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Objective:
Adnexal torsion can be challenging to diagnose, especially in children, when transvaginal ultrasound (US) may not be an option. If the ovary is not seen, it may lead to a dilemma for clinicians. Existing literature on nonvisualized ovaries on pediatric ultrasound has small numbers and does not specify technique used, whether transabdominal or transvaginal, which may affect the ability to see the ovaries. We conducted a review of all pelvis US examinations ordered in our ED over a 6-year period and studied the surgical outcomes for patients with one or both ovaries not visualized.

Materials and Methods:
Our retrospective review included female pelvis US examinations for patients at least 1-year old performed in our pediatric emergency department between 2015 and 2020. These examinations were all performed transabdominally. Exams read as “ovary not seen” were classified as equivocal and reason for ovary nonvisualization was documented. Reports were classified as adnexal torsion present, absent, or equivocal. Surgical findings were extracted from the operative report in the electronic medical record and were coded as positive or negative for ovarian and/or tubal torsion, while also noting presence of mass or cyst. Among US with nonvisualized ovaries, frequency of torsion and association of torsion with reason for nonvisualized ovaries was assessed using descriptive statistics, Fisher’s exact test, and chi-squared test.

Results:
Our data showed 219 pelvic US examinations with at least one ovary not visualized (4.76% of 4603 total examinations reviewed); 86 ovaries were nonvisualized on the right, 151 were on the left (p < 0.001). Mean (SD) age of girls with nonvisualized ovary was 12.98 years (SD 4.6). In 56 cases, the ovary was not visualized due to gas and stool in the adnexa. In 85 cases, no reason of nonvisualization was given. Twenty cases were due to a mass or cyst obscuring the adnexa, 15 had bladder under distension, 15 had another diagnosis, 6 cases were due to body habitus, and 7 cases were due to likely small or atrophic ovaries. Four of the nonvisualized overy cases had right adnexal torsion (2.01 % of all nonvisualized cases) and 3 had left adnexal torsion (1.51%). The side of nonvisualization differed from the side of the torsed overy in 3 cases (42.6% of torsions). Presence of any type of torsion was only associated with likely small or atrophic ovaries (OR: 10.6, CI 1.74 – 64.3).

Conclusion:
When evaluated with transabdominal approach, nonvisualization of an ovary is more likely to be left-sided which may relate to shadowing from the rectosigmoid colon as most common listed cause of a nonvisualized ovary was related to bowels. Nonvisible presumed small ovaries were associated with torsion. While this association may be related to the unaffected side, at least one case was presumed to be a small ovary due to previous torsion. Future study with a larger sample size may be elucidative.