Study: Delayed adnexal torsion diagnosis raises risk for ovarian loss in children

Key takeaways:

• Nearly one-third of girls with adnexal torsion had a delayed diagnosis.
• Girls whose diagnosis was delayed were more likely to need an oophorectomy vs. those without delayed diagnosis.

Nearly one-third of girls with adnexal torsion experienced a delay in diagnosis, and delays were associated with higher rates of oophorectomy, according to findings published in Pediatrics.

“What we demonstrated in this article is that a delay in diagnosis can lead to an increased risk for ovarian loss,” Barrie S. Rich, MD, pediatric general surgeon at Cohen Children’s Medical Center in New York and associate professor of surgery and pediatrics at Zucker School of Medicine at Hofstra/ Northwell, told Healio. “It is very important to keep this diagnosis in mind when a female patient presents with abdominal pain ... to help minimize delays.”

More than half of adnexal torsion cases occur in girls aged 9 to 14 years, Nicole Mercado Fischer, MD, MPH, and Joseph Sanfilippo, MD, MBA, from the University of Pittsburgh Medical Center, wrote in a related commentary. They explained that hormonal changes and gonadal growth increase the risk for torsion among girls aged older than 10 years.

Rich explained that adnexal torsion is difficult to diagnose because there is no definitive imaging or blood test that can identify it.

“There are certain ultrasound characteristics that are suspicious, but we have seen that those characteristics may not be present on imaging when torsion is present, and we have even seen that those characteristics can be present when patients do not have torsion,”Rich said.

In their latest study, Rich and colleagues assessed what factors led to delayed diagnosis of adnexal torsion in girls and whether their outcomes differed from girls who did not experience delays. They performed a retrospective review of 862 cases of adnexal torsion among girls aged 5 to 18 years that occurred at 10 children’s hospitals in the United States between 2013 and 2022.

More than 90% of patients presented to the ED with abdominal pain (99%) and tenderness (92%), and 63% reported vomiting. Most (90%) received an abdominal ultrasound in the ED, and 27% were evaluated with a CT or MRI. All patients were diagnosed with ovarian or tubal torsion in the operating room.

The researchers determined that 30% of cases involved delayed diagnosis; 73% had visited the ED within 7 days before diagnosis, 18.5% were admitted to the hospital without the intention to operate, and 8.5% visited the ED and were hospitalized with a different diagnosis in mind. Most patients who were admitted were taken to the operating room within 24 hours, but 26% waited more than 24 hours for surgery.

Rich and colleagues reported that patients whose diagnosis was delayed were more likely to undergo an oophorectomy vs. patients who did not experience delays (14% vs. 7%; P = .002). There was no significant difference in salpingectomy rates among each group.

The researchers also analyzed factors that were associated with delayed diagnosis. They found that patients who had a delayed diagnosis were more likely to have been transferred from an outside hospital (46% vs. 35%; P = .03). At their initial ED visit, patients who did not experience delays were more likely to have imaging (94% vs. 77%), and they were more likely to present with peripheralization of follicles (26% vs. 9.3%; P = .002), diminished flow (59% vs. 11%; P < .001) or a twisted pedicle (21% vs. 7.2%; P = .005) on their ultrasound.

In a multivariable analysis, each point increase in area deprivation index elevated patients’ odds of delayed diagnosis by 1.3% (OR = 1.013; 95% CI, 1.007-1.018). Additionally, patients who lived more than 30 miles from the hospital were 81% more likely to experience delayed diagnosis compared with patients who lived less than 10 miles from the hospital (OR = 1.812; 95% CI, 1.236-2.657).

Rich said the study confirmed how difficult it is to diagnose adnexal torsion in children, based on how many patients were discharged from the ED or admitted for a different possible diagnosis.

In the future, she wants to improve diagnostics to minimize the number of patients with adnexal torsion who are sent home, as well as the number of patients who are taken to the operating room without adnexal torsion.

She recommended that ED providers consider a consult with pediatric surgeons or pediatric and adolescent gynecologists any time a female patient presents with abdominal pain with any clinical suspicion for adnexal torsion.

“Pediatricians should always be mindful of this diagnosis, even if there are clinical criteria that may not be completely consistent with it,” Rich said.

For more information:

Barrie S. Rich, MD, can be reached at brich@northwell.edu.

References:

• Fischer NM, et al. Pediatrics. 2025;doi:10.1542/peds.2024-069823.
• Rich BS, et al. Pediatrics. 2025;doi10.1542/peds.2024-68204.