BY MATTHEW WU, & DEANDRE WILLIANS, MD
A 2-year-old girl presented to the emergency department for abdominal pain with urination. She had been diagnosed with a urinary tract infection three days earlier, and was in the process of completing a course of antibiotics.
The pain with urination made it difficult to void urine even when soaking in warm baths, according to the patient's parents. Her mother said the patient had to be bribed to drink anything. Their daughter did not urinate for 14 hours before arriving at our ED. They were concerned about dehydration due to the lack of fluid intake. The patient also refused to take her antibiotics for the UTI.
The patient weighed 35 pounds, and her vital signs were a blood pressure of 100/65 mm Hg, a pulse of 125 bpm, and a temperature of 98.8°F. She appeared well-developed, well-nourished, and active. She tolerated food, had an intact appetite, and had not recently vomited or had bloody stools. It was thought that she was voluntarily holding her urine and avoiding liquids. Her abdominal exam was negative for tenderness and guarding.
A sterile catheter was used to collect a sample for urine analysis, which revealed a large volume of urine. The sample contained squamous cells, erythrocytes, and ketones, with no signs of infection (no leukocytes or nitrites). Blood tests showed a white blood cell count of 17,800/ΜL, a platelet count of 423,000/ΜL, a C-reactive protein level of 11.7 mg/dL, and an erythrocyte sedimentation rate of 49 mm/hr.
Renal ultrasound revealed normal left and right kidneys with no hydronephrosis and an interval enlargement of the left ovary with abnormal heterogeneous echogenicity associated with cystic change, which was highly suspicious for ovarian torsion. A pelvic ultrasound revealed a simple-appearing cyst on the right ovary and an enlarged left adnexa with a heteroechoic lesion without internal vascularity concerning for left ovarian torsion or abscess. (Figure 1.) Pediatric surgery was consulted because of the broad differential.
Figure 1. An ultrasound of the pelvis showed an enlarged left adnexa with heterogeneous avascular portion, which may represent a developing abscess. Torsion cannot be entirely excluded.
The patient was admitted to a general pediatric service with gynecology and pediatric surgery following as consultants. The toddler had not spontaneously voided in the 12 hours after admission despite receiving IV fluids and pain medication. A Foley catheter was placed because of concern for urinary retention. She developed worsening abdominal pain overnight. An MRI was recommended by the consultants, and the results supported the previous ultrasound suggesting left acute ovarian torsion with lack of blood flow to the left ovary. (Figure 2.)
Figure 2. An MRI of the pelvis shows an enlarged left ovary without internal vascularity highly suspicious for ovarian torsion. A 7 mm cystic structure anterior to the left ovary with surrounding hypervascular tissue may represent a dilated Fallopian tube or residual ovarian tissue.
It was decided that surgical intervention was required, and she immediately went to the operating room with hope of preserving the ovary. The diagnostic laparoscopy confirmed a torsed left ovary and Fallopian tube, which were unviable and removed via left salpingo-oophorectomy. Her right ovary and Fallopian tube were normal.
Her Foley catheter was removed without further signs of urinary retention after one day of recovery. Her acute urinary retention was attributed to inflammation from the ovarian torsion. She did not require any additional pain medications, and could void spontaneously without abdominal discomfort or dysuria.
Ovarian torsion is a common, serious gynecologic emergency, and it occurs in women of all ages. The majority of cases, however, happen during reproductive age and rarely in premenarchal girls. Analyzing hospitalized women under age 20 in the Kids' Inpatient Database, a part of the Healthcare Cost and Utilization Project, Powell, et al., found that the incidence of ovarian torsion was 4.9 per 100,000. (Pediatrics. 2010;125:532.) The risk of torsion is increased if an ovarian mass is present. (Ultrasound Obstet Gynecol. 2002;20:47.)
Ovarian torsion can readily be treated without complications if diagnosed quickly, but prompt diagnosis is a challenge because of nonspecific symptoms. The most common ones include acute moderate to severe pelvic pain, nausea, and vomiting, and less common symptoms are fever and genital tract bleeding. (Ann Emerg Med. 2001;38:156; Emerg Med Australas. 2005;17:231; http://bit.ly/2zPSQ9X.) Abdominal pain is a common complaint made by children, and can have a variety of etiologies such as constipation and gastroenteritis, which may or may not be life-threatening. EPs face the challenge of not being able to reach a timely and accurate diagnosis because children may be unable to fully express and describe their symptoms. (Emerg Med Clin North Am. 2002;20:139.) The emergency physician must rely on information from parents and the physical exam.
Previous reports of pediatric ovarian torsion have described abdominal tenderness and pain, vomiting, nausea, and fever. These symptoms are often intermittent as a result of the ovary repeatedly becoming twisted and untwisted. (J Minim Invasive Gynecol. 2012;19:29; Can J Surg. 2013;56:103; http://bit.ly/2PNn1cL.) Ovarian torsion pain is usually localized to the left or right lower quadrant depending on the location of the torsed ovary, but has been found to occur three times more frequently on the right side in women of reproductive age. (Surg Clin North Am. 1988;68:385.) A study by Poonai, et al., of 13 pediatric ovarian torsion patients admitted to a London hospital also found that the right ovary was colicky and torsed more often. (Arch Pediatr Adolesc Med. 2005;159:532; http://bit.ly/2PQuk3e.) In contrast, our patient presented with left lower abdominal pain, a left torsed ovary, nausea, and pain when prompted to urinate. Initially, her presentation was similar to that of a urinary tract infection, but that was ruled out by a negative UA.
Imaging often reveals an adnexal mass in these cases. Ultrasound can be used to visualize ovarian masses such as cysts, which are an established risk factor for ovarian torsion in women of reproductive age. (Ann Emerg Med. 2001;38:156.) This modality has limitations, however, and must be interpreted carefully. Doppler imaging may still reveal vascular flow, which would lower the likelihood of ovarian torsion. (Arch Pediatr Adolesc Med. 2005;159:532; http://bit.ly/2PQuk3e.)
If clinical suspicion is high, surgical management is recommended to prevent further ischemia and to preserve reproductive tissue. Anders and Powell reported that ovarian salvage rates were high and detorsion-related complications were rare even when ovaries appeared necrotic during detorsion. (Arch Pediatr Adolesc Med. 2005;159:532; http://bit.ly/2PQuk3e.) A diagnostic laparoscopy and potential detorsion could therefore be invaluable. Unfortunately, our patient's ovary was not salvageable because of the unusual presentation of ovarian torsion and delayed detorsion.
Abdominal pain provoked by urination without a bacterial infection in a young girl should raise concern for ovarian torsion. If the diagnosis is still unclear following a genitourinary exam and ultrasound, prompt surgical management via laparoscopy will clarify if detorsion is needed. Detorsion should be attempted because of the low risk of postoperative complications and high salvage rates to preserve fertility.
Mr. Wu is a medical student in the class of 2021 at the Stritch School of Medicine at Loyola University in Chicago. Dr. Williams is an associate professor of emergency medicine at Loyola University Medical Center.