Adnexal torsion — A multimodality imaging review

Retrospective analysis of patients with surgically proven ovarian torsion, our experience

Aim

To study the patients who were admitted to our hospital with surgically proven ovarian torsion and were operated for the same and to study for whom detorsion was done.

Materials and Methods

A retrospective analysis of the medical records and surgical notes of 150 patients with surgically proven ovarian torsion over a 10-year period between January 2011 and January 2021 was carried out. Surgical notes included details like mode of the surgery (laparotomy or laparoscopy), type of surgery (oophorectomy, detorsion, detorsion with cystectomy), whether fixation was done or not, size of mass/ovary, laterality, appearance of the torted ovary, color of the ovary, and number of twists. Histopathologic reports of the patients who underwent oophorectomy or detorsion with cystectomy were also recorded.

Results

During the 10-year study period, 88 (58.7%) patients had undergone laparotomy and 62 (41.2%) patients had undergone laparoscopy. Detorsion with cystectomy was done in 96 (64%) cases, detorsion alone in 14 (9.3%) cases, and oophorectomy was done in 40 (26.6%) cases. There was no significant difference in terms of increase in postoperative complications.

Conclusion

Laparoscopic detorsion with cystectomy is the most common surgical procedure used for ovarian torsion at King Hussein Medical Center.

Scoring system for predicting ovarian necrosis in adnexal torsion using an ultra-short optimized MRI protocol

PURPOSE

To evaluate a MRI scoring system predicting haemorrhagic necrosis in adnexal torsion with intraoperative and/or histopathological correlation using an abbreviated and optimized MRI protocol.

METHODS

This retrospective observational study includes patients with adnexal torsion who underwent Magnetic Resonance Imaging(MRI) and surgery. T2 sequences were evaluated by three observers of varying experience for following findings: Hypo-intensity of ovarian stroma, around the follicle, cyst wall or ovarian capsule and the twisted pedicle. Hypo-intensities in the above and a thick cyst wall were considered as predictors of necrosis. A scoring system was created based on the number of positive findings. MRI was correlated with intraoperative and histopathological findings. Lesions showing haemorrhagic necrosis were considered true positives.

RESULTS

43 women with torsion were included. 74.4% were secondary to a lead point and 25.4% were without one. Hypointensity score of 2 or more had the highest diagnostic accuracy and inter-reader agreement in predicting necrosis (R1-sensitivity: 92%, specificity: 89%, positive predictive value (PPV): 92% and negative predictive value (NPV): 89%, R2-sensitivity: 92%, specificity: 94%, PPV: 96% and NPV: 90% and R3-sensitivity: 92%, specificity: 83%, PPV: 89% and NPV: 89%).

CONCLUSION

In patients with suspected adnexal torsion, optimized MRI using T2 weighted sequences will serve as a rapid and effective single imaging modality for diagnosing adnexal torsion and accurately predicting necrosis thereby triaging the patients for appropriate management.

Pediatric and Adolescent Gynecologic Emergencies

Pediatric gynecology encompasses a wide range of topics from the maternal estrogen impact on the neonate, to the unique pathophysiology of the lack of estrogen on prepubescent females, and the independence and sexual maturation that occurs with adolescence. This article will review the impact of normal hormonal variations in children, unique pathophysiology of certain conditions in the prepubescent period, as well as common injuries and infections of the genitourinary system in children.

The effects of amiodarone in ovarian injury due to oxidative stress and inflammation caused by ischemia-reperfusion

OBJECTIVE

Ovarian ischemia constitutes 2-3% of all gynecological emergencies. New-generation therapeutic agents need to be discovered, in addition to invasive interventions capable of reducing the risk of potential ovarian ischemia to a minimum and protecting against potential adverse outcomes.

AIMS

To investigate the effects of amiodarone (AMD) on ischemia-reperfusion-induced oxidative stress and inflammation-induced ovarian damage.

METHODS

The control group, received intraperitoneal (i.p.) injection of saline solution. The ischemia group (I-Group), was subjected to ischemia-induced injury without drug administration. The ischemia + AMD (50 mg/kg) group was subjected to ischemia injury and also received i.p. 50 mg/kg AMD prior to induction of ovarian ischemia. The ischemia-reperfusion (I/R group) was exposed to ischemia and reperfusion-induced injury without drug administration. The I/R + AMD (50 mg/kg) group underwent I/R injury together with i.p. administration of 50 mg/kg AMD prior to induction of ovarian I/R. The Sham + AMD group received intraperitoneal (i.p.) injection of 50 mg/kg AMD alone. In this study performed thiobarbituric acid reactive substances (TBARS), thiol (-SH), interleukin 1 Beta (IL-1β), interleukin 6 (IL-6), toll-like receptor 4 (TLR4) and nuclear factor-kappa B(NF-κβ).

RESULTS

Increased oxidative stress and inflammation as a result of ovarian I and I/R application activated the cascade. AMD was not sufficient to reduce the oxidative stress and inflammation. TLR4 and NF-kβ, which were up-regulated by triggering oxidative stress and inflammation, were not regressed by the effects of AMD.

