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Journal of Pediatric Surgery (2011) 46, E19E23

www.elsevier.com/locate/jpedsurg

Pediatric synchronous bilateral ovarian torsion: a case


report and review of the literature
Tania Dumont , Nicolette Caccia, Lisa Allen
Division of Endocrinology, Section of Gynecology, Sick Kids Hospital, Toronto, Ontario, Canada M5G 1XB
Received 16 May 2011; revised 28 August 2011; accepted 30 August 2011

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

quadrant pain with no associated symptoms. A pelvic


ultrasound study performed before referral was consistent
with polycystic ovaries. Repeat pelvic ultrasound imaging at
the time of consultation revealed bilateral bulky ovaries (43
32 38 mm with volume of 20.2 mL [right] and 56 35 55
mm with volume of 52.3 mL [left]) and peripheral follicles in
keeping with polycystic ovarian morphology (Fig. 1).
Normal ovarian volumes in the pediatric population have
been described by Garel et al [4], and the accepted range is 2
to 20 mL in the adolescent population with 2 to 4 mL as the
norm in the premenarchal population.
Four months after initial consultation, she presented to the
emergency department with a 30-hour history of periumbilical pain associated with nausea and vomiting. On physical
examination, the pain was localized to the left lower quadrant
and was associated with rebound tenderness. The white
blood cell count was normal. Repeat pelvic ultrasound
showed a significantly enlarged left ovary on gray scale
imaging (61 45 49 mm, 70 mL) that was more
heterogeneous than previously noted, contained peripheral
follicles, and had diminished flow on Doppler assessment.
The right ovary was unchanged from the previous study (41
37 28 mm, 22 mL), also contained peripheral follicles, but

E20

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.

had adequate Doppler flow (Fig. 1). The patient underwent


laparoscopy with a presumed diagnosis of left ovarian
torsion. However, on inspecting the pelvis, bilateral ovarian
torsion of 720 in each ovary was detected (Fig. 2). No focal
lesions were noted, but both ovaries were enlarged, with the
left ovary larger than the right. The ovaries were detorsed and,
as both infundibulopelvic and uteroovarian ligaments were
noted to be abnormally long, an oophoropexy was performed,
tacking both ovaries to their respective uterosacral ligaments
(Fig. 3). The ovary was pexed to the uterosacral ligament,
with a figure of eight 3.0 nonabsorbable suture in the ovarian
cortex with an intracorporeal knot tying technique. After
identifying that the ureter was medial to the uterosacral
ligament, a single pass through of the uterosacral ligament
was taken. Given the findings of bilateral torsion, the
oophoropexy procedure was repeated on the contralateral
side. At her 6-week postoperative visit, she had had no
further episodes of pain and had returned to normal
activities. Abdominal examination was unremarkable.
Postoperative ultrasound study confirmed neither ovarycontained focal lesions; the right ovary measured 54 24
33 mm (21 mL), and the left, 44 33 23 mm (17 mL).
Both showed multiple follicular cysts and central Doppler

flow (Fig. 1). At 9 months postsurgery, there has been no


recurrence of adnexal pain.

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

Pediatric synchronous bilateral ovarian torsion

Fig. 2

E21

Synchronous bilateral ovarian torsion of normal ovaries in a 12-year-old premenarchal girl.

setting of abdominal pain, vomiting, and peritoneal signs, this


led to a preoperative diagnosis of left ovarian torsion. The
smaller size and maintenance of Doppler flow to the
contralateral ovary resulted in a failure to identify the bilateral
synchronous ovarian torsion until surgery.
Bilateral ovarian torsion remains a rare entity. Medline
was searched using the key words bilateral, ovary, ovarian
diseases/cysts/neoplasms, and torsion and was limited to
human subjects. Articles were reviewed, and references were
checked for additional literature. There are 24 cases of
asynchronous torsion in the pediatric population and only 2
cases of synchronous bilateral ovarian torsion, both occurring with bilateral dermoids. Rogers [12], in 1925, reported
the first case of a 16-year-old girl with bilateral adnexal
torsion (original article unavailable) [3]. In 2002, zcan et al
[5] reviewed the literature and added 2 of his own cases
(summarized in Table 1). As seen in Table 1, there has since

