Non-visualization of the ovaries on pediatric transabdominal ultrasound with a non-distended bladder: Can adnexal torsion be excluded?

BACKGROUND: The pediatric reproductive organs are optimally imaged with a full bladder. The filling of the bladder, however, often leads to significant delay in diagnosis and can subject the patient to invasive bladder catheterization. As the key imaging feature in ovarian torsion is unilateral ovarian enlargement, we suspected that a torsed ovary is large enough to be visualized even if the bladder is not well distended. OBJECTIVE: The purpose of this study was to retrospectively investigate if clinically suspected adnexal torsion can be excluded based on non-visualization of the ovaries on transabdominal ultrasound (US) with a non-distended bladder in pediatric patients. MATERIALS AND METHODS: This retrospective study comprised 349 girls (1-19 years old) between Jan. 1, 2013, and July 30, 2018. Three hundred and forty-one of the girls were referred to transabdominal US to assess for adnexal torsion and/or appendicitis, and the ovaries were initially not visualized on US. Their bladders were subsequently filled and rescanned with a distended bladder showing the ovaries. Ovarian volumes and time between US scans were documented. The ratio of the volume of the larger ovary to the smaller one was calculated. Nine girls had surgically proven adnexal torsion and a preoperative transabdominal US with a non-distended bladder. There was an overlap of one girl between the two groups. The negative predictive value (NPV), positive predictive value (PPV), and sensitivity and specificity for exclusion of adnexal torsion based on non-visualization of the ovaries on US with a non-distended bladder were calculated. RESULTS: One of the girls (1/341) who had a US study done with a non-distended bladder in which the ovaries were not visualized had a positive diagnosis of adnexal torsion. In eight of the nine girls who had surgically proven adnexal torsion, the torted ovary was identified with a non-distended bladder. The NPV and PPV for exclusion of adnexal torsion with a non-distended bladder was 1.0 and 0.8, respectively. The specificity and sensitivity were 99.4% and 88.9%, respectively. The mean and median time difference between the initial scan and the scan after bladder filling was 105.1 min (standard deviation [SD] -65.8) and 89.0 min (interquartile range [IQR]- 59.0, 130.5), respectively. CONCLUSION: Non-visualization of the ovaries with a non-distended bladder on transabdominal US study can help exclude clinically suspected adnexal torsion, alleviating the need for bladder filling and prolonging the wait time in the emergency department. Inclusion of non-visualization of the ovaries as one of the features in a predictive score for adnexal torsion should be considered.

A case of adolescent pelvic inflammatory disease caused by a rare bacterium: Fusobacterium nucleatum.

BACKGROUND: Pelvic inflammatory disease (PID) is a polymicrobial infection that typically occurs in sexually active females. PID is rare in premenarchal and/or noncoital young women; however, there are case reports of PID occurring in virginal females. We present the first reported case of PID associated with F. nucleatum. In this unusual case of PID in an adolescent, the responsible organism may have originated from the patient's oral cavity. CASE: A 13-year-old noncoital Caucasian female presented to a tertiary children's hospital with fever and acute abdominal/pelvic pain. She had experienced a perforated appendix 14 months prior, which was treated by laparoscopy. Postoperatively, she experienced intermittent episodes of recurrent abdominal pain. During this presentation, the physical examination and ultrasound findings were suspicious for an ovarian torsion. She was taken to the operating room where she had an examination under anesthesia and a diagnostic laparoscopy. Findings at the time of laparoscopy were in keeping with a diagnosis of pelvic inflammatory disease. Oral and pelvic fluid cultures were positive for F. nucleatum. She was subsequently treated with antibiotics and her symptoms resolved. SUMMARY AND CONCLUSION: This case highlights the importance of including PID in the differential diagnosis of noncoital adolescent females presenting with an acute abdomen. Although most Fusobacteria infections are periodontal in nature, translocated infections to the pelvis may have long-term implications for reproductive health. This case also highlights the importance of the role of diagnostic laparoscopy in young women who have persistent pain following previous surgery due to the potential of missed pathology or subclinical infection.

Improved obstetrical outcomes for adolescents in a community-based outreach program: a matched cohort study.

