Conservative Management of Bilateral Asynchronous Adnexal Torsion with Necrosis in a Prepubescent Female

Abstract

Background Six cases of bilateral asynchronous adnexal torsion with necrosis have previously been reported in prepubertal girls. Management with oophorectomy has been the standard of care Case A six year old female underwent an exploratory laparotomy in December, 1995 at an outside hospital for abdominal pain and presumed appendicitis. A torsed, necrotic left ovary was diagnosed at the time of surgery; left oophorectomy was performed. In addition, a uniformly enlarged right ovary, approximately 5 cm in length, was noted. Her follow-up care included laboratory studies for precocious puberty, which were negative, and an ultrasound, which confirmed a uniformly enlarged ovary of 5.6 × 1.9 × 1.4 cm. Her uterus and kidneys were unremarkable. At the time of her second presentation with abdominal pain in May of 1996, an ultrasound was again obtained; a uniformly enlarged right ovary of 6.4 × 5.0 × 2.6 cm was seen; only tiny amounts of internal blood flow were observed. No other abnormalities were noted. The patient's temperature was 37.8, pulse was 72 and blood pressure was 134/73. Due to her history of prior torsion, the size of the right ovary, and her presenting symptoms, the patient underwent a second laparotomy for presumed ovarian torsion. Upon opening the peritoneum a blackened, engorged, edematous ovary was observed. The ovary was untorsed and significant resolution of the cyanosis and vascular congestion was noted. After extensive observation, the untorsed ovary was then sutured to the anterior and posterior peritoneal surfaces to prevent recurrence. The patient did well postoperatively and has been followed with serial ultrasounds, which show an ovary of normal prepubescent size and appearance. Conclusion In the pediatric population, up to 25% of torsed ovaries may be normal. The factors which cause a normal ovary to torse, and which place the second ovary at risk for subsequent torsion, are not well defined. This case supports the concept of detorsion of a necrotic appearing ovary followed by oophoropexy for surgical stabilization to avoid retorsion and necrosis, and preserve fertility and reproductive endocrine function. Six cases of bilateral asynchronous adnexal torsion with necrosis have previously been reported in prepubertal girls. Management with oophorectomy has been the standard of care A six year old female underwent an exploratory laparotomy in December, 1995 at an outside hospital for abdominal pain and presumed appendicitis. A torsed, necrotic left ovary was diagnosed at the time of surgery; left oophorectomy was performed. In addition, a uniformly enlarged right ovary, approximately 5 cm in length, was noted. Her follow-up care included laboratory studies for precocious puberty, which were negative, and an ultrasound, which confirmed a uniformly enlarged ovary of 5.6 × 1.9 × 1.4 cm. Her uterus and kidneys were unremarkable. At the time of her second presentation with abdominal pain in May of 1996, an ultrasound was again obtained; a uniformly enlarged right ovary of 6.4 × 5.0 × 2.6 cm was seen; only tiny amounts of internal blood flow were observed. No other abnormalities were noted. The patient's temperature was 37.8, pulse was 72 and blood pressure was 134/73. Due to her history of prior torsion, the size of the right ovary, and her presenting symptoms, the patient underwent a second laparotomy for presumed ovarian torsion. Upon opening the peritoneum a blackened, engorged, edematous ovary was observed. The ovary was untorsed and significant resolution of the cyanosis and vascular congestion was noted. After extensive observation, the untorsed ovary was then sutured to the anterior and posterior peritoneal surfaces to prevent recurrence. The patient did well postoperatively and has been followed with serial ultrasounds, which show an ovary of normal prepubescent size and appearance. In the pediatric population, up to 25% of torsed ovaries may be normal. The factors which cause a normal ovary to torse, and which place the second ovary at risk for subsequent torsion, are not well defined. This case supports the concept of detorsion of a necrotic appearing ovary followed by oophoropexy for surgical stabilization to avoid retorsion and necrosis, and preserve fertility and reproductive endocrine function.