Severe penile torsion of 180 degrees in an adult patient: a uro-radiological case report.

Penile torsion is the abnormal three-dimensional twisting of penile corporal bodies. It can be classified as mild, moderate, or severe, depending on the degree of torsion. Severe penile torsion (>90°) is a very rare condition, with an estimated incidence of 0.4%-1% among all penile torsion cases. Our patient was a 37-year-old man complaining of a 2-year history of lower urinary tract symptoms. These symptoms appeared after the patient sustained an iatrogenic injury during Foley catheter insertion. Physical examination incidentally revealed an obvious counterclockwise penile rotation of 180°. Several theories have been proposed to explain the etiology of penile torsion, including theories based on genetic factors, abnormal urethral development, and abnormal attachment of the dartos fascia to the skin. Penile torsion may be associated with other penile anomalies, including chordee, hypospadias, and epispadias; however, it is often detected as an isolated finding. Clinical examination is sufficient to confirm its diagnosis without the need for further imaging. While no standardized procedure has been indicated for all penile torsion cases, the severity of torsion and the presence of other anomalies determine the most suitable procedure. No reports on the imaging features of penile torsion (irrespective of the degree of torsion) are available. We present the first such report on the imaging features, including advanced magnetic resonance imaging findings, of a 180° penile torsion in an adult patient.

High risk and low prevalence diseases: Ovarian torsion.

INTRODUCTION: Ovarian torsion is a rare, frequently misdiagnosed condition that carries with it a high rate of morbidity. OBJECTIVE: This review highlights the pearls and pitfalls of ovarian torsion, including presentation, evaluation, and management in the emergency department (ED) based on current evidence. DISCUSSION: Ovarian torsion is one of the most common gynecological surgical emergencies and occurs with complete or partial rotation of the ovary along the supporting ligaments, obstructing vascular flow. Several risk factors include the presence of an ovarian mass or cyst. The most common population affected includes reproductive aged women, though cases also occur in premenarchal females, pregnant women, and postmenopausal women. Abdominal or pelvic pain is common but is not always sudden in onset or severe. Nausea and vomiting occur in 70%. Ultrasound can assist with diagnosis, but a normal ultrasound examination cannot exclude the diagnosis. Computed tomography with intravenous contrast can assist with diagnosis. Treatment includes emergent gynecologic consultation for surgical detorsion, along with symptomatic therapy in the ED. CONCLUSIONS: An understanding of ovarian torsion can assist emergency clinicians in diagnosing and managing this disease.

Oophorectomy for ovarian torsion - should this be abandoned?

BACKGROUND: Management of ovarian torsion ranges from de-torsion to oophorectomy and is dependent on various factors. Oophorectomy can have significant implications for fertility and general health, thus requiring careful consideration. AIMS: We evaluate the management of ovarian torsion at a tertiary hospital over a ten-year period and identify the predictors of oophorectomy in ovarian torsion cases. MATERIALS AND METHODS: Inpatient notes of patients who underwent surgical management for acute ovarian torsion at a tertiary hospital in Victoria, Australia, were reviewed, from January 2008 to June 2018. We reported the incidence and predictors of oophorectomy and ovarian ischaemia and current practices in oophoropexy. RESULTS: Our analysis included 159 patients. The incidence of oophorectomy was 47%. After confounders were adjusted, increasing age was the only significant predictor for oophorectomy. The adjusted odds ratio of having an oophorectomy based on age alone was 1.10 for each year increase in age between the ages of 15 and 68 (P = 0.001, 95% confidence interval 1.04-1.16). Of those with oophorectomy, 57% had ischaemia confirmed histologically. There were no significant predictors for ischaemia. CONCLUSION: The incidence of oophorectomy in this audit is comparable to reported incidences in current literature. However, with increasing evidence to support ongoing ovarian function even in cases where ischaemia is histologically confirmed, this incidence could be lowered. Age was the only variable that was found to have a significant effect on the incidence of oophorectomy.

