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Key words:
Ovary;
Torsion;
Bilateral;
Synchronous;
Oophoropexy;
Pediatric
Abstract Ovarian torsion is a surgical emergency that can present with a variety of symptoms and
hence is difficult to diagnose. We present the first case of a pediatric synchronous bilateral ovarian
torsion in ovaries without pathology and review its presentation, diagnosis, treatment, outcome, and
the associated literature.
2011 Elsevier Inc. All rights reserved.
1. Background
Ovarian torsion, one of the few gynecologic surgical
emergencies, has an incidence of 4.9 in 100 000 [1]. In up
to 46% of cases of ovarian torsion in children, no
underlying ovarian mass is found [2]. Warnek in 1895
reported the first adult case of bilateral ovarian torsion,
which remains a rare occurrence to this day [3]. To the best
of our knowledge, we report the first confirmed childhood
case of synchronous bilateral ovarian torsion in ovaries
without an underlying cyst or mass and provide a review of
the literature on the topic.
2. Case
A previously healthy, premenarchal, 12-year-old girl was
referred to the pediatric and adolescent gynecology clinic
with a 2-year history of recurrent episodes of right lower
Corresponding author. Tel.: +1 416 813 4981; fax: +1 416 813 7271.
E-mail address: taniadumont@yahoo.ca (T. Dumont).
0022-3468/$ see front matter 2011 Elsevier Inc. All rights reserved.
doi:10.1016/j.jpedsurg.2011.08.024
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T. Dumont et al.
Fig. 1 Ultrasound images of case. A, Pretorsion. B, At time of diagnosis of torsion (notice absence of Doppler flow in left ovary). C, At
postoperative visit.
3. Comments
Ovarian torsion is a rare entity in which the diagnosis is
difficult to make, particularly in children where torsion may
involve a normal ovary without a leading mass. Presenting
symptoms are variable and can include variable abdominal
pain (the most common presenting symptom), nausea,
vomiting, diarrhea, and fever [5-7]. Clinical findings also
differ between patients who may present with an acute
surgical abdomen, a palpable mass, and/or leukocytosis [5-7].
The diagnosis of ovarian torsion relies on history, clinical
findings, and supportive imaging. The most common
ultrasound finding is an enlarged ovary [8]. Other findings
include absence of Doppler flow, peripheral follicles of 8 to
15 mm with fluid debris levels, free intraperitoneal fluid,
thickening of cyst wall, and whirlpool sign [5,9-11]. The only
ultrasound abnormality in the current case was an enlarged
left ovary with diminished Doppler flow; in the clinical
Fig. 2
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Fig. 3 Laparoscopic view after ovarian detorsion and bilateral oophoropexy to the uterosacral ligaments. Note the elongated
uteroovarian ligaments.
E22
Table 1
T. Dumont et al.
Summary of pediatric bilateral ovarian torsions from review of the literature
Authors
zcan et al
2002 [5]
7
12
3
7
6
7
6.5
3.5
8.5
10
2 y, 3 mo
6 wk
3y
2y
2y
2y
4y
7y
12 mo
8 mo
RSO
RSO
RSO
RSO
LSO
RSO
LSO
RSO
RSO
RSO
10
2y
LSO
9y
Incidental finding
(left side)
RSO
4.5
17 mo
LSO
7 mo
Incidental finding
(left side)
RSO
12
5 mo
Beaunoyer 3
et al 2004
[13]
12
2y
5 mo
First OR
Findings
720 torsion Rt
hemorrhagic
edematous ovary
720 torsion of Rt
ruptured necrotic
ovary
Torsion of Lt ovary
without pathology
Torsion of Lt ovary
without pathology
Torsion of Lt ovary
without pathology
Torsion of Lt ovary
without pathology
Torsion of Rt ovary
with follicular cysts
12
6 mo
10
18 mo
Karnik et al 11
2005 [15]
10 mo
Takeda et al 9
2006 [17]
6
Svensson
et all
2008 [16]
13
Rousseau
et al 2008
[14]
Dumont
12
et al 2011
SYNCHRONOUS Torsion of Rt
dermoid cyst
Torsion of Lt
dermoid cyst
SYNCHRONOUS Torsion of Rt
adnexa, no cyst
or masses
Torsion of Lt
adnexal, no cyst
or masses
Second OR
Procedure
Findings
Procedure
LSO
LSO
LSO
LSO
Detorsion
LSO
RSO
LSO
LSO
Detorsion and
oophoropexy
Detorsion and
oophoropexy
Detorsion and
oophoropexy
Detorsion and
oophoropexy
Detorsion and
oophoropexy
Detorsion
720 torsion of Lt
edematous ovary
Detorsion and
oophoropexy
RSO
720 torsion of Lt
edematous ovary
Detorsion and
oophoropexy
LSO
Torsion of Rt ovary
without pathology
Torsion of Rt ovary
without pathology
Torsion of Rt ovary
without pathology
Torsion of Rt ovary
without pathology
1260 torsion of Lt
ovary without
pathology
NA
Detorsion and
oophoropexy
Detorsion and
oophoropexy
Detorsion and
oophoropexy
Detorsion and
oophoropexy
Laparotomy,
detorsion,
oophoropexy
NA
720 torsion of Lt
ovary without
pathology
NA
Laparoscopy,
detorsion, hyperbaric
oxygen therapy
NA
LSO
LSO
LSO
Laparotomy, RSO,
appendectomy
Bilateral detorsion
and cystectomy
Laparotomy, RSO,
appendectomy
RSO
Detorsion, Lt
cystectomy
Laparoscopy, bilateral NA
detorsion, and bilateral
oophoropexy
NA
Rt indicates right; Lt, left; RSO, right salpingo-oophorectomy; LSO; left salpingo-oophorectomy; NA, not applicable; blank box, data not available.
E23
diagnosis could have led to subsequent bilateral loss of
ovarian function. We urge all caregivers to consider the
possibility of ovarian torsion and bilateral torsion as a
diagnosis and suggest prompt laparoscopic intervention,
reduction of the torsion, and consideration of oophoropexy.
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