Pediatric Ovarian Torsion in a Medical Center in
Taiwan: Case Analysis
Jun-Kai Kaoa,*, Chun-Chien Chiub, Po-Yu Wanga, Meng-Kung Yua
aDepartment of Pediatrics, Children’s Hospital, Changhua Christian Hospital, Taiwan
bDepartment of Emergency Medicine, Show Chwan Memorial Hospital, Changhua, Taiwan
Received Mar 22, 2011; received in revised form May 30, 2011; accepted Jun 16, 2011
Background: Abdominal pain is one of the most common complaints made by patients visiting
emergency departments; however, ovarian torsion is an uncommon cause of abdominal pain,
especially in young children. Early diagnosis is essential in order to salvage the ovaries. We per-
formed a retrospective analysis of patients under 18 years of age who visited Changhua Chris-
tian Hospital with adnexal torsion between June 2003 and June 2010.
Methods: Medical records were reviewed for age, associated symptoms, past and present
medical histories, physical findings, diagnostic tests performed, clinical course, pathological
findings, and diagnoses.
Results: A total of 21 patients were identified and included in the analysis; their mean (SD) age
was 13.62 (3.75) years. Abdominal pain was the universal symptom. Vomiting or nausea was the
second most common symptom (33.3%). The average period between symptom onset and diag-
nosis was 3.29 (6.39) days. Right-side adnexal torsion occurred in 14 patients, and left-side
torsion in seven patients. Ovarian cysts, most often dermoid cysts (e.g., teratomas), were
found in 16 patients (76%). Except for one conservatively treated case and one malignant case
(adult granulose cell tumor), the other results of the pathological examination were as follows:
eight dermoid cysts, two cystadenomas, one follicular cyst, and eight simple cysts.
Conclusion: Although it is uncommon, adnexal torsion should be included in the differential
diagnosis of lower abdominal pain in all girls, regardless of age. Sonography is helpful for
making such a diagnosis. Time is a critical factor, and early laparoscopy or laparotomy may
save a viable ovary.
Copyright ª 2012, Taiwan Pediatric Association. Published by Elsevier Taiwan LLC. All rights
* Corresponding author. Children’s Hospital, Changhua Christian Hospital, 135 Nanhsiao Street, Changhua, Taiwan 500.
E-mail address: firstname.lastname@example.org (J.-K. Kao).
1875-9572/$36 Copyright ª 2012, Taiwan Pediatric Association. Published by Elsevier Taiwan LLC. All rights reserved.
Available online at www.sciencedirect.com
journal homepage: http://www.pediatr-neonatol.com
Pediatrics and Neonatology (2012) 53, 55e59
Abdominal pain is one of the most common complaints
of patients visiting emergency departments.1e3Approxi-
mately one-third of children who present with abdominal
pain at an emergency department do not receive a specific
diagnosis.3Diagnosis of abdominal pain in children can
be difficult given the high prevalence of gastrointestinal
disorders, especially in young children who may not be able
to describe their symptoms particularly well or localize
their discomfort. Failing to diagnose an emerging surgical
condition, such as acute appendicitis, is the primary
concern of physicians when treating patients with abdom-
inal discomfort. However, ovarian torsion is an uncommon
cause of abdominal pain, especially in young children, and
early diagnosis is essential in order to salvage the affected
ovaries. In this study, we analyzed the epidemiological
characteristics of patients below 18 years of age with
adnexal torsion at Changhua Christian Hospital (CCH). We
retrospectively examined all patients with adnexal torsion
who visited the pediatric emergency department or
outpatient clinic of CCH between June 2003 and June 2010.
We also reviewed relevant studies in the literature.
2. Materials and Methods
We reviewed the medical charts of all patients who treated
between June 2003 and June 2010 who were diagnosed with
adnexal torsion or ovarian torsion (International Classifica-
tion of Diseases 620.5). Medical records were reviewed for
age, associated symptoms, past and present medical histo-
ries, physical findings, diagnostic tests performed, clinical
course, pathological findings, and diagnoses. Leukocytosis
was defined as >10,000 white blood cells (WBCs)/mL in
a peripheral blood sample, and pyuria was defined as >5
WBCsperhigh-power field (HPF)ofa urinesample. The study
was approved by the institutional review board of CCH.
A total of 21 patients below 18 years of age with adnexal
torsion were identified over the 7-year period and included
in the analysis. Of these children, three had visited the
outpatient department and the remaining had visited the
pediatric emergency department of our hospital. All
patients were eventually admitted to our hospital. Their
mean (SD) age was 13.62 (3.75) years (Table 1). Four
patients were below 10 years of age, and the youngest was 7
years old. Eight children had previously visited other private
clinics or were transferred from other local hospitals. The
incidence rate of adnexaltorsion in the pediatric emergency
room of CCH was one case per 10,000 visiting patients.