Prevalence of Individual Differences in Tibial Torsion: A CT-Based Study.

OBJECTIVES: To measure baseline bilateral tibial torsion in a cohort of uninjured patients to assess for a difference in torsion between sides. METHODS: Consecutive bilateral lower extremity CT angiography scans from 229 patients without tibial or fibular pathology were collected and reviewed. Torsion of each tibia was measured by two independent reviewers, and individual differences in torsion were calculated. RESULTS: On average, patients have a 6.0° difference in tibial torsion between sides. A difference of greater than 10° was present in 18% of patients. Across the cohort of patients, the right tibia was on average 4.4° more externally rotated than the left. In patients with a greater than 5° difference, the right tibia was more externally rotated than the left in 85% of cases. Tibial torsion did not correlate with age or sex. DISCUSSION: Differences in tibial torsion are common and should be considered during intramedullary nailing of tibial fractures. When a difference in torsion is present, external torsion of the right tibia when compared with the left occurs predominantly. LEVEL OF EVIDENCE: Prognostic level IV.

Adnexal torsion in a pediatric population: Acute presentation with question of chronicity.

OBJECTIVES: To establish the frequency of torsion with multiple twists of the adnexa in girls 19 years old and younger surgically diagnosed with torsion. STUDY DESIGN: A retrospective chart review using an institutional tool to review charts of female patients 19 years old or younger who presented with acute abdominal pain leading to a surgical diagnosis of adnexal torsion. RESULTS: Of 141 pediatric patients with torsion, 61 (43%) had documentation of multiple twists, with 2 to 12 rotations present. 33% reported acute pain (<24 hrs) whereas most (67%) had pain > 24 h up to 4 weeks without abatement (23%) or experienced discrete episodes with pain resolution between episodes (44%). Even when vascular flow was demonstrated, multiple twists were frequently found (14/36 = 39%). When multiple twists were documented, more patients had an extirpative procedure due to a nonviable appearing ovary than when a single or unstated number of twists twist was found, although the results were not statistically significant (53.5% vs 42.9%, p = 0.098). CONCLUSIONS: Forty-three percent of girls presenting with symptoms of torsion had multiple twists in the adnexa. Many had provided a history of previous similar episodes of pain and presentation to emergency departments, suggesting possible previous undiagnosed episodes of torsion. Earlier diagnosis may provide a better opportunity for ovarian conservation prior to a recurrent torsion. Further study may reveal whether multiple twists are more likely to result in a nonviable ovary and need for oophorectomy.

Evaluation of factors affecting external tibial torsion in patients with cerebral palsy.

BACKGROUND: Gait deviation and associated torsional problems are common in patients with cerebral palsy (CP). Although femoral anteversion in CP has been extensively reviewed in previous studies, only a few studies have focused on tibial torsion. Therefore, this study aimed to evaluate tibial torsion in patients with CP and investigate the affecting factors. METHODS: Consecutive patients with cerebral palsy who underwent 3-dimensional computed tomography for the assessment of rotational profiles were reviewed. Femoral anteversion and tibial torsion were measured, and the demographic characteristics of the patients were recorded. A linear mixed model was implemented to overcome the retrospective nature of the study. RESULTS: After the implementation of inclusion and exclusion criteria, 472 patients were enrolled for this study. With age, external tibial torsion increased, while femoral anteversion decreased. The factors affecting external tibial torsion were increased femoral anteversion (p = 0.0057), increased age (p < 0.0001), higher Gross Motor Function Classification System (GMFCS) level (p < 0.0001), and involved/uninvolved limbs of hemiplegia (p = 0.0471/p = 0.0047). CONCLUSIONS: Older age, GMFCS level IV/V, hemiplegia, and increased femoral anteversion were the independent risk factors of increased external tibial torsion; therefore, performing an imaging study is recommended for assessing the extent of tibial torsion in patients with such characteristics.