OBJECTIVE: Adolescent pregnancies are higher-risk pregnancies, and standard obstetrical care environments may not meet their needs. The objective of this study was to determine if adolescents followed in a community-based adolescent outreach obstetrical program had improved perinatal outcomes compared with provincial control subjects. METHODS: We conducted a matched cohort study. Adolescent women who received prenatal care in the outreach program between 2004 and 2010 (intervention group, n = 206) were identified and matched 1:4 to adolescent control subjects in the provincial perinatal database (n = 831). Chi-square and Student t tests were performed for categorical and continuous variables. Regression models assessed the association between the intervention and pregnancy/perinatal outcomes. RESULTS: The intervention cohort had significantly higher rates of smoking, drug use, and alcohol use than control subjects P < 0.001); however, rates of first trimester visits (76.7% vs. 64%, P = 0.009), prenatal class attendance (52.8% vs. 30.3%; P < 0.001), and group B streptococcus screening (P = 0.01) were also higher. Although the intervention cohort had higher risk behaviours than control subjects, there were no significant differences between the groups in the proportion of preterm or very preterm births, low birth weight or very low birth weight infants, or intrauterine growth restricted/small for gestational age infants. The intervention cohort had a significantly higher mean gestational age at delivery (P = 0.005) and higher mean birth weight (P = 0.002) than control subjects. The adjusted relative risk of low birth weight was significantly lower in the intervention group (RR 0.41; 95% CI 0.18 to 0.95) and a decreased risk of preterm delivery was seen (RR 0.47; 95% CI 0.22 to 1.00). CONCLUSION: Pregnant adolescents may engage in higher-risk behaviours that can affect perinatal outcomes. Early prenatal care and education in adolescent-friendly programs may mitigate the effect of these behaviours on perinatal outcomes. Multidisciplinary adolescent-focused outreach programs that facilitate early and regular access to care are important models for future adolescent obstetrical care.

Toxic shock syndrome of a probable gynecologic source in an adolescent: a case report and review of the literature.

BACKGROUND: Toxic shock syndrome (TSS) is an acute toxin-mediated infectious syndrome characterized by fever, hypotension, desquamation, and multiorgan involvement. It is a rare condition (incidence of 0.79/100,000 women), particularly in the adolescent population, and it may be menstrual (mTSS) or non-menstrual (nmTSS) in origin. CASE: A 15-year-old girl developed symptoms of nausea, vomiting, and diarrhea that worsened over a 3-day period. At initial presentation, she was hypotensive, febrile, and tachycardic. Her condition deteriorated and within 36 hours she required intubation, vasopressor treatment, and antibiotic therapy. Multiple sites were cultured but only the vaginal culture, which grew Staphylococcus aureus, was positive. Recent menses with tampon use was reported. She responded to aggressive therapy and was discharged home 3 weeks after initial presentation. SUMMARY AND CONCLUSION: We describe a rare case of TSS of a probable gynecologic source in a 15-year-old female who successfully responded to aggressive intensive care treatment. mTSS should be considered in the differential diagnosis of an adolescent presenting with signs of septic shock, particularly if there is a recent history of tampon use. Early intervention is critical to improving survival.

Pregnancy in adolescents.

Adolescent pregnancy remains a public health issue with significant medical, emotional, and societal consequences for the adolescent mother, her child, and her family. Teenage pregnancies are at higher risk of many adverse outcomes, including preterm delivery, low birth weight, and neonatal and infant mortality. Teen pregnancy and motherhood may have detrimental effects on the teen mother and her child; antenatal and postpartum care need to be adapted to meet the special needs of pregnant adolescents because standard obstetrical environments may not do so. This comprehensive review of adolescent pregnancy will highlight global statistics, factors contributing to adolescent pregnancy, social implications of adolescent pregnancy, obstetrical and neonatal outcomes, and the importance of multidisciplinary antenatal and postnatal care.

Juvenile granulosa and theca cell tumor of the ovary as a rare cause of precocious puberty: case report and review of literature.

BACKGROUND: The differential diagnosis for precocious puberty in a young female includes peripheral causes. This case documents a rare cause of peripheral precocious puberty--a juvenile granulosa and theca cell ovarian tumor--and a brief review of the literature for this tumor type. CASE: A 7-year-old girl presented with rapid onset of pubertal development and elevated estradiol levels. Menarche occurred 5 months after thelarche. A thorough workup revealed a large multicystic left ovary. Other causes of precocious puberty were excluded. She underwent an exploratory laparotomy and left salpingo-oophorectomy. Pathology reported a juvenile granulosa and theca cell tumor of the ovary, FIGO stage 1A. Postoperatively, she experienced a cessation of vaginal bleeding and estradiol levels normalized. A literature review found that early stage disease has an excellent prognosis and that adjuvant chemotherapy is not indicated in this setting. SUMMARY AND CONCLUSION: Juvenile granulosa and theca cell tumor of the ovary is a rare cause of peripheral precocious puberty, even more so than juvenile granulosa cell tumor, due to the theca component. Treatment is surgical and an excellent prognosis is possible for early stage disease.

