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OVARIAN TORSION MIMICKING UROLOGICAL DISEASE
0022-5347/98/1606-2160$03.00/0
Vol. 160,2160,December 1998 Printed in U.S.A.
THE JOURNAL OF U R O W Y
Copyright 8 1998 by AMERICAN U R O ~ I CASSOCIATION, AL INC.
OVARIAN TORSION MIMICKING UROLOGICAL DISEASE WILLIAM I. JAFFE, CHRISTOPHER S. COOPER, JAMLIK OMARI JOHNSON ANDREW J . KIRSCH
AND
From the Division of Pediatric urology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
KEYWORDS: hematuria, ovary, calculi, appendicitis Ovarian torsion is a n uncommon cause of abdominal We report on 2 female patients with microhematuria, and lower abdominal and flank pain who were initially believed to have urolithiasis but in whom subsequent evaluation revealed ovarian torsion. CASE REPORTS
Case 1. A 9-year old girl presented with intermittent right lower quadrant pain radiating to the right flank, low grade fever, emesis and dysuria 4 days in duration. Her father had a history of recurrent nephrolithiasis. Physical examination revealed right lower quadrant tenderness to deep palpation without peritoneal signs. Rectal examination was normal. Urinalysis demonstrated calcium oxalate crystals and 5 to 7 red blood cells per high power field. Ultrasonography showed normal kidneys and a 7 x 4 cm. right ovary with cystic components, and blood flow was decreased on a Doppler study. Exploration through a Pfannenstiel incision revealed a necrotic right ovary. The patient underwent oophorectomy and contralateral oophoropexy. Hematuria had resolved by 3 weeks postoperatively. Case 2. A 19-year-old woman presented with acute onset of right lower quadrant and mild right flank pain associated with nausea and vomiting. Episodes of pain lasted up to 30 minutes. Physical examination demonstrated mild right flank and right lower quadrant tenderness without peritoneal signs. Pelvic examination was normal. Urinalysis revealed 5 to 7 red blood cells per high power field. Excretory urography was normal. Pain resolved and the patient left the hospital but she returned within 12 hours with excruciating right lower quadrant pain. Pelvic ultrasound was consistent with ovarian torsion. Laparoscopic right oophorectomy was performed without contralateral oophoropexy. The patient was subsequently lost to followup. DISCUSSION
Ovarian torsion is a rare entity that is usually associated with abnormal ovaries or adnexa.l.2 The normal tube and ovary are mobile, and they may rotate 90 degrees without Accepted for publication July 31, 1998.
causing symptoms. As in testicular torsion, the factors causing torsion of a normal ovary are unknown but Mordehai et al suggested that predisposing anatomical factors include an abnormally long fallopian tube, mesosalpinx or mesomesovarium (No. 10).2 Patients present with nonspecific complaints, including abdominal pain, nausea, vomiting, constipation, fever and urinary symptoms, which often delay the correct diagnosis.1 In the series of Mordehai et a1 fewer than half of the patients who underwent surgery for ovarian torsion in a 20-year period were correctly diagnosed preoperatively.2 Ovarian torsion may mimic appendicitis because it develops more frequently on the right side.' To our knowledge we report the first cases of ovarian torsion presenting with microhematuria. The cause of microhematuria in our 2 patients may have been related to the retroperitoneal inflammation associated with torsion, similar to that in retroperitoneal appendicitis. Hematuria also occurs with ovarian vein varices.3 It is not known whether a similar pathophysiology may cause the microhematuria in ovarian torsion. CONCLUSIONS
The urologist must consider ovarian torsion when evaluating girls or women who have abdominal pain with or without microhematuria. A delayed diagnosis decreases the probability of salvaging the ovary. Sonographic evaluation is generally adequate, and it may reveal a n enlarged edematous ovary with or without cysts and a preserved blood flow.' Prompt laparotomy, oophorectomy and contralateral oophoropexy comprise a rational treatment approach since the remaining ovary may be at increased risk for torsion.l.2 REFERENCES
1. Shust, N. M. and Hendricksen, D. K.: Ovarian torsion: an unusual cause of abdominal pain in a young girl. h e r . J. Emerg. Med., 1 3 307, 1995. 2. Mordehai, J., Mares, A. J., Barki, Y., Finaly, R. and Meizner, I . : Torsion of uterine adnexa in neonates and children: a report of 20 cases. J. Ped. Surg., 2 6 1195, 1991. 3. Weiner, S. N., Bernstein, R. G., Morehouse, H. and Golden, R. A,: Hematuria secondary to left peripelvic and gonadal vein varices. Urology, 22: 81, 1983.