Management of Adnexal Torsion in the Pediatric and Adolescent Population at Western Australia's Single Tertiary Children's Hospital over the Last 10 Years: Retrospective Study.

OBJECTIVE: To review our institutional data regarding the management of adnexal torsion (AT) and assess the ovarian conservation rates. DESIGN: Retrospective study. SETTING: Tertiary children's hospital. PATIENTS: Pediatric and adolescent patients with surgically diagnosed AT. Participants (n = 54, mean age 9.80 ± 3.95 years) were identified between June 2010 and May 2019. INTERVENTIONS: Surgical management of AT. MEASUREMENTS AND MAIN RESULTS: The primary outcome was to determine the ovarian conservation rates in AT cases. The secondary outcomes were to determine the incidence of AT to total emergency department (ED) presentations, decision to operation theater (OT) time in AT cases, return to OT, histopathology, and follow-up with ultrasound to determine ovarian function. Data were collected on demographic and clinical characteristics. Continuous data were compared with t tests or Kruskal-Wallis tests; categoric data were compared with chi-square tests. A total of 52 (96.29%) patients had ovarian conservation, and 53 (98.14%) had laparoscopic management. The incidence rate for AT cases to total ED presentations for the last 10 years was 9.9 per 100 000, which was based on a Poisson distribution. Presentations to an ED for AT cases have trended upward since 2010. Decision to OT time was statistically significantly shorter in cases with preoperative suspicion of AT than those with intraoperative diagnosis of AT (p = .000). A total of 7 (12.96%) patients returned to OT for suspicion of recurrent torsion. Of these, 5 (9.26%) had confirmed repeat AT. The presence of fever, pain duration, severity of pain, and severity of torsion did not correlate with the follow-up ultrasound findings of ovarian activity. CONCLUSION: The findings from our study suggest that high ovarian conservation rates are achievable in AT cases. A high index of suspicion is required to prevent a delay in surgery.

Prevalence of combined abnormalities of tibial and femoral torsion in patients with symptomatic hip dysplasia and femoroacetabular impingement.

AIMS: The prevalence of combined abnormalities of femoral torsion (FT) and tibial torsion (TT) is unknown in patients with femoroacetabular impingement (FAI) and hip dysplasia. This study aimed to determine the prevalence of combined abnormalities of FT and TT, and which subgroups are associated with combined abnormalities of FT and TT. METHODS: We retrospectively evaluated symptomatic patients with FAI or hip dysplasia with CT scans performed between September 2011 and September 2016. A total of 261 hips (174 patients) had a measurement of FT and TT. Their mean age was 31 years (SD 9), and 63% were female (165 hips). Patients were compared to an asymptomatic control group (48 hips, 27 patients) who had CT scans including femur and tibia available for analysis, which had been acquired for nonorthopaedic reasons. Comparisons were conducted using analysis of variance with Bonferroni correction. RESULTS: In the overall study group, abnormal FT was present in 62% (163 hips). Abnormal TT was present in 42% (109 hips). Normal FT combined with normal TT was present in 21% (55 hips). The most frequent abnormal combination was increased FT combined with normal TT of 32% (84 hips). In the hip dysplasia group, 21% (11 hips) had increased FT combined with increased TT. The prevalence of abnormal FT varied significantly among the subgroups (p < 0.001). We found a significantly higher mean FT for hip dysplasia (31°; SD 15)° and valgus hips (42° (SD 12°)) compared with the control group (22° (SD 8°)). We found a significantly higher mean TT for hips with cam-type-FAI (34° (SD 6°)) and hip dysplasia (35° (SD 9°)) compared with the control group (28° (SD 8°)) (p < 0.001). CONCLUSION: Patients with FAI had a high prevalence of combined abnormalities of FT and TT. For hip dysplasia, we found a significantly higher mean FT and TT, while 21% of patients (11 hips) had combined increased TT and increased FT (combined torsional malalignment). This is important when planning hip preserving surgery such as periacetabular osteomy and femoral derotation osteotomy. Cite this article: Bone Joint J 2020;102-B(12):1636-1645.