Abdominal pain presented in each child. The lower
abdomen was the most common area where children
described the location of their pain (Table 2). Among these
children, one child mentioned radiating flank pain but did
not have a urinary tract infection. Vomiting and nausea was
the second most common symptom (33.3%). Two children
presented with diarrhea, one had difficulty in urinating,
and one presented with a fever. A palpable mass was
detected by physical examination in one child, and one
Epidemiological characteristics of patients with adnexal torsion.
Ovarian simple cyst, follicular
cyst, serious cystadenoma
Tubal serous cystadenoma,
1 ( cystectomy 3 mon later)
Corpus luteum hematoma (1)
Ovarian hemorrhagic necrosis (1)
56J.-K. Kao et al
child presented with signs of peritonitis. The period
between symptom onset and diagnosis varied from 4 hours
to 30 days. On average, children were diagnosed 3.29 (6.39)
days after the onset of symptoms.
In terms of medical history, one child had a known
ovarian cyst (measuring 4.2 ? 3.5 ?3.0 cm) on the side of
torsion for 2 years. Two children had experienced the same
symptoms for 3 months before this study, but the symptoms
were resolved through conservative treatment at that time.
One child had a history of intussusception. None had ever
Nine (45%) children demonstrated leukocytosis with
neutrophils as the predominant cell. The average WBC (SD)
count among all patients was 11.12 (3.65) ? 103cells/mL. A
mildly elevated C-reactive protein (CRP) level was noted,
with an average of 2.45 (3.06) mg/dL and large variation
across all patients (normal to 10.9 mg/dL). Urine analysis
showed that one child had hematuria and three patients
had pyuria, but none of these four patients had a positive
urine culture. Tumor markers and hormone levels, including
cancer antigen 125(CA125), a-fetoprotein (AFP), carci-
noembryonic antigen (CEA),
progesterone, b-human chorionic gonadotropin (b-HCG),
and follicle-stimulating hormone (FSH), were tested in
some patients, but the results were normal.
patients underwent computed tomography (CT). The diam-
eters of the identified cysts were between 3.4e14.3 cm:
7.77 (3.16)? 6.15 (2.25) (Figure 1).
One child received conservative treatment during
hospitalization and never underwent an operation; the
others received laparoscopic operations. Right-side adnexal
torsion occurred in 14 patients, and left-side adnexal
torsion occurred in seven. Ovarian cysts were found in 16
patients and parafallopian cysts were found in four. One
child had a pseudocyst due to a hemorrhagic corpus luteum
hematoma that was found in addition to an ovarian cyst
during surgery. One 17-year-old patient had a solid ovarian
tumor mass that was diagnosed as an adult granulose cell
Eight patients underwent an oophorectomy (including
five patients who underwent a salpingo-oophorectomy),
and three underwent a partial oophorectomy. Six patients
underwent an ovarian cystectomy and three underwent
a salpingectomy (Table 1).
A Kaplan-Meier survival curve was constructed and
analyzed to investigate the relationship between time of
symptom onset, clinical presentation, and surgery. The
median ovary-saving time was 3 days, which means that at
the 3rd day half of the patients needed to receive an
oophorectomy. If the surgery was performed within 1 day,
75% of patients would have their ovary saved, as shown by
our results (Figure 2).
Except for one conservatively treated case and one
malignant case, the other results of the pathological
Clinical manifestations of abdominal pain.
Right lower abdomen
Left lower abdomen
Could not be localized
Types of painProgress from mild to severe
Mild and intermittent
No particular description
Size distribution of ovarian cysts in patients with
time from symptom onset until surgery and percentage of
ovaries that were saved.
Kaplan-Meier analysis of the relationship between
Ovary torsion in children 57
examination were as follows: eight children had dermoid
cysts (teratomas), two had serious cystadenomas, one had
a follicular cyst, and eight had simple cysts. Ovarian
hemorrhagic necrosis was found in seven children, and
hemorrhagic changes on micropathological examination
were observed in another five patients.
The average length of hospital stay was 4.05 (1.95) d.
One patient underwent an additional surgery 7 months later
to treat a contralateral ovarian cyst and pelvic adhesion.
