• About Us
    • Contact Us
    • Login
    • ObGFirst
  • COVID-19
  • Alerts
  • OB
  • 2T US Atlas
  • The Genome
  • GYN
    • GYN
    • Sexual Health
  • Primary Care
  • Your Practice
  • GrandRounds
  • My Bookshelf
  • Now@ObG
  • Media
About Us Contact Us Login ObGFirst
  • COVID-19
  • Alerts
  • OB
  • 2T US Atlas
  • The Genome
  • GYN
    • GYN
    • Sexual Health
  • Primary Care
  • Your Practice
  • GrandRounds
  • My Bookshelf
  • Now@ObG
  • Media
Alerts
CMECNE

Diagnosis and Management of Adnexal Torsion in Adolescents

image_pdfFavoriteLoadingFavorite

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 faculty, planners, and others in control of educational content to disclose all their financial relationships with ineligible companies. All identified conflicts of interest (COI) are thoroughly vetted and mitigated according to PIM policy. PIM is committed to providing its learners with high quality accredited continuing education activities and related materials that promote improvements or quality in healthcare and not a specific proprietary business interest of an ineligible company.


The PIM planners and others have nothing to disclose. The OBG Project planners and others have nothing to disclose.

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.

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

Take a post-test and get CME credits

TAKE THE POST TEST

Want to be notified when new guidelines are released? Get ObGFirst!

Learn More  »

image_pdfFavoriteLoadingFavorite
< Previous
All Alerts Posts
Next >

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

Sections

  • COVID-19
  • Alerts
  • OB
  • GYN
    • GYN
    • Sexual Health
  • 2T US Atlas
  • The Genome
  • Primary Care
  • Your Practice
  • Grand Rounds
  • My Bookshelf
  • Now@ObG
  • Media

Are you an
ObG Insider?

Get specially curated clinical summaries delivered to your inbox every week for free

  • Site Map/
  • © ObG Project/
  • Terms and Conditions/
  • Privacy/
  • Contact Us/
© ObG Project
SSL Certificate


  • Already an ObGFirst Member?
    Welcome back

    Log In

    Want to sign up?
    Get guideline notifications
    CME Included

    Sign Up

Get Guideline Alerts Direct to Your Phone
Try ObGFirst Free!

Sign In

Lost your password?

Sign Up for ObGFirst and Stay Ahead

  • - Professional guideline notifications
  • - Daily summary of a clinically relevant
    research paper
  • - Includes 1 hour of CME every month

ObGFirst Free Trial

Already a Member of ObGFirst®?

Please log in to ObGFirst to access the 2T US Atlas

Password Trouble?

Not an ObGFirst® Member Yet?

  • - Access 2T US Atlas
  • - Guideline notifications
  • - Daily research paper summaries
  • - And lots more!
ObGFirst Free Trial

Media - Internet

Computer System Requirements

OBG Project CME requires a modern web browser (Internet Explorer 10+, Mozilla Firefox, Apple Safari, Google Chrome, Microsoft Edge). Certain educational activities may require additional software to view multimedia, presentation, or printable versions of their content. These activities will be marked as such and will provide links to the required software. That software may be: Adobe Flash, Apple QuickTime, Adobe Acrobat, Microsoft PowerPoint, Windows Media Player, or Real Networks Real One Player.

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.

Disclaimer

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.

Jointly provided by

NOT ENOUGH CME HOURS

It appears you don't have enough CME Hours to take this Post-Test. Feel free to buy additional CME hours or upgrade your current CME subscription plan

Subscribe

JOIN OBGFIRST AND GET CME/CE CREDITS

One of the benefits of an ObGFirst subscription is the ability to earn CME/CE credits from the ObG entries you read. Tap the button to learn more about ObGFirst

Learn More
Leaving ObG Website

You are now leaving the ObG website and on your way to PRIORITY at UCSF, an independent website. Therefore, we are not responsible for the content or availability of this site