Conservative surgery for ovarian torsion in young women: perioperative complications and national trends.

OBJECTIVE: To analyse populational trends and perioperative complications following conservative surgery versus oophorectomy in women <50 years of age with ovarian torsion. DESIGN: Population-based retrospective observational study. SETTING: Nationwide Inpatient Sample in the USA (2001-2015). POPULATION: In all, 89 177 ovarian torsions including 20 597 (23.1%) conservative surgeries and 68 580 (76.9%) oophorectomies. METHODS: (1) Trend analysis to assess utilisation of conservative surgery over time, (2) multivariable binary logistic regression to identify independent factors associated with conservative surgery and (3) inverse probability of treatment weighting with a generalised estimating equation to analyze perioperative complications. MAIN OUTCOME MEASURES: Trends, characteristics and complications related to conservative surgery. RESULTS: Performance of conservative surgery increased from 18.9 to 25.1% between 2001 and 2015 (32.8% relative increase, P = 0.001) but decreased steadily after age 15, and sharply declined after age 35 (P < 0.001). On multivariable analysis, younger age exhibited the largest effect size for conservative surgery among the independent factors (adjusted odds ratios 3.39-7.96, P < 0.001). In the weighted model, conservative surgery was associated with an approximately 30% decreased risk of perioperative complications overall (10.0% versus 13.6%, odds ratio 0.73, 95% confidence interval 0.62-0.85, P < 0.001) and was not associated with venous thromboembolism (0.2 versus 0.3%, P = 0.457) or sepsis (0.4 versus 0.3%, P = 0.638). CONCLUSION: There has been an increasing utilisation of conservative surgery for ovarian torsion in the USA in recent years. Our study suggests that conservative surgery for ovarian torsion may not be associated with increased perioperative complications. TWEETABLE ABSTRACT: Conservative surgery for ovarian torsion may not be associated with increased perioperative complications.

Surgically treated ovarian lesions in preadolescent girls.

INTRODUCTION: The purpose of this study was to investigate the epidemiology and characteristics of surgically treated ovarian lesions in preadolescent girls. MATERIAL AND METHODS: This was a retrospective cohort study including all 0- to 11-year-old girls operated at a single center from 1999 to 2016 for ovarian cysts, neoplasms or torsions. Patient charts were reviewed for symptoms, preoperative radiological imaging, operative details and histopathology. RESULTS: We identified 78 girls, resulting in a population-based incidence of 4.2/100 000. Infants (n = 44) presented with benign cysts (42/44, 95%, one bilateral), a benign neoplasm (1/44, 2%) and a torsion without other pathology (1/44, 2%). Torsion was found in 25/29 (86%) ovaries with complex cysts and in 3/15 (21%) ovaries with simple cysts in preoperative imaging (P < 0.001). Most infants were symptomless. Lesions in 1- to 11-year-old girls (n = 34) included benign neoplasms (n = 21/34, 62%), malignant neoplasms (n = 5/34, 15%), a cyst with torsion (n = 1/34, 3%) and torsions without other pathology (n = 7/34, 21%). Torsion was more common in benign (17/21, 81%) than in malignant neoplasms (1/5, 20%) (P < 0.020). Ovarian diameter did not differ between ovaries with or without torsion (P = 0.238) or between benign and malignant neoplasms (P = 0.293). The duration of symptoms in lesions with or without torsion was similar. CONCLUSIONS: The majority of surgically treated ovarian lesions in preadolescent are benign lesions with torsion. Surgery should be ovary-preserving and performed without delay.

Adnexal Torsion in Pregnancy Managed by Laparoscopy Is Associated with Favorable Obstetric Outcomes.