CONCLUSIONS

AMD, used as an antiarrhythmic agent, was found to be insufficient, despite its antioxidant and anti-inflammatory properties, to reduce the experimentally induced ovarian tissue damage.

Adnexal torsion: a review of diagnosis and management strategies

PURPOSE OF REVIEW

Adnexal torsion remains a diagnostic challenge heavily reliant on high clinical suspicion, with patient presentation and imaging used as adjuncts to aid in its diagnosis. This review summarizes diagnostic and management techniques of adnexal torsion to assist providers when encountering this surgical emergency.

RECENT FINDINGS

Common findings of adnexal torsion include abdominal pain, nausea, vomiting, and adnexal mass or ovarian enlargement. An elevated neutrophil to lymphocyte ratio may be useful for diagnosis. A 'whirlpool' sign, 'follicular ring' sign, enlarged/edematous ovary, and absent Doppler flow to the ovary are highly suggestive of adnexal torsion. Intraoperative visual diagnosis of ovarian death is highly inaccurate, with only 18-20% of ovaries necrotic on pathological examination. Necrotic appearing ovaries have been shown to have follicular activity on ultrasound one year postoperatively.

SUMMARY

Pelvic ultrasound remains the first-line imaging modality. In patients of reproductive age, we recommend performing detorsion with ovarian conservation, even in cases where the tissue appears necrotic, given poor intraoperative diagnostic rates of tissue death. Retention of ovarian function is also reliant on a timely diagnosis and intervention. We emphasize that the risk of ovarian damage/loss outweigh the risk of a diagnostic laparoscopy in patients of reproductive age.

Ultrasonographic scoring system for the diagnosis of adnexal torsion

PURPOSE

To establish the utility of an ultrasonographic scoring system for the diagnosis of adnexal torsion.

METHODS

We retrospectively analyzing 358 adnexal torsion cases. Using Pearson's χ² test we determined whether ultrasonographic signs were significantly associated with adnexal torsion. Receiver operating characteristic curves were used to evaluate the diagnostic efficacy of the system. Ultimately by using binary logistic regression we established a precise and convenient scoring system.

RESULTS

The torsion score was based on five criteria that were identified to be independently associated with adnexal torsion: (1) abnormal position of the index adnexa (odds ratio [OR], 2.311); (2) presence of a mass or cyst (OR, 3.495); (3) unilateral ovarian enlargement (OR, 3.051); (4) vascular pedicle twisting (OR, 2.105); and (5) peripheral hypervascularity of the corpus luteum with ovarian edema(encapsulating cyst sign) (OR, 4.164).patients with torsion who scored 0, have a predicted diagnosis rate of 20.9%; patients whose scores were 1,2 have a predicted probability of 41.8% and 66.15%, respectively. For patients with torsion scores of 3, 4, and 5, predicted diagnosis rates were 84.16%, 93.52%, and 98.27%, respectively.

CONCLUSION

The ultrasonographic scoring system is feasible and precisely diagnoses adnexal torsion using ultrasound.

High risk and low prevalence diseases: Ovarian torsion

INTRODUCTION

Ovarian torsion is a rare, frequently misdiagnosed condition that carries with it a high rate of morbidity.

OBJECTIVE

This review highlights the pearls and pitfalls of ovarian torsion, including presentation, evaluation, and management in the emergency department (ED) based on current evidence.

DISCUSSION

Ovarian torsion is one of the most common gynecological surgical emergencies and occurs with complete or partial rotation of the ovary along the supporting ligaments, obstructing vascular flow. Several risk factors include the presence of an ovarian mass or cyst. The most common population affected includes reproductive aged women, though cases also occur in premenarchal females, pregnant women, and postmenopausal women. Abdominal or pelvic pain is common but is not always sudden in onset or severe. Nausea and vomiting occur in 70%. Ultrasound can assist with diagnosis, but a normal ultrasound examination cannot exclude the diagnosis. Computed tomography with intravenous contrast can assist with diagnosis. Treatment includes emergent gynecologic consultation for surgical detorsion, along with symptomatic therapy in the ED.

CONCLUSIONS

An understanding of ovarian torsion can assist emergency clinicians in diagnosing and managing this disease.

A clinical prediction model for adnexal torsion in pediatric and adolescent population

PURPOSE

To describe the clinical characteristics of children and adolescents that underwent diagnostic laparoscopy for suspected adnexal torsion (AT), and to develop a prediction model for preoperative detection of AT among young women.

METHODS

A retrospective cohort study. We included all girls ≤18 years old with clinically suspected AT who underwent a diagnostic laparoscopy between 3/2011 and 6/2020. We compared patients with AT to those without AT and constructed a prediction model.

RESULTS

Overall, 120 children and adolescents with suspected AT were included in the study. Of those, AT was identified in 83 (69.2%). In a multivariate analysis, the following risk factors were independently associated with AT and included in the prediction model: absence of right lower quadrant tenderness upon examination [adjusted odds ratio (aOR) (95% Confidence interval (CI)) 3.23 (1.23-8.47), p = 0.017], platelets level >240 K [aOR (95% CI) 3.15 (1.19-8.36), p = 0.021], and neutrophils level >5.4 [aOR (95% CI) 2.71 (1.02-7.52), p = 0.046]. The rate of AT was 12.5% in cases without risk factors for AT, 56.7% with one, 68.8% with two, and 94.1% with three risk factors present, respectively.

