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

Faculty:

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 Sema4, 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 1/15/2021, 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.

Read Disclaimer & Fine Print

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.  

CLINICAL ACTIONS:

Diagnosis

• Symptoms: Generally non-specific and may include
  • Abdominal pain
    • Intermittent | Nonradiating
    • Associated nausea and vomiting

Physical Exam

• Abdominal tenderness
• Adnexal mass may or may not be present
• Bimanual exam unnecessary and unlikely tolerated in this population
• Note: Peritoneal signs uncommon

Labs

• 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 | ESR

Imaging

• 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
• CT
  • 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
• MRI
  • 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

SYNOPSIS:

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

Follow-Up

• 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
• Surgical approach
  • 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
  • Insufflation pressure
    • 12 mm Hg with flow rates of 3–6 L/min | Reduce if patient <20 kg
• Pain management
  • 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  

Learn More – Primary Sources:

ACOG Committee Opinion 783:  Adnexal torsion in adolescents

Related ObG Topics:

Evaluation of the Adnexal Mass

Teenagers and Medical Care – When Is Parental Consent Not Required?

Expert Opinion: Over-the-Counter Contraceptives for Adolescents

Does Pelvic Exam Provide Any Additional Benefit When Diagnosing STDs in Adolescents and Young Women?

ACOG Guidance on Evaluation and Management of Endometriosis and Dysmenorrhea in Adolescents