STUDY OBJECTIVE: Most cases of adnexal torsion in pregnancy are currently managed by laparoscopy, which may be associated with increased risks for spontaneous abortion and preterm delivery. We sought to evaluate the obstetric outcomes of these women, with emphasis on their live birth rate and gestational age at delivery. DESIGN: Retrospective cohort study and telephone questionnaire. SETTING: University-affiliated obstetrics and gynecology department. PATIENTS: All pregnant women who underwent laparoscopy for adnexal torsion between 2007 and 2017. Their obstetric outcomes were obtained by retrospective review of medical records and a telephone questionnaire. INTERVENTIONS: Laparoscopy for adnexal detorsion, with or without cyst drainage or cystectomy. MEASUREMENTS AND MAIN RESULTS: The study cohort included 94 women. Most torsion cases (71, 75.5%) were diagnosed in the first trimester of pregnancy, whereas 21 (22.3%) cases and 2 (2.1%) cases were diagnosed in the second and third trimesters, respectively. Conception was achieved by in vitro fertilization or by ovulation induction in 45 (47.9%) cases. The information on pregnancy outcomes was available for 93 women. Of those, live birth was reported for 86 (92.5%) pregnancies, while 6 (6.5%) women had a spontaneous abortion, and 1 woman experienced an intrauterine fetal death. Five cases of spontaneous abortion were diagnosed in the first trimester, all within 3 weeks of surgery. Preterm delivery before 37 gestational weeks was reported for 18 (19.4%) pregnancies and was significantly associated with twin pregnancy (p = .002) and with conception following in vitro fertilization and ovulation induction (p = .03). On logistic regression analysis, preterm delivery was only associated with twin vs singleton gestation (odds ratio, 6.7; 95% confidence interval, 1.3-34.8; p = .02). CONCLUSION: The obstetric outcomes of pregnant women who underwent laparoscopy for adnexal torsion are generally favorable. However, there is a risk for preterm delivery, which is primarily associated with multiple gestations.

Lung lobe torsion in 35 dogs and 4 cats.

The purpose of this study was to assess survival to discharge of animals with surgical or postmortem confirmation of a lung lobe torsion (LLT) as well as to evaluate pre-operative effusion, lung lobe affected, and patient size as prognostic indicators. Medical records search identified 35 dogs and 4 cats with a confirmed diagnosis including 17 small-breed dogs, 18 large-breed dogs, 3 domestic shorthair cats, and 1 minskin cat. Lobes affected included right middle (n = 18), left cranial (n = 18), right cranial (n = 2), left caudal (n = 1), and accessory (n = 1). Two animals died before surgery; the remaining 37 animals underwent thoracotomy. All treated small-breed dogs and cats survived; 12/18 large-breed dogs survived, with an overall survival to discharge of 87%. Pre-operative pleural effusion and affected lung lobe did not affect survival to discharge in this population. Small dogs and cats with LLT appear to have an excellent survival to discharge following thoracotomy and the survival is good in larger dogs.

Torsion de lobe pulmonaire chez 35 chiens et 4 chats. Le but de cette étude est d'évaluer le taux de survie jusqu'à la sortie d'hôpital, chez des animaux ayant eu confirmation chirurgicale ou post-mortem de torsion de lobe pulmonaire (TLP), ainsi que d'évaluer la présence d'épanchement pleural, le lobe pulmonaire affecté et la taille des patients en tant que facteurs pronostics. Les dossiers médicaux de 35 chiens et 4 chats avec un diagnostic de TLP confirmé furent identifiés, comprenant 17 chiens de petite race, 18 chiens de grande race, 3 chats Européens et 1 Minskin. Les lobes pulmonaires affectés étaient le lobe moyen droit (n = 18), le lobe cranial gauche (n = 18), le lobe cranial droit (n = 2), le lobe caudal gauche (n = 1) et le lobe accessoire (n = 1). Deux animaux décédèrent avant chirurgie, et une thoracotomie fut pratiquées chez les 37 animaux restant. Tous les chiens de petites races et les chats survécurent à leur chirurgie; 12/18 des chiens de grande race survécurent, et le taux de survie global était de 87 %. La présence d'épanchement pleural et le lobe pulmonaire affecté n'avaient pas d'influence sur la probabilité de survie dans cette population. Le taux de survie au congé hospitalier semble excellent chez les chiens de petite taille et les chats diagnostiqués avec une torsion de lobe pulmonaire et il est bon pour les chiens de grande taille.(Traduit par les auteurs).