CONCLUSIONS

We have identified preoperative indicators independently associated with surgically confirmed AT in a large cohort of young women. Level of evidence- III.

Computed Tomography Features of Adnexal Torsion: A Meta-Analysis

OBJECTIVES

We performed a meta-analysis of studies examining the computed tomography (CT) features of adnexal torsion (AT).

METHODS

We searched PubMed, Embase, Web of Science, and the Cochrane Library for studies involving the proportion of CT features in patients with AT and that used surgery as the reference test. Study quality was assessed using the Newcastle-Ottawa scale and the Agency for Healthcare Research and Quality tool.

RESULTS

Twelve articles involving 483 patients were included. The pooled proportion of right-sided adnexal lesion was 54% (95% confidence interval [CI]: 49%-56%). The pooled proportions of the ovarian lesion histopathological types were: benign germ cell tumors, 33% (95% CI: 28%-37%); benign cystic lesions, 26% (95% CI: 21%-30%); benign epithelial neoplasms, 24% (95% CI: 20%-29%); sex cord-stromal tumors, 4% (95% CI: 2%-6%); borderline neoplasms, 3% (95% CI: 1%-6%); and hemorrhagic cysts, 2% (95% CI: 0%-3%). The pooled proportions of CT features were: Adnexal enlargement, 99% (95% CI: 98%-99%); adnexal with mass, 98% (95% CI: 97%-100%); twisted pedicle, 81% (95% CI: 78%-83%); mass with thickened wall, 77% (95% CI: 73%-81%); tubal thickening, 73% (95% CI: 68%-77%); abnormal location of adnexa, 69% (95% CI: 63%-75%), pelvic ascites, 43% (95% CI: 38%-49%); pelvic fat infiltration, 41% (95% CI: 34%-48%); uterine deviation, 37% (95% CI: 31%-42%); and lack of enhancement, 20% (95% CI: 14%-25%).

CONCLUSION

Adnexal enlargement, adnexal mass, and twisted pedicle may be the most important CT features for diagnosing AT.

A validated predictive model for adnexal torsion pre-operative diagnosis

PURPOSE

To develop a simple predictive model for pre-operative diagnosis of adnexal torsion (AT).

METHODS

A retrospective cohort study with a retrospective validation, including 669 separate episodes of women who underwent laparoscopy due to a suspected AT between January 2011 and June 2020. We compared the pre-operative characteristics between women with surgically confirmed AT and those without.

RESULTS

The derivation cohort included 615 episodes of suspected AT. AT was surgically confirmed in 445 episodes (72%). The retrospectively collected validation cohort included 54 episodes, with 31 (57.4%) surgically confirmed AT. In a multivariate regression analysis, vomiting, neutrophils to lymphocytes ratio > 3.5 and sonographic finding of enlarged ovary were independently associated with AT [OR 95% CI 2.78 (1.21-6.36), 3.15 (1.42-6.97) and 2.80 (1.33-5.88), respectively]. In the derivation cohort, the PPV for AT diagnosis was 69.7%, 84.5% and 93.1% if 1, 2 and 3 risk factors were present, respectively. Retrospective validation analysis underlined a PPV of 67.6%, 82.6 and 66.6% for 1, 2 and 3 risk factors, respectively.

CONCLUSION

We have developed and validated a simple predictive model for pre-operative diagnosis of AT, based on three parameters. Our model may assist clinicians while evaluating patients with suspected AT and improve pre-operative diagnosis.

Imaging of complications following treatment with assisted reproductive technology: keep on your radar at each step

Since the advent of assisted reproductive technology (ART), the utilization of ART procedures has become increasingly popular among women seeking to establish pregnancy. Radiologists are therefore likely to encounter the various complications of ART therapy. The most common is ovarian hyperstimulation syndrome; others are multiple, ectopic, and heterotopic pregnancies. Ultrasonography is considered the initial modality to investigate ART complications, However, nonspecific symptoms might need the use of an additional imaging modality, such as computed tomography or magnetic resonance imaging, as a problem-solving tool. This article briefly discusses the steps involved in assisted reproduction. Its aim is to help radiologists become familiarized with the multimodality imaging features of the spectrum of ART-related complications. Their key imaging features and differential considerations are emphasized. This will facilitate the provision of precise and timely diagnoses, and aid the avoidance of fatal consequences.

