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Ovarian torsion masquerading as a pelvic malignancy
170
Letters
to the Editor
vaginoplasty should only be performed when the patient starts her sexual activity. A.A. Nogueirn Department of Gynecology and Obstetrics M.F. Silve de Sa’ Faculty of Medicine of RibeiGo Preto University of Sao Paula, Brazil M.D. de Moura
3 4
of the ninety cases. Acta Obstet Gynecol Stand 57: 89, 1978. Ashworth MF, Marton KE, Denhurst SJ: Vaginoplasty using amnion. Obstet Gynecol 67(3): 433, 1986. Geary LW, Weed JC: Congenital atresia of the uterine cervix. Obstet Gynecol 42; 213, 1973.
Correspondence to:
References
A.A. Nogaeirn
1
2
Griffin JE, Edwards C, Madden JD, Harrod MJ, Wilson JD: Congenital absence of the vagina; The Mayer Rokitansky-Kuster-Hauser Syndrome. Ann Intern Med 85: 224, 1976. Salvatore CA, Lodovicci 0: Vaginal agenesis: An analysis
Departmentof Gynecology and Obstetrics Faculty of Medicine of R&i&o University of Go Paul0 Ribeinio Preto SP, Brazil
Preto
Ovarian torsion masquerading as a pelvic malignancy To the Editor
October lOth, 1994
Torsion can complicate a diseased [l] or occasionally a normal ovary [3]. If a torsion is missed during the acute stage, it can (although rarely) develop into a chronic inflammatory mass and create diagnostic difficulty. We encountered one case where the missed ovarian torsion mimicked a pelvic malignancy. An 8-year-old girl was admitted with a suprapubic mass. Three weeks earlier she had acute lower abdominal pain associated with two episodes of nonbilious vomiting, followed by constant dull lower abdominal pain and dysuria. She was hospitalized elsewhere and urine microscopy, intravenous urogram and fine needle aspiration cytology were done. She was referred to us with a diagnosis of pelvic sarcoma. On examination she was moderately nourished. There was a 10 x 8 cm abdominal mass arising from the pelvis and extending into the left iliac fossa. It was irregular, firm, nontender and fixed. There was another 8 x 6 cm firm nontender mass in the right iliac fossa, mobile in the transverse axis. The external genitalia were normal. Rectal examination revealed an extra-rectal firm mass in the pouch of Douglas, continuous with the abdominal mass and
Keywords: Ovary; Torsion; Pelvic malignancy. 0020-7293/94/$07.00 @ 1994 International Federation of Gynecology and Obstetrics Printed and Published in Ireland
Fig. 1. Peroperative picture showing the discolored torsed left ovary with the attached omentum. The bladder is retracted anteriorly and the cystic right ovary is seen (arrow).
Letters to the Editor
compressing the rectum anteroposteriorly. The routine investigations were normal. Ultrasonography revealed a variegated mass lying posterosuperior to the bladder and continuous with the uterus. The ovaries could not be defined. A micturating cystourethrogram showed indentation of the posterior bladder wall without any mucosal involvement. Urinary vanillyl mandelic acid was normal. Fine needle aspiration cytology was repeated along with review of the previous cytology slides; neither of them showed evidence of malignancy. With a preoperative diagnosis of benign tumor from the ovary/uterus, the child was operated on. At laparotomy, the omentum was found to be adherent to the bladder, covering the mass. The sigmoid colon was dilated. The right ovary was enlarged and had multiple small cysts. After meticulous separation from the bladder, uterus and rectum, the mass was found to be torsed left ovary and fallopian tube (Fig. 1). Left salphingo-oophorectomy was done and the cysts in the right ovary were punctured. The postoperative period was uneventful. The cut section of the mass revealed a hemorrhagic area in the center. Histopathology examination showed the necrosed ovarian tissue with a rim of compressed but viable ovary at the periphery. There was no evidence of any cyst wall. Missed ovarian torsion is more common on the left side as the right sided lesions are explored as
171
‘appendicitis’ [4]. In our case, the fallacious cytology report, nature of the mass and the ultrasonogram findings led us to suspect a pelvic malignancy. Problems due to missed torsion can be avoided either by developing and employing the experience of emergency ultrasonography [2], or exploration at the slightest suspicion of ovarian torsion. K. Radhakrisbna P.C. Das P.L.N.G. Rao
Department of Pediatric Surgery Kasturba Medical College Manipal, India
References 1
2
3 4
Adelman S, Benson CD, Hertzler JH: Surgical lesions of ovary in infancy and childhood. Surg Gynecol Obstet 141: 219, 1975. Graif M, Itxchak Y. Sonographic evaluation of ovarian torsion in childhood and adolescence. AJR 150: 647, 1988. Shun A. Unilateral ovarian loss: an indication for contralateral oophoropexy? Aust NZ J Surg 60: 791, 1990. Spigland N, Ducharme JC, Yarbeck S. Adnexial torsion in children. J Pediatr Surg 24: 974, 1989.