Mullerian adenosarcoma of the cervix in a 10-year-old girl: case report and review of the literature.

UNLABELLED: Müllerian adenosarcoma is a rare neoplasm usually found in postmenopausal women. It usually presents as a polypoid mass within the endometrium. It is a biphasic tumor, composed of a benign epithelial component and a malignant stromal component. To date, this neoplasm has been reported in only 16 adolescent girls. We present a case of a 10-year-old girl who was diagnosed with müllerian adenosarcoma arising from the endocervix, the youngest female ever reported. CASE REPORT: A 10-year-old previously healthy girl presented to the Emergency Department at the Children's Hospital of Eastern Ontario with a painless mass protruding from her vagina. She had experienced mild vaginal bleeding for two weeks prior to her presentation. On physical examination, her vital signs were stable, and pubertal development was Tanner III breast and Tanner II pubic development. Rectoabdominal examination was negative. Two polypoid lesions were seen protruding past the hymenal ring and were removed in the emergency department. On gross examination, they were a dark tan color and had a fleshy appearance with a gelatinous consistency. They measured 5.5 x 1.5 x 1.0 cm and 3.5 x 1.5 x 1.5 cm. The final pathology revealed müllerian adenosarcoma, favoring an endocervical origin. Further investigations, including an abdominal/pelvic ultrasound and MRI and chest radiography, were negative. The patient subsequently underwent examination under anesthesia, vaginoscopy, hysteroscopy, polypectomy, and dilatation and curettage. The vagina appeared normal. At the level of the cervix, there were 3 polypoid gelatinous structures arising from the endocervix and extruding past the exocervix. They measured 0.8 x 0.5 x 0.2 cm up to 1.1 x 0.7 x 0.5 cm. The lesions were removed. Hysteroscopic inspection of the uterine cavity did not find any abnormalities. An endometrial curettage was performed. Pathology confirmed a diagnosis of müllerian adenosarcoma originating from the endocervix. Uterine curettings were negative for malignancy. After a thorough evaluation of the available literature, review with the Regional Tumor Board and extensive discussions with the family, a decision was made to perform a radical hysterectomy, bilateral salpingectomy, bilateral pelvic lymph node dissection, upper vaginectomy and preservation of ovaries. The procedure was uncomplicated. Clinically, there was no evidence of residual disease. The final pathology was negative for malignancy. CONCLUSION: Müllerian adenosarcoma of the endocervix is a very rare pediatric tumor. Due to the rarity of this tumor in this age group, optimal therapy is uncertain. Most experts recommend hysterectomy. The review of literature reveals a high recurrence rate following conservative surgical management. Chemotherapy and radiation have not been used in the absence of extensive pelvic and/or residual disease. Poor prognostic factors include depth of invasion, sarcomatous overgrowth and high-grade malignant features in the stromal component. If recurrence occurs, it tends to be local and following prior conservative treatments such as cone biopsy or trachelectomy. Recurrences may occur late and thus long term follow-up of these patients is recommended.

Hypercalciuria as a cause of genital bleeding in a 6-year-old girl.

STUDY OBJECTIVE: To document an unusual cause of genital bleeding in a 6-year-old girl. DESIGN: Case report. SETTING: Outpatient pediatric gynecology clinic in a tertiary care hospital. RESULTS: Clinical presentation of a case of genital bleeding secondary to hypercalciuria in a 6-year-old female. Gynecologic investigations were negative. There were hematuria on urinalysis and an elevated calcium-to-creatinine ratio on initial presentation; however, no evidence of urolithiasis was found on ultrasound. In the context of negative investigations and persistent episodes of bleeding, the hypercalciuria was treated with hydrochlorothiazide. Normalization of calciuria was associated with the end of genital bleeding episodes. CONCLUSION: Hypercalciuria with microcrystals and urethral irritation should be considered as part of the differential diagnosis for genital bleeding in girls.