World Federation for Ultrasound in Medicine Review Paper: Incidental Findings during Obstetrical Ultrasound

Although the prevalence of incidental findings revealed during an obstetric ultrasound examination is low, the findings may include adnexal and cervical masses, uterine or urinary congenital malformations, free fluid in the pouch of Douglas or tortuous vessels (varices). Adnexal masses are the most common finding and vary in imaging characteristics. They are mainly unilateral, cystic masses with a low risk of malignancy that are treated conservatively. The International Ovarian Tumor Analysis scoring models may be helpful in differentiating benign from malignant masses. For those masses >5 cm, follow-up is recommended, and resection could be considered to avoid risk of torsion, rupture and hemorrhage, which may compromise pregnancy outcome. Uterine masses such as fibroids are commonly diagnosed early in the first trimester and should be followed up during pregnancy to evaluate any changes. Transabdominal and transvaginal ultrasound is the first-line test for the diagnosis of such incidentalomas; however, magnetic resonance ultrasound may have a useful role in excluding malignancy potential. As a result of their low frequency and the lack of good evidence, there are no specific guidelines on the management of incidentalomas detected at obstetric scans. Their management should follow the related general guidelines for ovarian, cervical and uterine masses, with individualized management depending on the pregnancy status.

Ovarian Torsion in Adolescents with and without ovarian mass: A Cross-sectional Study

STUDY OBJECTIVE

The aim of this study was to compare the characteristics of adolescents with and without adnexal mass who were diagnosed with ovarian torsion (OT).

DESIGN

Retrospective cross-sectional study.

SETTING

Gynecology Department at Tepecik Education and Reseach Hospital, Izmir, Turkey.

PARTICIPANTS

Adolescent girls who received surgery for OT between March 2012 and October 2020 in our institution.

INTERVENTIONS AND MAIN OUTCOME MEASURES

The patients were divided into 2 groups according to the presence or absence of an ovarian mass and compared. Demographic and clinical characteristics, imaging findings, surgery, and pathology reports of the patients were obtained. Differences in initial symptoms, ultrasound findings, the diagnostic process, and the degree of torsion in patients with and without ovarian mass.

RESULTS

Seventy-six patients were diagnosed with OT. Of the 76 patients, 41/76 (53.9%) had an ovarian mass (OTwM), and 35/76 (46.1%) had no pathology (OTnP). The admission to surgery interval was longer in the OTnP group (P = .03). Ultrasound findings of ovarian edema and the appearance of free fluid were significant in the OTnP group (P = .001). The largest dimension of the nontorsion ovary in the OTnP group was greater than in the OTwM group (P = .03). In addition, it was found that torsion more than 360° was more common in the OTnP group than in the OTwM group (24/35, 68.5% vs 41/18, 43.9%; P = .03).

CONCLUSION

In symptomatic adolescents without an ovarian mass, the presence of follicle peripheralization suggesting ovarian edema on ultrasound and the presence of free fluid in the abdomen are important in terms of suspicion of torsion for clinicians. In addition, the degree of torsion was increased in these patients.

Predictive Value of Single or Combined Ultrasound Signs in the Diagnosis of Ovarian Torsion

OBJECTIVES

To determine predictive values of isolated and combined ultrasound signs in the diagnosis of adnexal torsion.

METHODS

This work was a retrospective study of 129 adult female patients who underwent an ultrasound examination followed by a definitive surgical procedure within a 24-hour period to determine whether adnexal torsion was present.

RESULTS

The positive predictive value (PPV) of the ultrasound diagnosis of adnexal torsion was 82.2%. The statistically significant ultrasound signs in multivariate logistic regression with single-predictor analyses were relative enlargement of the ovary, an abnormal adnexal position, a twisted vascular pedicle, and the follicular edema "ring sign." Possible combinations of these ultrasound criteria showed high specificities (74%-100%), high PPVs (93%-100%), and lower sensitivities (29%-71%) and negative predictive values (24%-35%). Any combination that included a twisted vascular pedicle or the follicular ring sign as one of the signs had high odds ratios and positive likelihood ratios.

CONCLUSIONS

Ultrasound has a high PPV as a first-choice imaging modality in the diagnosis of adnexal torsion. The combinations of the following 4 statistically significant ultrasound signs, consisting of an abnormal position, relative enlargement of the index ovary, a twisted vascular pedicle, and the follicular edema ring sign, substantially narrow the imaging differential diagnosis in such cases. The presence of vascular pedicle twisting and the follicular ring sign was highly associated with a positive ovarian torsion diagnosis, with 100% specificity.

CT predictive model for torsion angle as a marker for risk of necrosis in patients with adnexal torsion

AIM

To assess the feasibility of preoperative computed tomography (CT) prediction of torsion angle for stratifying the risk of necrosis in patients with adnexal torsion.

MATERIALS AND METHODS

In this multicentre, retrospective study, 72 patients underwent preoperative CT and surgically verified adnexal torsion. Surgeons identified the torsion angle and adnexal necrosis requiring adnexectomy. The twisted angles were compared between conservative surgery group and salpingo-oophorectomy group. Variables included demographic, pathological and CT details. Logistic analysis was used to identify the indicators of twisted angle associated with high-risk necrosis.

RESULTS

The necrosis associated with adnexal torsion treated with adnexectomy was performed more often in patients with a torsion angle of ≥720° (odds ratio [OR]=7, 95% confidence interval [CI]: 1.314-37.295, p=0.023). The enlarged twisted pedicle (OR=14.592, 95% CI: 2.048-103.953, p=0.007) and pedicle haemorrhage (OR=5.612, 95% CI: 1.088-28.941, p=0.039) can predict a torsion angle of ≥720°, and area under the receiver operating characteristic (ROC) curve (AUC=0.758±0.058) was generated with the combined variables.