Towards complication-free assisted reproduction technology.

Assisted reproductive technology (ART) has vastly improved over the last 40 years, from a frequently unsuccessful and complicated procedure requiring hospital admission and routine laparoscopy to a fairly simple outpatient technique with relatively high success rates. However, it is important to stress that ART is not without risk and medical complications may still occur. The incidence of most of these ART-related complications is associated with how women undergo ovarian stimulation. For this reason, physicians should be aware that a carefully thought-out ovarian stimulation protocol and cycle monitoring are of paramount importance to maximise the success of the treatment while avoiding potentially life-threating complications to occur in this frequently otherwise healthy patient population. This review discusses the rationale and evolution of ovarian stimulation strategies over the years and the current developments towards finding a balance between the retrieval of a sufficient number of oocytes and ART-related complication prevention.

Predictors of Oophorectomy in Girls Hospitalized in Texas With Ovarian Torsion.

OBJECTIVES: Inconsistent results have been reported by authors of studies of the management of pediatric patients with ovarian torsion (OT). Our objective was to identify predictors of oophorectomy in girls hospitalized throughout Texas with OT. METHODS: The Texas Public Use Data File (years 2013-2014) was queried for the records of girls under the age of 18 years who had a principal or secondary discharge diagnosis of OT (International Classification of Diseases, Ninth Revision, Clinical Modification code 620.5). Adjusted odds ratios were estimated from a logistic regression model by using Firth's bias-reducing penalized likelihood. Variables for inclusion in the final model were identified by using a directed acyclic graph. RESULTS: A sample of 158 girls was identified with an overall risk of oophorectomy during the hospital stay of 41.1% (65 out of 158). After adjusting for the patient's age, health insurance status, and the presence of an ovarian cyst, girls who were treated at a nonteaching hospital were more than twice as likely to undergo oophorectomy than girls who were treated at a teaching hospital (odds ratio = 2.22; 95% confidence interval: 1.05-4.69). CONCLUSIONS: Our analysis of a statewide database revealed that girls with OT who presented at nonteaching hospitals were significantly more likely to undergo oophorectomy compared with girls who presented at teaching hospitals.

Ovarian torsion in children: Development of a predictive score.

The aim of this study was to identify clinical signs and symptoms of ovarian torsion (OT) in children and to develop a simple predictive score.A chart review of patients with acute adnexal pathologies treated at the University Children's Hospital Basel, Switzerland, between March 2006 and June 2015 was performed. Medical records were screened for demographic and clinical data. These included clinical symptoms, laboratory studies, imaging, and type of treatment. The diagnosis OT was defined as intraoperative visualization of the torsed ovary around its pedicle at least 360 degrees. Variables predictive for OT were identified and the following score for the likelihood of having OT was developed: age (points = number of years) minus 3 points (if vomitus = "yes") and plus 1 point (if "pain duration >12 hours").A total of 80 patients with acute adnexal pathologies were identified. OT was recorded in 17 (21%) cases and ovarian cysts (OC) only in 63 (79%) cases. Patients who presented with OT were significantly younger than patients with OC only (P = .001). Correspondingly, 11 (65%) of the patients with OT had no menarche compared to 3 (5%) patients with OC only (P = .001). Vomiting (P = .001), a shorter pain duration (P = .01), and an elevated C-reactive protein (CRP) (P = .01) were observed significantly more often in patients with OT. The sensitivity of a positive OT score was 0.81 and increased to 1.00 if restricted to girls between 2 to 12 years of age.The presence of vomiting, short duration of abdominal pain, and elevated CRP level have a predictive value for the diagnosis of OT. In these patients, an exploratory laparoscopy should be conducted without delay. The presented OT score appears to be a helpful tool in diagnosing OT in children.