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Vol. 160,2160,December 1998 Printed in U.S.A.
THE JOURNAL OF U R O W Y
Copyright 8 1998 by AMERICAN U R O ~ I CASSOCIATION, AL INC.
OVARIAN TORSION MIMICKING UROLOGICAL DISEASE WILLIAM I. JAFFE, CHRISTOPHER S. COOPER, JAMLIK OMARI JOHNSON ANDREW J . KIRSCH
AND
From the Division of Pediatric urology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
KEYWORDS: hematuria, ovary, calculi, appendicitis Ovarian torsion is a n uncommon cause of abdominal We report on 2 female patients with microhematuria, and lower abdominal and flank pain who were initially believed to have urolithiasis but in whom subsequent evaluation revealed ovarian torsion. CASE REPORTS
Case 1. A 9-year old girl presented with intermittent right lower quadrant pain radiating to the right flank, low grade fever, emesis and dysuria 4 days in duration. Her father had a history of recurrent nephrolithiasis. Physical examination revealed right lower quadrant tenderness to deep palpation without peritoneal signs. Rectal examination was normal. Urinalysis demonstrated calcium oxalate crystals and 5 to 7 red blood cells per high power field. Ultrasonography showed normal kidneys and a 7 x 4 cm. right ovary with cystic components, and blood flow was decreased on a Doppler study. Exploration through a Pfannenstiel incision revealed a necrotic right ovary. The patient underwent oophorectomy and contralateral oophoropexy. Hematuria had resolved by 3 weeks postoperatively. Case 2. A 19-year-old woman presented with acute onset of right lower quadrant and mild right flank pain associated with nausea and vomiting. Episodes of pain lasted up to 30 minutes. Physical examination demonstrated mild right flank and right lower quadrant tenderness without peritoneal signs. Pelvic examination was normal. Urinalysis revealed 5 to 7 red blood cells per high power field. Excretory urography was normal. Pain resolved and the patient left the hospital but she returned within 12 hours with excruciating right lower quadrant pain. Pelvic ultrasound was consistent with ovarian torsion. Laparoscopic right oophorectomy was performed without contralateral oophoropexy. The patient was subsequently lost to followup. DISCUSSION
Ovarian torsion is a rare entity that is usually associated with abnormal ovaries or adnexa.l.2 The normal tube and ovary are mobile, and they may rotate 90 degrees without Accepted for publication July 31, 1998.
causing symptoms. As in testicular torsion, the factors causing torsion of a normal ovary are unknown but Mordehai et al suggested that predisposing anatomical factors include an abnormally long fallopian tube, mesosalpinx or mesomesovarium (No. 10).2 Patients present with nonspecific complaints, including abdominal pain, nausea, vomiting, constipation, fever and urinary symptoms, which often delay the correct diagnosis.1 In the series of Mordehai et a1 fewer than half of the patients who underwent surgery for ovarian torsion in a 20-year period were correctly diagnosed preoperatively.2 Ovarian torsion may mimic appendicitis because it develops more frequently on the right side.' To our knowledge we report the first cases of ovarian torsion presenting with microhematuria. The cause of microhematuria in our 2 patients may have been related to the retroperitoneal inflammation associated with torsion, similar to that in retroperitoneal appendicitis. Hematuria also occurs with ovarian vein varices.3 It is not known whether a similar pathophysiology may cause the microhematuria in ovarian torsion. CONCLUSIONS
The urologist must consider ovarian torsion when evaluating girls or women who have abdominal pain with or without microhematuria. A delayed diagnosis decreases the probability of salvaging the ovary. Sonographic evaluation is generally adequate, and it may reveal a n enlarged edematous ovary with or without cysts and a preserved blood flow.' Prompt laparotomy, oophorectomy and contralateral oophoropexy comprise a rational treatment approach since the remaining ovary may be at increased risk for torsion.l.2 REFERENCES
1. Shust, N. M. and Hendricksen, D. K.: Ovarian torsion: an unusual cause of abdominal pain in a young girl. h e r . J. Emerg. Med., 1 3 307, 1995. 2. Mordehai, J., Mares, A. J., Barki, Y., Finaly, R. and Meizner, I . : Torsion of uterine adnexa in neonates and children: a report of 20 cases. J. Ped. Surg., 2 6 1195, 1991. 3. Weiner, S. N., Bernstein, R. G., Morehouse, H. and Golden, R. A,: Hematuria secondary to left peripelvic and gonadal vein varices. Urology, 22: 81, 1983.
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