CONCLUSION

The risk of adnexal necrosis is high in patients with torsion angle of ≥720°. CT findings of enlarged twisted pedicle and pedicle haemorrhage can be used to predict torsion angle of ≥720° and can imply adnexal necrosis indirectly.

Pearls and Pitfalls in Imaging of Pelvic Adnexal Torsion: Seven Tips to Tell It's Twisted

Pelvic adnexal torsion is a collective term referring to twisting of an ovary, fallopian tube, or paraovarian cyst on its axis with varying degrees of vascular compromise. Although it is the fifth most common gynecologic emergency, the diagnosis is challenging and often missed due to symptoms, physical examination findings, and imaging features that are nonspecific. Delay in salvage surgery may lead to ovarian or tubal loss, dysfunction, and infertility. The tips shared herein are based on the authors' observations of key clinical and imaging features of torsion, with the intent of heightening radiologists' index of suspicion and diagnostic accuracy in a clear and memorable fashion. Clinically, severe acute pain with a known adnexal mass or of severity to elicit nausea or vomiting should raise concern. At imaging, features of ovarian edema are key to the diagnosis, including asymmetric ovarian enlargement, peripheralized follicles, adjacent free fluid, and foci of stromal hemorrhage. The converse finding of symmetric nonenlarged ovaries in a normal location with any imaging modality has a high negative predictive value for torsion, obviating the need for additional imaging. The whirlpool sign (twisted vascular pedicle), abnormal ovarian location, and uterine tilting are additional key imaging manifestations. The presence of color Doppler flow or contrast enhancement only suggests that an ovary is still viable and should not be used to exclude the diagnosis of torsion. In cases of isolated tubal or paraovarian cyst torsion, the ovaries may appear normal; therefore, recognition of this entity along with appreciation of several key imaging findings may assist with this difficult diagnosis. An invited commentary by Dighe is available online. Online supplemental material is available for this article. ^©RSNA, 2021.

Clinical and CT features of ovarian torsion in infants, children and adolescents

OBJECTIVE

To investigate the clinical features and computed tomography (CT) findings of pediatric ovarian torsion.

METHODS

A retrospective analysis of the clinical and CT data of 61 newborns, infants, children, and adolescents with ovarian torsion confirmed by histopathology was performed.

RESULTS

Clinical features included abdominal mass, abdominal pain, nausea and vomiting, and fever. The tumor marker α-fetoprotein was increased in five cases. Ovarian enlargement was found in 26 cases, and follicles were detected in the peripheral region of the ovary in 21 cases. Twenty-one cases presented as solid mixed-density masses on CT images. A total of 30 cases of ovarian torsion were associated with a benign ovarian mass. Among 27 cases of cystic or predominantly cystic masses, the mass had a thickened wall in 26 cases and showed an uneven density in 23 cases. Among all 61 patients, a torsed pedicle was detected in 47 cases. A torsed ovary or mass exhibited mild contrast enhancement in seven cases. Uterine deviation toward the involved side, blurred fat space around lesions, and pelvic free fluid were also found.

CONCLUSION

Pediatric ovarian torsion presents a relatively characteristic CT appearance. Correct diagnosis can be established based on clinical and imaging features.

Isolated tubal twist: A case series of a rare event occurring at different times in reproductive life

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Isolated fallopian tube torsion is a rare but potentially serious event occurring at different times in reproductive life.

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This diagnosis is often overlooked before surgery.

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It should be evoked in front acute pelvic pain in patients with history of hydrosalpinx or paratubal cyst.

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Conservative management must be privileged especially in woman of childbearing age and in a pediatric population.

Introduction and importance

Isolated fallopian tube torsion (IFTT) is a rare but potentially serious cause of pelvic pain in women. Despite being a surgical emergency, this diagnosis is often overlooked before surgery. To raise awareness of this diagnosis among clinicians, we describe here five cases, which occurred at different times in reproductive life.

Cases presentation

We present five cases of isolated fallopian tube torsion at different ages (13–54 years). It often manifests with sudden onset of acute pelvic pain in four cases and chronic pelvic pain in one case.

At admission, patients were suspected of adnexal torsion (3 cases), genital infection (1 case), and renal pain (1 case). CT-scan showed IFTT in only one patient. Laparoscopic surgical management, performed by experienced surgeons, consisted of salpingectomy in 4 cases and conservative treatment in one case. The latter was complicated with hydrosalpinx 6 years later. All patients were followed in outpatient clinic at least one time after surgery and had favorable outcomes.

Clinical discussion

Given the rarity of the pathology and the lack of pathognomonic imaging, IFTT is rarely diagnosed before surgery. Its etiology is still unknown but hydrosalpinx following an infectious process seems to be a major risk factor.

Conclusion

Increasing awareness of this rare entity is advocated, especially in woman of reproductive age. Torsion should be evoked in front acute pelvic pain in patients with hydrosalpinx or paratubal cyst. Conservative management must be privileged especially in women of childbearing age and in pediatric population.

