High risk of recurrent torsion in premenarchal girls with torsion of normal adnexa

Capsule:
Recurrent adnexal torsion is more common when the first torsion episode occurs in the premenarchal period and involves otherwise normal adnexa.

Authors:
Noam Smorgick, M.D., Yaakov Melcer, M.D., Tal Sarig-Meth, B.S., Ron Maymon, M.D., Zvi Vaknin, M.D., Moty Pansky, M.D.

Volume 105, Issue 6, Pages 1561-1565

Abstract:

Objective:
To compare adnexal torsion characteristics and torsion recurrence rates in a pre- and postmenarchal pediatric and adolescent population.

Design:
Retrospective cohort study.

Setting:
University-affiliated medical center.

Patient(s):
Females <18 years old with surgically diagnosed adnexal torsion. Intervention(s):
Adnexal detorsion, cystectomy, salpingectomy, or salpingo-oophorectomy by laparoscopy or laparotomy. Oophoropexy using the utero-ovarian ligament plication technique was performed in cases of recurrent torsion of normal adnexa.

Main Outcome Measure(s):
The clinical presentation, laboratory and ultrasound characteristics, surgical findings, surgical procedures, pathologic diagnosis, and torsion recurrence rates were analyzed and compared between pre- and postmenarchal patients.

Result(s):
Twenty premenarchal and 24 postmenarchal patients were identified. The clinical presentation, laboratory findings, and ultrasound characteristics were similar between the two groups, except for a higher prevalence of paraovarian cysts on preoperative ultrasound in the postmenarchal compared with in the premenarchal group (20.8% vs. 0%). For the whole cohort, torsion of normal adnexa constituted 25.0% (11/44) of cases, while torsion of “pathologic” adnexa constituted 75.0% (33/44) of torsion cases. Torsion recurrence was significantly more common among girls whose first torsion episode occurred in the premenarchal period compared with in postmenarche (35% vs. 4.2%). On multivariate logistic regression analysis, torsion recurrence was significantly associated with premenarchal status (odds ratio [OR] = 12.7; 95% confidence interval [CI], 1.1–152.0) and with torsion involving normal adnexa (OR = 19.1; 95% CI, 2.3–154.5).

Conclusion(s):
Recurrent torsion is common in patients whose first torsion episode occurred in the premenarchal period and involved otherwise normal adnexa. Ovarian fixation procedures may be considered in patients at risk for torsion recurrence.

  • Daniel J. Kaser, MD

    Thanks for this interesting read about adnexal torsion in premenarchal and adolescent patients. Given the magnitude of the effect estimate for recurrent torsion in patients who previously torsed prior to menarche, this certainly raises the possibility that oophoropexy in this high-risk population may be beneficial, as you acknowledge. Are you able to calculate a number needed to treat to prevent recurrent torsion in this situation (assuming oophoropexy results in no cases of torsion, which admittedly may not be realistic.)
    Thanks very much for your comments.

    • Noam Smorgick

      Thank you for this excellent comment.
      I’m not sure the study design enables me to calculate the number needed to treat. I suspect it should be in the single digit range, assuming that oophoropexy does prevent recurrent torsion, which is certainly not true for the adult female population (see ref below) and as yet unknown in the premenarchal population. Unfortunately, an RCT comparing oophoropexy to no treatment would be problematic to conduct, given the rarity of this condition on one hand and the possible future fertility sequela of recurrent torsion on the other hand.

      ref:
      Fuchs N, Smorgick N, Tovbin Y, Ben Ami I, Maymon R, Halperin R, Pansky M. Oophoropexy to prevent adnexal torsion: how, when, and for whom? J Minim Invasive Gynecol. 2010;17:205-8.

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