Testicular Workup For Ischemia Research Articles

UnTWISTing the BALS: A study of predictive accuracy of clinical scoring tools for testicular torsion identification in adults.

Testicular torsion is an uncommon but time-critical condition in EDs. If the diagnosis is missed or delayed, there are significant medicolegal and patient fertility implications. Scoring tools are advocated for use in children but have limited validation in adults. The aim of the present study was to explore the predictive accuracy of the testicular torsion scoring tools, Testicular Workup for Ischemia and Suspected Torsion (TWIST) and Boettcher Alert Score (BALS), in adult patients with a final ED diagnosis of torsion. All patients with an ED working diagnosis of testicular torsion were identified retrospectively. Data collected from digital medical records included demographics, processes of care and clinical information. The outcome of interest was the predictive performance of the scores for a confirmed diagnosis of testicular torsion as adjudicated by an urologist or a surgeon. Fifty-four patients had complete clinical data, of whom 13 had confirmed torsion. The TWIST score had a high area under the receiver operating characteristics curve (AUROC) of 0.89 (95% confidence interval [CI] = 0.78-0.999) with a score of 6-7 corresponding to a positive predictive value (PPV) of 80% (95% CI = 38-96%). The BAL score had an AUROC of 0.79 (95% CI = 0.69-0.92). PPV for a score ≥2 was 38% (95% CI = 22-56%). A high TWIST score correlates to a high likelihood of torsion and can inform surgical decision-making in the absence of US.

Predictive factors for manual detorsion success in testicular torsion.

In cases of testicular torsion (TT), prompt diagnosis and treatment are highly associated with organ salvage, and manual detorsion (MD) is a recommended maneuver as a first intervention. In our study, we aimed to investigate the effect of predictive factors of TT in predicting the success of MD. A retrospective, 2-center study was conducted on patients diagnosed with TT between January 2015 and 2024. Demographic, clinical, ultrasound, and laboratory characteristics at presentation were analyzed. MD was routinely performed as the first intervention in all patients. Predictive parameters were compared in the MD success and failure groups. Univariate and multiple logistic regression analysis was used to identify risk factors for MD failure. A total of 94 patients were included in the study. The median age of the patients was 20 (IQR: 12-69) years, and the median symptom duration was 6 (IQR: 4-12) hours. MD confirmed by Doppler ultrasonography was successful in 52 (55.3%) patients and unsuccessful in 42 (44.7%). Age, symptom duration, Testicular Workup for Ischemia and Suspected Torsion (TWIST) score, TWIST risk groups, WBC, neutrophil, monocyte counts, and Monocyte/Eosinophil ratio (MER) were statistically different between the two groups. In multiple logistic regression analysis, the risk factors for failure of MD were found to be being over 18years of age, the duration of symptoms being longer than 9h, and MER > 28. Current urology guidelines suggest that age, symptom duration, and MER are reliable predictors of the success of MD, which is recommended in all cases of TT.

The diagnosis and treatment of testicular torsion in children with non-scrotal initial symptoms.

To explore the clinical characteristics of testicular torsion in children with non-scrotal initial symptoms who were misdiagnosed. A retrospective analysis of 73 cases children with testicular torsion and non-scrotal symptoms who were admitted to our department from October 2013 to December 2021 was performed. Patients were divided into misdiagnosis (27 cases) and clear diagnosis at first visit (46 cases) groups. Clinical data, including age at surgery, clinical presentation, physical examination, number of visits (≥2 times), affected side, time from initial symptoms to surgery, and surgical outcomes, were collected. The TWIST (Testicular Workup for Ischemia and Suspected Torsion) score was calculated and analyzed. Statistically significant differences between the misdiagnosis and clear diagnosis groups were seen in the time from initial symptoms to surgery, the number of visits, the degree of testicular torsion, and the rate of orchiectomy (P < 0.05). There were no statistically significant differences (P > 0.05) in age, affected side, TWIST score, guardian, direction of testicular torsion, intra-vaginal or extra-vaginal torsion, and Arda classification. Postoperative follow-up was 6-40 months. Of the 36 patients who required an orchiopexy, 1 had testicular atrophy at six months and 2 were lost to follow-up. The contralateral testis of the 37 children who underwent orchiectomies developed normally without torsion. The clinical manifestations of testicular torsion in children are diverse and can easily lead to misdiagnosis. Guardians should be aware of this pathology and seek timely medical attention. When the initial diagnosis and treatment of testicular torsion is difficult, the TWIST score during the physical examination may be useful, especially for patients with intermediate-to-high risk scores. Color Doppler ultrasound can assist in making the diagnosis, but when testicular torsion is highly suspected, routine ultrasound is not necessary as it may lead to delayed surgical treatment.