been 8 additional cases reported [13-16] of which 2 were


synchronous torsions of bilateral ovarian dermoids [14,17].
Our case presents the first child with bilateral synchronous
pediatric torsion of ovaries without distinct pathology such
as an ovarian cyst or neoplasm.
Considering that this condition can result in subsequent
infertility because of loss of both ovaries if the diagnosis is
missed, bilateral ovarian torsion should be considered when
a young female presents with abdominal pain on alternating
sides or recurrent bilateral abdominal pain with no obvious
etiology. In our patient, the initial presenting pain was in the
right lower quadrant; her acute episode of pain on the day of
surgery was localized to the contralateral side. The
awareness of the potential for synchronous bilateral ovarian
torsion should be conveyed to all health care providers caring
for infants, children, and adolescents. It has been recognized
in our institution that there is a service-specific discrepancy

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

Age at first Time interval


torsion
between torsions

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]

SYNCHRONOUS 360 torsion of Lt


dermoid cyst
180 torsion of Rt
dermoid cyst
2y
Torsion of Rt ovary
on hemorrhagic cyst

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.

Pediatric synchronous bilateral ovarian torsion


in the preoperative suspicion of torsion between pediatric
surgeons who suspect torsion in 47% of cases compared with
94% preoperative diagnosis for gynecologists [18].
The currently accepted treatment of torsion is detorsion
with concurrent or subsequent cystectomy if an ovarian cyst/
neoplasm exists. Oophoropexy, however, remains a controversial management choice in ovarian torsion. This procedure
consists of stabilizing the ovary to prevent recurrent torsion.
Various methods can be used including pexing the ovary to the
uterosacral ligament, as described above. After suturing the
ovary to the uterosacral ligament, it will often reside easily in
the pelvis, and in the case of the acutely torted, friable, blueblack ovary, we feel that this location minimizes the risk of the
suture pulling through the ovarian cortex. Another method
commonly used is plication of the uteroovarian ligament to
minimize the laxity of this elongated structure and reduce the
risk of torsion. Plication is completed by suturing the distal and
proximal ends of the ligament to each other or by gathering the
excess ligament length within an Endoloop (Ethicon EndoSurgery, Inc., Cincinnati, OH) [19,20]. Alternatively, the ovary
can be sutured, to either the posterior aspect of the uterus or to
the pelvic sidewall at the level of the pelvic brim, after ensuring
adequate localization of the iliac vessels and the ureter [19,22].
Permanent, nonabsorbable suture material should be used for
all procedures [21]. Theoretical concerns for future fertility
exist for this procedure such as interruption of blood flow to the
fallopian tube as well as disruption of the intricate communication between the tube and the ovary [6,20,21]. Controversy
exists as well on when to perform the procedure. Performing
oophoropexy at the time of torsion may be technically more
difficult given the edema and size of the ovary. It also may not
allow for full discussion of the benefits and risks of the
procedure with the family. It does, however, prevent a
subsequent surgical procedure [21]. On the other hand,
performing the oophoropexy during a second procedure
would allow detailed discussion with patients and family
about the risks and benefits and would allow for choosing the
procedure that best fits the patient's natural placement of the
fallopian tube and ovary when the ovary is neither enlarged nor
edematous. In our institution, consistent with indications found
in the literature, oophoropexies are performed for recurrent
torsion, obviously abnormal adnexal attachments or, where
there has been a previous loss of an ovary subsequent to
adnexal torsion without a lead point [21]. Because there are
case reports of complete loss of ovarian function in children
who have had bilateral oophorectomies performed for
asynchronous bilateral ovarian torsions, synchronous bilateral
ovarian torsion should be considered as a potential indication
for oophoropexy as was performed in our case [5]. Given that
the diagnosis of ovarian torsion remains clinical, physicians
and parents should understand that there will be times when
laparoscopy, performed to ensure ovarian salvage and future
fertility, will not demonstrate evidence of torsion.
We present the first case of a pediatric synchronous
bilateral ovarian torsion on ovaries without cysts or
neoplasms. If not identified in a timely fashion, this

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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