A systematic review and meta-analysis on fetal ovarian cysts: impact of size, appearance and prenatal aspiration.

OBJECTIVE: The objective of the study is to compare outcomes of ultrasound-guided aspiration of fetal ovarian cysts with conservative management. METHOD: A systematic review of MEDLINE and Web of Science included studies reporting outcomes (prenatal and postnatal torsion, spontaneous resolution and surgery) of fetuses with ovarian cysts. Subgroup analysis was performed according to cyst diameter at diagnosis and cysts ≥40 mm. RESULTS: Ninety-two non-randomised studies reported on 380 cysts (324 observed and 56 aspirated in utero) in 365 fetuses. All studies were case reports or series with high heterogeneity and risk of bias. The overall spontaneous resolution rate of conservatively managed cysts was 46%, yet decreased with increasing cyst size. Risk of prenatal ovarian torsion in conservatively managed cases depended on cyst size and was particularly important in the range 30 to 59 mm (15-34%). The rate of prenatal torsion in simple cysts ≥40 mm was lower in aspirated than conservatively managed cysts (0% vs 10%, p = 0.03). Aspirated cysts had lower rates of postnatal surgery (7%) compared with conservatively managed cysts (49%, p < 0.001). CONCLUSION: Cysts 30 to 59 mm were at highest risk of torsion. Simple cysts >40 mm had lower rates of torsion when aspirated prenatally. Randomised studies and safety data are needed prior to routine prenatal ovarian cyst aspiration. © 2017 John Wiley & Sons, Ltd.

The incidence of isolated penile torsion in North India: A study of 5,018 male neonates.

OBJECTIVE: Congenital penile torsion is a three-dimensional deformity with helical rotation of the distal corporal bodies with the penile crurae remaining fixed to the pubic rami. The first case of congenital penile torsion (hypospadias) was described in 1857. Isolated penile torsion is an under-reported anomaly. The reported incidence of isolated penile torsion is 1.7-27% and severe torsion is 0.7%. There are no studies available from Indian subcontinent on the incidence of isolated penile torque. The objective of this study was to determine the overall incidence of isolated penile torque in a north Indian population. MATERIALS AND METHODS: A prospective study of deliveries of male children was conducted at our institute between April 2014 and June 2015. Penile torsion was measured using a small protractor either by the deviation of the median raphae or the direction of the meatus. Data were collected on the incidence of congenital isolated penile torsion, including the degree and direction (left or right) of torsion. Torsion was classified as mild (<450), moderate (450-900), and severe (>900). Statistical analysis was done using the chi-square test with variables of age and parity of the mother and weight of the child. RESULTS: There were 99 cases of isolated penile torque among 5018 male neonates assessed for penile torque. The incidence of isolated penile torque was 19.7 per 1000 births. The degree of torsion varied from 30 to 110° (average 51.46°). Seventy-nine percent (79%) of them had left side and 21% had right side torque (4:1). The degree of torsion was mild in 30%, with 20% having left side torque and 10% having right side torque (2:1). A moderate degree of torsion was seen in 69%: 84% of them had left torque and only 16% had right sided torque (5:1). Only one patient had severe left torque. The incidence of isolated congenital penile torsion was highest in the maternal age group of >30 years followed by the 26-30-year age group, and was lowest in 21-25 year age group. In multiparous women, the incidence of isolated congenital penile torsion was highest (2.54%), and it was lowest in primiparous women (1.36%). CONCLUSION: The incidence of isolated penile torsion was 1.97% and the left-to-right ratio was 3:1, but for moderate torque it was 5:1. There was a strong association between incidence of penile torque with the age of the mother (p = 0.012) and parity (p = 0.008) but not with the weight of the baby (p = 0.415).

Pediatric Adnexal Torsion: Not Just a Postmenarchal Problem.