Validation of TWIST score in the diagnosis of testicular torsion in children: A Prospective study

Early diagnosis is key in testicular torsion. This study is to validate the diagnostic value of the “Testicular Workup for Ischemia and Suspected Torsion (TWIST)” score for evaluating acute scrotum in children. Patients from 1 month old to 16 years old presented to Children’s hospital No.1 with acute scrotum between June 1 st, 2020, and May 31 st, 2021 were prospectively studied. General surgeons performed an examination and recorded signs and symptoms in the collection form. After that, all patients had Scrotal Doppler Ultrasound (DUS). We calculated the sensitivity, specificity, positive predictive, and negative predictive values of the TWIST score. The ROC curve was used to find out the optimal cut-off in diagnosing Testicular torsion (TT) in Children. Among 68 children with acute scrotum, 16 cases had TT (23.5%). The median age was 12.5 years in the TT group and 9 years in the non-TT group. None of 32 patients with the TWIST score ≤ 2 had TT and among 20 patients with a score of 3 – 4, only one had TT. More importantly, in the high-risk group with a score ≥ 5, 15 had TT (93.8%). ROC curve revealed an AUC of 0.987 (p&lt;0,001) representing a high diagnostic value. The sensitivity and specificity for TT at 5-point cut-off were 93.7% and 98.1%, respectively. The TWIST scoring system has high sensitivity and specificity values. Therefore, it should be used as a useful tool for the diagnosis of testicular torsion. The score ≥ 5 is an indicator of testicular torsion, hence emergency surgical intervention is required.

Validation of TWIST (Testicular Workup for Ischemia and Suspected Torsion) Score System for Differential Diagnosis in Acute Scrotum in Tertiary Teaching Hospital

The acute scrotum is a common urological emergency and has a broad differential diagnosis. There is no clear consensus on a particular algorithm to follow in the diagnosis of testicular torsion. Testicular Workup for Ischemia and Suspected Torsion (TWIST) Score, a risk scoring system based on signs and symptoms, can be invaluable in managing patients with the acute scrotum, specifically testicular torsion. This study aimed to evaluate the effectiveness of the TWIST scoring system for differential diagnosis of acute scrotal patients. The study was conducted using secondary data, medical records from 111 male patients diagnosed with acute scrotum in Saiful Anwar General Hospital Malang between January 2015 and December 2018. Data about the onset of pain, first contact, history, physical examination findings, any adjunct test performed, and intra-operative findings were collected. The effectiveness of the TWIST score in diagnosing testicular torsion was determined by calculating the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV). Of the 111 patients, 43 patients (38.7%) had testicular torsion. The mean age was 17.49 (6.69) years. A total of 39 patients were classified as high risk as per the TWIST Score with cut point 5 had 83.7% sensitivity, 95.6% specificity, 92.3% positive predictive value (PPV), and 90.3% negative predictive value (NPV). The area under the curve was 0.93. The use of the TWIST Score in clinical practice can accurately determine high-risk patients who can proceed straight to the operating theatre without the need for an ultrasound.

Diagnosing with a TWIST: Systematic Review and Meta-Analysis of a Testicular Torsion Risk Score.

The Testicular Workup for Ischemia and Suspected Torsion (TWIST) score is a 7-point tool to evaluate acute scrotal pain. Parameters include testicular swelling (2 points), hard testis (2), high-riding testis (1), absent cremasteric reflex (1) and nausea/vomiting (1). This review aimed to determine the diagnostic utility of TWIST and its role in risk stratification. A systematic review and meta-analysis of diagnostic test accuracy was conducted. Five risk stratification systems were explored, including the Barbosa (0-2, 3-4, 5-7) and Sheth (0, 1-5, 6-7) scoring systems, to obtain sensitivity, specificity and area under the receiver operating curve. Thirteen studies were identified, 9 prospective studies proceeded to meta-analysis of diagnostic test accuracy and 5 pediatric studies (1,060 patients, 199 torsions) were included in the primary analysis. The most accurate risk stratification system was Barbosa (0-2, 3-4, 5-7), with an AUC of 0.924 (95% CI: 0.865, 0.956). Barbosa showed favorable sensitivity in low-risk patients (0.984), facilitating rule out of torsion, and favorable specificity (0.975) in high-risk patients, facilitating urgent surgical exploration. Sensitivity and specificity in intermediate-risk patients were 0.922 and 0.682, respectively, indicating a need for further workup with ultrasound. Using this stratification, 65.2% of patients were low-risk, 19.9% were intermediate-risk and 14.9% were high-risk. Per 100 presentations of acute scrotum, there was a missed torsion rate of 1.6/100, ultrasound rate of 19.9/100 and negative exploration rate of 2.5/100. TWIST is an effective tool for suspected testicular torsion and is appropriate for widespread adoption. The Barbosa scoring system is reliable and reduces reliance on scrotal ultrasound.

