACOG states that “Given the importance of ovarian preservation…a negative finding at laparoscopy is an acceptable clinical outcome.”
Note: Only a
necrotic ovary that falls apart intraoperatively should be removed
Cyst present at surgery and not drained
Ultrasound at 6-12 weeks post-op (often cysts are physiologic and may regress spontaneously)
Consider a second surgery using minimally invasive technique if cyst does not resolve
ACOG recommends that guidelines used to evaluate and manage adnexal masses in premenopausal women should be followed for adolescents (see ‘Related ObG Topics’ below) with focus on ovarian preservation
Other Considerations in the Pediatric and Adolescent Population
Concern for malignancy
Overall risk for ovarian malignancy in this age group is rare
Note: Worry about leaving behind malignant tissue should not be used as a reason for oophorectomy at time of surgery
Fascial tissue may not have reached adult strength – consider closing the fascia in these patients to reduce risk of hernia
Increased risk for vascular injury given large vessels that may be a shorter distance away from the umbilical trocar site compared to adults
Smallest trocars should be used
12 mm Hg with flow rates of 3–6 L/min | Reduce if patient <20 kg
Use low amount of insufflation pressure
Administer local anesthetic at trocar sites
Use ‘scheduled’ NSAIDs with consideration of <3 days opioids
Consider consultation with specialty team familiar with pain management and appropriate dosing in this population
Note: Currently, there is no well-defined, optimal pain management approach
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Disclosure of Unlabeled Use
This educational activity may contain discussion of published and/or investigational uses of agents that are not indicated by the FDA. The planners of this activity do not recommend the use of any agent outside of the labeled indications.
The opinions expressed in the educational activity are those of the faculty and do not necessarily represent the views of the planners. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings.
Participants have an implied responsibility to use the newly acquired information to enhance patient outcomes and their own professional development. The information
presented in this activity is not meant to serve as a guideline for patient management. Any procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this activity should not be used by clinicians without evaluation of their patient’s conditions and possible contraindications and/or dangers in use, review of any applicable manufacturer’s product information, and comparison with recommendations of other authorities.
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