BACKGROUND: Pediatric adnexal torsion is rare, can be challenging to recognize, and may result in ovarian loss. OBJECTIVE: We sought to identify and compare the defining characteristics of adnexal torsion in premenarchal and postmenarchal girls. METHODS: A retrospective cohort study was performed at a tertiary care children's hospital, including patients diagnosed postnatally with adnexal (ovarian or tubal) torsion between 1997 and 2013. Proportions were compared using relative risk regression. RESULTS: Adnexal torsion was found in 59 premenarchal and 43 postmenarchal girls. Abdominal pain was the most common chief complaint (54%). History included reports of pain (96%), vomiting (67%), and fever (19%). Excluding 12 patients with isolated tubal torsion and 19 with a teratoma, there were no statistically significant differences in ovarian loss in premenarchal vs. postmenarchal girls (47% and 25% respectively; relative risk [RR] = 1.8 [95% confidence interval {CI} 0.9-3.8]), left- vs. right-sided torsion (47% and 32%; RR = 1.5 [95% CI 0.8-2.7]), pain duration ≤ 2 days vs. > 2 days (31% and 41%; RR = 0.8 [95% CI 0.4-1.5]; n = 64) and severe pain vs. mild to moderate (38% and 33%; RR = 1.1 [95% CI 0.7-1.5]; n = 56). CONCLUSIONS: The diagnosis of pediatric adnexal torsion is difficult and often delayed. Pain and tenderness may not be isolated to a unilateral lower quadrant. Although traditionally considered a postmenarchal problem, in a pediatric academic emergency department adnexal torsion occurred with similar frequency in premenarchal and postmenarchal girls. The potential for organ salvage means that adnexal torsion should be considered in all females presenting with acute abdominal pain regardless of age or menstrual history.

Chronic adnexal torsion: An under-recognized disease entity.

OBJECTIVE: To clarify the incidence, clinical background and surgical characteristics of chronic adnexal torsion in comparison to acute adnexal torsion. STUDY DESIGN: The patients were divided into three categories based on the period from the onset of symptoms to surgical management: acute (≤24h), subacute (2days) and chronic adnexal torsions (≥3days). Cases, in which the onset of symptoms was unspecified, were included in the chronic adnexal torsion group. Then, a retrospective comparative study of acute (49 patients) and chronic adnexal torsion (45 patients) was performed. Laparoscopic surgery was performed as a primary surgical procedure. RESULTS: In chronic adnexal torsion, surgery was performed at a median of 9days (range: 3-270days) after the onset of symptoms. The apparent onset of symptoms was not noted in 2 cases. All cases with acute adnexal torsion received emergency surgery. In contrast, emergency surgery was performed only in 13 patients with chronic adnexal torsion. Patients with chronic adnexal torsion were significantly older than those with acute adnexal torsion. Isolated tubal torsion was more frequent in chronic adnexal torsion. With the exception of 2 cases with chronic adnexal torsion in which laparotomic conversion was required due to severe adhesion, and 2 cases with acute adnexal torsion with advanced gestational age, who were managed by initial laparotomy, laparoscopic surgery was successful. Unilateral salpingo-oophorectomy was the most frequent surgical procedure in both groups. When confined to the patients who expressed a wish for adnexal preservation, adnexal cystectomy or detorsion was possible in 60.9% of the acute torsion cases and 57.1% of the chronic adnexal torsion cases. Severe necrosis of the adnexal tissue and extensive pelvic adhesion were the more frequent associated conditions in chronic adnexal torsion. Among the patients who were successfully managed by laparoscopic surgery, the duration of surgery was significantly longer in the patients with chronic adnexal torsion. Severe necrosis that makes a pathological diagnosis difficult was the most frequent finding in cases of chronic adnexal torsion. CONCLUSION: Chronic adnexal torsion still represents a diagnostic and therapeutic challenge that should be recognized as a distinct and more frequently encountered disease entity.