Correspondence to: K. Radkakriskna Dept. of Pediatric Surgery Kastarba Medical College & Hospital Manipal India
Int
J Gvnecol Ohstet
44
Letters
to the Editor
vaginoplasty should only be performed when the patient starts her sexual activity. A.A. Nogueirn Department of Gynecology and Obstetrics M.F. Silve de Sa’ Faculty of Medicine of RibeiGo Preto University of Sao Paula, Brazil M.D. de Moura
3 4
of the ninety cases. Acta Obstet Gynecol Stand 57: 89, 1978. Ashworth MF, Marton KE, Denhurst SJ: Vaginoplasty using amnion. Obstet Gynecol 67(3): 433, 1986. Geary LW, Weed JC: Congenital atresia of the uterine cervix. Obstet Gynecol 42; 213, 1973.
Correspondence to:
References
A.A. Nogaeirn
1
2
Griffin JE, Edwards C, Madden JD, Harrod MJ, Wilson JD: Congenital absence of the vagina; The Mayer Rokitansky-Kuster-Hauser Syndrome. Ann Intern Med 85: 224, 1976. Salvatore CA, Lodovicci 0: Vaginal agenesis: An analysis
Departmentof Gynecology and Obstetrics Faculty of Medicine of R&i&o University of Go Paul0 Ribeinio Preto SP, Brazil
Preto
Ovarian torsion masquerading as a pelvic malignancy To the Editor
October lOth, 1994
Torsion can complicate a diseased [l] or occasionally a normal ovary [3]. If a torsion is missed during the acute stage, it can (although rarely) develop into a chronic inflammatory mass and create diagnostic difficulty. We encountered one case where the missed ovarian torsion mimicked a pelvic malignancy. An 8-year-old girl was admitted with a suprapubic mass. Three weeks earlier she had acute lower abdominal pain associated with two episodes of nonbilious vomiting, followed by constant dull lower abdominal pain and dysuria. She was hospitalized elsewhere and urine microscopy, intravenous urogram and fine needle aspiration cytology were done. She was referred to us with a diagnosis of pelvic sarcoma. On examination she was moderately nourished. There was a 10 x 8 cm abdominal mass arising from the pelvis and extending into the left iliac fossa. It was irregular, firm, nontender and fixed. There was another 8 x 6 cm firm nontender mass in the right iliac fossa, mobile in the transverse axis. The external genitalia were normal. Rectal examination revealed an extra-rectal firm mass in the pouch of Douglas, continuous with the abdominal mass and
Keywords: Ovary; Torsion; Pelvic malignancy. 0020-7293/94/$07.00 @ 1994 International Federation of Gynecology and Obstetrics Printed and Published in Ireland
Fig. 1. Peroperative picture showing the discolored torsed left ovary with the attached omentum. The bladder is retracted anteriorly and the cystic right ovary is seen (arrow).
Letters to the Editor
compressing the rectum anteroposteriorly. The routine investigations were normal. Ultrasonography revealed a variegated mass lying posterosuperior to the bladder and continuous with the uterus. The ovaries could not be defined. A micturating cystourethrogram showed indentation of the posterior bladder wall without any mucosal involvement. Urinary vanillyl mandelic acid was normal. Fine needle aspiration cytology was repeated along with review of the previous cytology slides; neither of them showed evidence of malignancy. With a preoperative diagnosis of benign tumor from the ovary/uterus, the child was operated on. At laparotomy, the omentum was found to be adherent to the bladder, covering the mass. The sigmoid colon was dilated. The right ovary was enlarged and had multiple small cysts. After meticulous separation from the bladder, uterus and rectum, the mass was found to be torsed left ovary and fallopian tube (Fig. 1). Left salphingo-oophorectomy was done and the cysts in the right ovary were punctured. The postoperative period was uneventful. The cut section of the mass revealed a hemorrhagic area in the center. Histopathology examination showed the necrosed ovarian tissue with a rim of compressed but viable ovary at the periphery. There was no evidence of any cyst wall. Missed ovarian torsion is more common on the left side as the right sided lesions are explored as
171
‘appendicitis’ [4]. In our case, the fallacious cytology report, nature of the mass and the ultrasonogram findings led us to suspect a pelvic malignancy. Problems due to missed torsion can be avoided either by developing and employing the experience of emergency ultrasonography [2], or exploration at the slightest suspicion of ovarian torsion. K. Radhakrisbna P.C. Das P.L.N.G. Rao
Department of Pediatric Surgery Kasturba Medical College Manipal, India
References 1
2
3 4
Adelman S, Benson CD, Hertzler JH: Surgical lesions of ovary in infancy and childhood. Surg Gynecol Obstet 141: 219, 1975. Graif M, Itxchak Y. Sonographic evaluation of ovarian torsion in childhood and adolescence. AJR 150: 647, 1988. Shun A. Unilateral ovarian loss: an indication for contralateral oophoropexy? Aust NZ J Surg 60: 791, 1990. Spigland N, Ducharme JC, Yarbeck S. Adnexial torsion in children. J Pediatr Surg 24: 974, 1989.
Correspondence to: K. Radkakriskna Dept. of Pediatric Surgery Kastarba Medical College & Hospital Manipal India
Int
J Gvnecol Ohstet
44