Testicular torsion in children.

As a family physician caring for a large pediatric population, I evaluate numerous adolescents with testicular pain. Given the gravity of prognosis for late treatment of children with testicular torsion, what are best practices for its assessment and management? The Testicular Workup for Ischemia and Suspected Torsion (TWIST) score has been developed and validated to identify children at risk of testicular torsion. If the TWIST score is 0 and clinical suspicion is low in the office setting, a referral to urology for urgent consultation is not needed. If the TWIST score is 1 or higher or if the clinical presentation suggests torsion, manual detorsion should be attempted and the patient should be urgently sent to the nearest emergency department.

The BAL-Score Almost Perfectly Predicts Testicular Torsion in Children: A Two-Center Cohort Study.

Introduction: Testicular torsion (TT) is a common emergency that warrants immediate exploration to prevent infertility or testicular loss. To improve diagnostic reliability, various scoring systems have been published. The aim of this study was to evaluate and validate different testicular torsion scores in a large cohort of children with acute scrotum.Methods: Retrospective analysis of all male children that were admitted for acute scrotum at the Pediatric Surgery Department of the Altonaer Kinderkrankenhaus and University medical Center Hamburg-Eppendorf from 01/2013 to 03/2019. Two testicular torsion scores (Boettcher Alert Score, Testicular Workup for Ischemia and Suspected Torsion Score) were applied to all data sets. Furthermore, an artificial intelligence (AI)-based score was developed and compared to the two current scores.Results: In total, 460 boys were included in the study. Of those, 48 (10.4%) had TT. Children with TT suffered most often from short duration of pain, nausea and vomiting, high riding testicle and absent cremasteric reflex. The BALS and the AI-based score had excellent predictive values and all patients with TT would have been detected.Conclusion: The BAL and the AI score show excellent predictive capabilities and may be used to identify all cases of TT in a pediatric population. The scores are easy to apply. As the BALS was slightly better, we advocate to use this score but to validate our findings in prospective multicenter studies.

Performance of the TWIST Score in Patients with Testicular Torsion that Present to the Emergency Department

Abstract Objective Testicular torsion (TT) is an emergency with an incidence of 1:1,500 in patients &lt; 18 years old. Irreversible changes in the testicular parenchyma may happen. The Testicular Workup for Ischemia and Suspected Torsion (TWIST) questionnaire evaluates signs and symptoms to determine the risk of TT and improve the time of management. The aim of the present study was to compare the intraoperative findings of patients with TT with the result of the preoperative TWIST questionnaire. Methods A cohort of 33 pediatric patients that consulted to the emergency room was evaluated. The TWIST questionnaire was applied in the first approach. Imaging studies, time to the operating room (OR) and intraoperative findings were evaluated. Theoretical and real findings were compared. Results The median age was 13 years old (interquartile range [IQR] 10–15 years old). Edema and scrotal inflammation was the most frequent finding (42.4%), followed by testicular induration (21.2%), nausea and vomiting (15.2%), and horizontal testicle and absence of cremasteric reflex (9.1%). The TWIST stratification was 3% high-risk, 18.2% intermediate-risk and 78.8% low-risk. Testicular Doppler ultrasound was performed in 93.9% of the patients: vascular congestion was found in 21.9%. A total of 30.3% of the kids were taken to surgery after 163 minutes (±116.5). Intraoperative diagnosis of TT was confirmed in the high-risk patient, in 33.3% of the intermediate-risk, and in 50% of the low-risk. The receiver operating characteristic (ROC) curve showed an accuracy of 60% (p = 0.602). Conclusions The TWIST questionnaire in the first approach allows to take the high-risk patients immediately to the OR. However, it might not be a reliable tool for diagnosis of TT in intermediate and low-risk patients.

Testicular Workup for Ischemia and Suspected Torsion in Pediatric Patients and Resource Utilization

BackgroundTesticular torsion (TT) is a pediatric emergency requiring prompt diagnosis and management. The Testicular Workup for Ischemia and Suspected Torsion (TWIST) scores patients on clinical symptoms and can predict TT. This study aimed to determine if the application of TWIST to children with acute scrotal pain could decrease the use of Doppler ultrasonography (DUS) and emergency department (ED) length of stay and ischemic time. Materials and methodsA retrospective cohort study applying TWIST to patients who presented to a pediatric ED with acute testicular pain from December 2017 to June 2019 was performed. Demographics, TWIST score, diagnosis, DUS, consults, and time to the operation were recorded. Patients were stratified into low (LR), intermediate (IR), and high (HR) risk groups for TT based on TWIST score. Descriptive and comparative analyses were performed. ResultsSeventy-seven patients were included in the study and had a mean age of 9.24 y ±5.24. All 9 HR patients (TWIST = 5-7) had TT, and none of the 57 LR patients (TWIST = 0-2) had TT. Use of TWIST could have reduced the number of DUS needed to diagnose TT from 69 to 11 (75.3% reduction in DUS). ConclusionsTWIST accurately predicts torsion in HR groups and excludes torsion in LR groups. Application of TWIST to HR patients may eliminate the need for DUS and decrease ischemic time and cost of care. Application of TWIST in LR patients may likewise eliminate the need for DUS and decrease ED length of stay and cost of care.