Ovarian borderline tumor presenting as ovarian torsion in a 17-year-old patient: a case report

Background

Ovarian torsion is a gynecological surgical emergency whose diagnosis remains a challenge. Torsion occurs most frequently in women of reproductive age. It is usually associated with the presence of benign masses in the ovary, as malignant tumors are less frequent and less prone to undergo torsion.

Case presentation

We report the case of a 17-year-old Caucasian patient who presented to the emergency department with lower abdominal pain. Ultrasonography evaluation revealed a unilateral ovarian lesion, 11.2 cm, with features suspicious for malignancy and torsion. The patient was referred for surgical torsion treatment and underwent unilateral salpingo-oophorectomy. The pathology report confirmed a serous borderline ovarian tumor with torsion.

Conclusions

Malignant ovarian torsion in pediatric age groups is rare. Ultrasound examination should be recognized as a powerful tool for diagnosis and management, especially when performed by an experienced ultrasonographer.

Acute abdomen or life-threatening heterotopic pregnancy with tubal rupture: where does imaging play a role?

Heterotopic pregnancy (HP) is a rare, potentially life-threatening complication of an intrauterine pregnancy with a simultaneous ectopic pregnancy. There is a higher incidence with assisted reproduction techniques (ART) and radiology can be pivotal in its diagnosis. A 28-year-old woman underwent ART and at 7 weeks' gestation presented with acute right iliac fossa pain. Transvaginal ultrasound (US) imaging confirmed a viable intrauterine pregnancy. The patients' pain persisted however, and transabdominal US demonstrated a complex, heterogeneous right adnexal mass. Subsequent magnetic resonance imaging (MRI) confirmed an HP with a ruptured ectopic and haemoperitoneum. Emergency laparoscopic surgery and right salpingo-oopherectomy were performed without complication. We highlight the importance of considering HP as a diagnosis in the acute gravid abdomen, especially when initial investigations have confirmed a viable intrauterine pregnancy. Furthermore, this case highlights MRI as a useful modality in complex cases due to its high soft tissue contrast resolution using non-ionising radiation.

Just the Facts: Ovarian torsion in the emergency department setting

A 23-year-old female presents with right lower quadrant pain that has been intermittent for the past several days. The pain suddenly worsened 1 hour ago. She denies vaginal bleeding or discharge, dysuria, fever, and back pain, but she has had several episodes of nausea with nonbloody, nonbilious vomiting. On examination, she is tender in the right lower quadrant, but her abdomen is not rigid.

Multimodality imaging review for suspected ovarian torsion cases in children

OBJECTIVES

Ovarian torsion (OT), although rare, can be described as a complete or partial twist of the ovary with impairment of blood flow. Although occurring at any age, it is more common in children and during pregnancy. Presenting symptoms are non-specific but include either persistent or intermittent acute abdominal pain, making early diagnosis difficult. Delayed diagnosis is associated with an increased need for oophorectomy. The aim of this literature review is to establish the safest and most efficacious imaging strategy for OT by comparing and contrasting evidence for current imaging modalities found in the literature.

KEY FINDINGS

Characteristically, OT can be identified through a combination of findings some of which includes an enlarged ovary, multiple follicles at the periphery and a "whirlpool" sign. Currently, ultrasound is the preferred primary imaging modality; although computed tomography (CT) and magnetic resonance imaging (MRI) may also be used when findings are equivocal; with MRI being the safer option.

CONCLUSION

Ultimately, while it is true that ovarian torsion is not a common cause of acute abdominal pain in children, it should always be considered in the differential diagnosis. Prior to selecting an imaging modality; the clinical presentation, age group, possible radiation dose and availability of the modality needs to be considered to ensure the appropriate imaging strategy.

IMPLICATIONS FOR PRACTICE

With new tools such as scoring systems, B-flow imaging (BFI), diffusion-weighted imaging (DWI) and susceptibility-weighted imaging (SWI) currently being explored for possible use in the future, early diagnosis of OT may be attainable. Thus, reducing the likelihood of adverse complications and consequently the need for oophorectomy.

Pelvic hemorrhagic lesions in women: MRI findings and differential diagnosis

A large spectrum of pathologic pelvic conditions can present with hemorrhage in structures or organs. These may present acutely, subacutely, chronically or as incidental findings. Clinical history and MRI characteristics can often narrow the differential diagnosis and guide management. The purpose of this article is to showcase a wide array of pelvic lesions, in which the presence of blood is a key imaging feature, and their differential diagnosis.

Laparoscopic detorsion of the ovary in ovarian hyperstimulation syndrome during the sixth week of gestation: A case report and review

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Delayed treatment & diagnosis of ovarian torsion may cause pregnancy termination.

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Optimal management for these patients remains unstandardized.

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No consensus exists regarding the appropriate surgical approach.

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A 40-year-old pregnant female presented to us with ovarian torsion and OHSS.

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She was successfully treated with laparoscopic detorsion.