One child who had initially undergone an ovarian cys-
tectomy underwent another surgery 6 years later to treat
a bilateral ovarian teratoma. One patient was later diag-
nosed with Graves’ disease and received follow-up exami-
nations at the outpatient department. The patient with the
adult granulose cell tumor was treated with chemotherapy
and received regular follow-up examinations at our
Gynecological disorders are not often considered in the
differential diagnosis of prepubertal girls because of their
infrequent occurrence. Acute ovarian torsion is uncommon
in children and timely diagnosis is difficult. Adnexal torsion
has been reported to occur from the antenatal period to as
late as 53 years of age.4Torsion of the right ovary was more
common in this study, similar to the findings of other
studies.1,3A study of torsion in 20 girls below 14 years of
age in Israel found that 30% had normal adnexa and 40% had
diseased ovaries (mostly cysts).5Bilateral adnexal torsion
may occur simultaneously, or the unaffected side may
become torsed years later, resulting in sterility.6,7Although
two of our patients (10%) had undergone other surgeries for
the treatment of ovarian cysts on the contralateral side, no
patient in our study presented with simultaneous bilateral
The onset of symptoms has been reported to range from
6 hours to 3 weeks before admission.5In this study, the
longest duration was 30 days. Abrupt onset or chronic
abdominal pain due to occlusion of the vascular supply to
the twisted ovary is the only common symptom.1,2,8Phys-
ical findings and pain characteristics are highly variable. In
contrast to the results presented by Houry and Abbott,9
which showed that 51% of torsion patients have radiating
pain in the flank, back, or groin, only one patient in our
analysis complained of flank pain. As in other studies,
vomiting and nausea were the most commonly associated
symptoms in our study. Two patients in our study experi-
enced repeated symptoms in the months leading up to the
operation, which suggests recurrent torsion and detorsion.
Although previous studies have shown that the location of
abdominal pain, as described by the patient, always
corresponds to the side of torsion,10two patients in our
study reported pain on the side opposite to that of the
Torsion is more likely to occur in a diseased ovary.11,12
Younger children more commonly present with a mature
cystic teratoma or without an underlying abnormality
compared with older children, in whom torsion is more
likely to result from a follicular or corpus luteum cyst.13
Although the occurrence rate of bilateral mature cystic
teratomas is approximately 10%, contralateral biopsy
remains controversial.13,14Solid ovarian masses in children
are much more likely to be malignant. In this situation,
preoperative tumor markers, such as AFP and b-HCG, may
help postoperative management. According to a report by
Warner et al, cysts greater than 5 cm in diameter rarely
cause ovarian torsion,15however only three patients in our
study had cysts less than 5 cm in diameter.
An abnormal blood count may indicate mild leukocy-
tosis. However, this finding, as well as the results of other
routine laboratory studies, is too nonspecific to be helpful
for the diagnosis of ovarian torsion. Ultrasonography is the
imaging method of choice for evaluating and managing
suspected ovarian torsion.5,16,17The most common sono-
graphic finding is an echogenic/hypoechoic pelvic mass
with nonvisualization of the ipsilateral ovary because
occlusion of venous and lymphatic flow often results in
Fifteen of our patients (75%) had
a hypoechoic cystic mass and five (25%) had a echogenic or
solid mass noted on sonography. Fluid was visualized in the
cul-de-sac of one patient, and ovary hematomas were
found in two other cases. In addition, if malignancy is
suspected on ultrasonography, a CT scan may be helpful for
assessing the spread of the tumor.
A laparotomy can also be used to make a definitive
diagnosis. If the vascular supply to the ovary is thrombosed,
the organ should be excised without detorsion in order to
decrease the risk of pulmonary embolus.2The current
findings and results of previous studies suggest that children
usually present for organ salvage very late (more than 8
hours) after the onset of symptoms.1,2,5,18,19Thus, treat-
ment for acute ovarian torsion generally includes unilateral
salpingo-oophorectomy. Our results indicate that 50% of
patients with ovarian torsion can still have their ovary
saved if they receive an operation within 3 days of symptom
As a retrospective study, this study is limited because
there are some inaccurate or missing data. There are also
some unknowable factors that might have affected the
surgeons’ decisions regarding whether or not to remove the
involved ovaries. For example, surgeons who believe that
the ovaries have been torsed for a long time, and, thus,
unable to be saved, would presumably be more likely to
remove those ovaries.
Although uncommon, adnexal torsion should be included in
the differential diagnosis of lower abdominal pain in any
girl, regardless of age. Sonography is helpful when making
such a diagnosis. Time is a critical factor, and early lapa-
roscopy or laparotomy may be able to save a viable ovary.
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Ovary torsion in children 59