Introduction

Ovarian torsion in ovarian hyperstimulation syndrome (OHSS) is a relatively rare but serious complication in pregnant women. A delay in treatment increases the risk for functional loss of the ovary and early termination of pregnancy. In this report, we present the case of a 40-year-old female with OHSS who experienced ovarian torsion that was successfully treated with laparoscopic detorsion.

Presentation of case

A 40-year-old pregnant woman in the 6th week of gestation who had conceived following in vitro fertilization presented to us with severe and persistent lower abdominal pain. Ultrasound examination revealed a viable singleton intrauterine pregnancy and bilateral enlarged ovaries with scanty ascites. Approximately 14 h after symptom onset, exploratory laparoscopy was performed. The right ovary was found to be twisted once around over the pedicle, and laparoscopic detorsion was completed. Postoperative follow-up was uneventful, and she successfully delivered a healthy infant at 38 weeks of gestation.

Discussion

Although the reports on successful laparoscopic surgery for pregnant women with ovarian torsion are becoming more frequent, there are few reports on laparoscopic surgery for ovarian torsion in OHSS during the early first trimester. Optimal management of ovarian torsion during pregnancy needs to be explored for these patients.

Conclusion

Immediate explorative laparoscopic surgery is a potentially safe and useful strategy for treating ovarian torsion during the early first trimester of pregnancy.

Spectrum of magnetic resonance imaging findings in ovarian torsion

Purpose

Ovarian torsion is the twisting of the ovary on its vascular pedicle resulting in vascular compromise. Diagnosis of ovarian torsion is challenging in patients who have atypical clinical or ultrasound (US) findings. The objective of our study was to demonstrate the magnetic resonance imaging (MRI) features of ovarian torsion to help radiologists make a conclusive diagnosis when the clinical and US findings are unclear.

Material and methods

We retrospectively reviewed the clinical and MRI features in 10 females with surgically proven ovarian torsion, who had inconclusive clinical, US, or computed tomography findings.

Results

All patients showed a significantly enlarged ovary with size ranging from 5 to 18 cm. 'Twisted ovarian pedicle' sign was seen in seven patients. Eight cases showed areas of haemorrhage within the ovarian stroma. Non-enhancement of ovarian stroma was observed in six patients. Seven patients showed an ipsilateral deviation of the uterus.

Conclusions

MRI features of ovarian torsion include ovarian enlargement, twisted ovarian pedicle, ovarian haemorrhage, abnormal ovarian enhancement, and ipsilateral deviation of the uterus. Awareness of these imaging features will enable the radiologist to recognise ovarian torsion and differentiate it reliably from other benign or malignant ovarian lesions.

A new biomarker for the early diagnosis of ovarian torsion: SCUBE-1

Objective

Prompt diagnosis and management are essential for saving the adnexal organs from infarction in cases of ovarian torsion (OT). This study aimed to determine the diagnostic significance of signal peptide, complement C1r/C1s, Uegf, and Bmp1 (CUB), and epidermal growth factor-like domain-containing protein-1 (SCUBE-1) levels in cases of OT, an emergent ischemic condition, and the relationship of SCUBE-1 with oxidative stress parameters.

Methods

This prospective study was conducted among 15 OT patients and 20 age- and gravidity-matched healthy women. SCUBE-1 serum concentrations were determined by using enzyme-linked immunosorbent assays. In addition, oxidative stress was evaluated by measuring the serum levels of advanced oxidation protein products (AOPP), ferric reducing ability of plasma (FRAP), and glutathione (GSH).

Results

The SCUBE-1 titers were significantly higher in the patients with OT than in the controls (p=0.008). In addition, serum FRAP and GSH levels were significantly lower in the OT patients than in the controls (p<0.001 for both). Serum AOPP levels were higher in the OT patients, but this trend was not statistically significant (p>0.05). Furthermore, there were no correlations between SCUBE-1 levels and age, gravidity, parity, cyst size, and AOPP, FRAP, or GSH levels (p>0.05).

Conclusion

We believe that SCUBE-1 may be a promising biomarker for the early diagnosis of OT.

CT features in surgically proven cases of ovarian torsion-a pictorial review

Ovarian torsion is a surgical emergency characterized by a partial or complete rotation of the ovarian vascular pedicle, causing obstruction to venous outflow followed by arterial inflow. Clinically, ovarian torsion frequently mimics other causes of acute pelvic pain such as appendicitis, diverticulitis, renal colic etc. Ultrasonography is the first-line imaging modality of choice for evaluation of ovarian torsion. MRI is useful as a problem-solving tool in patients with equivocal or non-diagnostic ultrasonography studies. CT is ordinarily not utilized in a young female with suspected ovarian torsion due to the radiation dose. However, the significant expansion in use of CT imaging in emergency departments for female patients presenting with acute abdominal pain has increased the likelihood that ovarian torsion may be first seen on CT. In addition, a non-specific clinical presentation may lead to an initial imaging with CT rather than ultrasonography. Ultrasound features of the ovarian torsion are well known and sufficiently described across literature as compared with the CT scan findings. In view of the increasing usage of CT as the modality of choice in emergency settings, it is imperative for the radiologist to familiarize with the CT features of ovarian torsion. An early correct diagnosis by the radiologist in clinically unsuspected cases, facilitating a prompt surgery to restore the ovarian blood flow can prevent permanent irreversible damage. There is limited published data available on the CT features of ovarian torsion. This pictorial essay illustrates CT findings with histological correlation of surgically proven ovarian torsion in our institution. These patients were primarily investigated with CT scan for acute pelvic pain ascribed to non-gynaecological causes such as bowel or urinary tract lesions.

Oophoropexy for ovarian torsion: a new easier technique

Background

Oophoropexy for ovarian torsion is easy to be done by many tools either suturing to the lateral pelvic wall, plication of the ovarian ligament or even fixation to the back of the uterus, but it is little bit difficult to do it for pregnant women with less manipulation.

Objective

We propose that using trocar site closure needle can be easier and faster technique to do this. To assess the feasibility of using the trocar site closure needle to do oophoropexy in ovarian torsion and its possible applicability.

Patients

Seven patients presented with ovarian torsion; four of them were pregnant at 7, 15, 19 and 20 weeks of gestation, two patients with ovarian hyperstimulation in IVF cycles and one adolescent patient with hemorrhagic cyst. They were diagnosed by clinical presentation and ultrasound with Doppler analysis, and confirmed by laparoscopy where they underwent detorsion and fixation of the ovary using the trocar site closure needle.

Results

Follow up of all the cases after one week showed improvement of the symptoms and normal Doppler flow of the target ovary then after three weeks by ultrasonography which revealed normal Doppler flow in the previously torsioned ovary. Two pregnant women underwent cesarean delivery where the operated ovary was observed during the delivery and was normal in shape and freely mobile with no adhesions.

Conclusion

We propose that this technique is easier, faster and more comfortable especially in ovarian torsion in pregnant women and torsion in hyperstimulated ovaries.

Electronic supplementary material

The online version of this article (doi:10.1186/s10397-017-1001-9) contains supplementary material, which is available to authorized users.

A review of ovary torsion

Ovarian torsion is a rare but emergency condition in women. Early diagnosis is necessary to preserve the function of the ovaries and tubes and prevent severe morbidity. Ovarian torsion refers to complete or partial rotation of the adnexal supporting organ with ischemia. It can affect females of all ages. Ovarian torsion occurs in around 2%-15% of patients who have surgical treatment of adnexal masses. The main risk in ovarian torsion is an ovarian mass. The most common symptom of ovarian torsion is acute onset of pelvic pain, followed by nausea and vomiting. Pelvic ultrasonography can provide information on ovarian cysts. Once ovarian torsion is suspected, surgery or detorsion is the mainstay of diagnosis and treatment.

Case 4: an adolescent girl with left lower quadrant pain

The imaging management of an adolescent girl with pelvic pain and ovarian pathology is discussed through the details of a specific case.

Acute Gynecologic Disorders

Premenopausal women with acute pelvic pain comprise a significant percentage of patients who present to the emergency room. Etiologies can be gynecologic, urologic, gastrointestinal, or vascular. Signs and symptoms are often nonspecific and overlapping. The choice of imaging modality is determined by the clinically suspected differential diagnosis. Ultrasound (US) is the preferred imaging modality for suspected obstetric or gynecologic disorders. CT is more useful when gastrointestinal or urinary tract pathology is likely. MR imaging is rarely used in the emergent setting, except to exclude appendicitis in pregnant women. This article presents a comprehensive review of imaging of acute gynecologic disorders.

Surgical Approach to Ovarian Torsion in Children

STUDY OBJECTIVE

Ovarian torsion in children is a relatively rare cause of acute abdominal pain. This study evaluates the diagnosis and treatment of ovarian torsion with an emphasis on conservative treatment approaches including the long-term follow-up results.

DESIGN AND PARTICIPANTS

Patients with surgically treated ovarian torsions between December 2006 and February 2014 were included in this retrospective study. The patient population consisted of 41 patients with 42 ovaries involved. The mean age was 11 ± 3.9 (range, 1-17) years. The most common presenting symptom was abdominal pain.

INTERVENTION

All patients underwent preoperative pelvic color Doppler ultrasonography that identified torsion in 34 (81%) ovaries.

RESULTS

During surgery, a right-sided torsion was detected in 25 (59.5%), and a left-sided one was detected in 17 (40.5%) ovaries. An excisional surgery was used for 16 (38%) ovaries, and detorsion with conservation of the ovary was used for 26 (62%). A trend toward conservative management was seen over the years. Regular follow-up for those patients who underwent conservative surgery was done in 22 patients for a mean of 25 months (range, 1.5-83 months). Control color Doppler ultrasonographic results were within normal limits in terms of ovarian size and blood supply in 17 (77%) patients. Despite normal parenchymal echogenicity, an involved ovary was smaller in size compared to the other ovary in five patients. Ovarian follicles were present in three of them.

CONCLUSION

The ovary-sparing, conservative surgery is found to be highly successful in the presented series. Although malignancies are rarely encountered in torsed ovaries with associated masses, biopsy samples should be obtained in suspicious cases.