Validation of the TWIST score for testicular torsion in adults.

The TWIST (Testicular Work-up for Ischemia and Suspected Torsion) score was developed to allow for expedited diagnosis of testicular torsion (TT) in children based on clinical variables: edema (2 points), hard mass (2), absent cremasteric reflex (1), high-riding testis (1) and nausea/vomiting (1). We sought to validate the TWIST Score applied by non-expert physicians for the diagnosis of testicular torsion in an adult population. We prospectively analyzed all consecutive males presenting to a tertiary hospital with acute scrotum. Patients with previous scrotal pathology or trauma were excluded. Physical examination was performed by a general surgeon and variables of TWIST were recorded. All patients underwent Scrotal Doppler Ultrasound. Measures of accuracy of the TWIST score and ROC curves were generated to evaluate its performance in diagnosing TT in adults. Of 68 patients, 34 had TT (50%). Median age was 24.9years. According to the original cutoffs of TWIST, 23 patients had a score ≤ 2 among which none had TT. Fifteen patients had a score of 3-4, among which seven had TT. Thirty patients had a score ≥ 5, among which 27 had TT. All 18 patients with a score of 6 or greater had TT (100% PPV). ROC curve revealed an AUC of 0.95. The TWIST Score is valid for the diagnosis of Testicular Torsion in adults, presenting a PPV of 90% for a cutoff of 5 points and 100% for six points. In all patients with a score of 2 or less, the disease could be safely excluded (100% NPV).

Acute Testicular Torsion: Presentation and Diagnosis

Testicular torsion is the most common pediatric urologic emergency and is a common cause of acute scrotal pain. Timely diagnosis is important for testicular salvage,as treatment delayed beyond 6 hours from the onset of symptoms is the most predictive factor of testicular death. There is a bimodal distribution of age with extravaginal torsion most commonly presenting in the neonatal period and intravaginal torsion most commonly presenting around the onset of puberty. Intermittent testicular torsion presents a unique challenge in making an accurate diagnosis, as patients most often present when asymptomatic. Several risk factors exist, although bell-clapper deformity is the most important. The diagnosis is made largely on history or physical examination. In equivocal cases, imaging with color Doppler ultrasonography may be helpful in making the diagnosis. Additional tools including near-infrared spectroscopy and Testicular Workup for Ischemia and Suspected Torsion score may be helpful in diagnosing testicular torsion. Possible long-term effects on fertility and hormonal function are also often a concern for the patient and clinician. This review contains 6 figures, 5 tables, and 34 references. Keywords: acute, infarction, ischemia, orchidopexy, scrotum, spermatic cord, testis, torsion

BET 2: Twist score in cases of suspected paediatric testicular torsion

A shortcut review of the literature was carried out to establish whether the Testicular Workup for Ischemia and Suspected Torsion (TWIST) score was reliable and accurate enough to rule out...

Diagnosing Testicular Torsion before Urological Consultation and Imaging: Validation of the TWIST Score

The TWIST (Testicular Workup for Ischemia and Suspected Torsion) score uses urological history and physical examination to assess risk of testis torsion. Parameters include testis swelling (2 points), hard testis (2), absent cremasteric reflex (1), nausea/vomiting (1) and high riding testis (1). While TWIST has been validated when scored by urologists, its diagnostic accuracy among nonurological providers is unknown. We assessed the usefulness of the TWIST score when determined by nonurological nonphysician providers, mirroring emergency room evaluation of acute scrotal pain. Children with unilateral acute scrotum were prospectively enrolled in a National Institutes of Health clinical trial. After undergoing basic history and physical examination training, emergency medical technicians calculated TWIST score and determined Tanner stage per pictorial diagram. Clinical torsion was confirmed by surgical exploration. All data were captured into REDCap™ and ROC curves were used to evaluate the diagnostic usefulness of TWIST. Of 128 patients (mean age 11.3 years) 44 (13.0 years) had torsion. TWIST score cutoff values of 0 and 6 derived from ROC analysis identified 31 high, 57 intermediate and 40 low risk cases (positive predictive value 93.5%, negative predictive value 100%). TWIST score assessed by nonurologists, such as emergency medical technicians, is accurate. Low risk patients do not require ultrasound to rule out torsion. High risk patients can proceed directly to surgery, with more than 50% avoiding ultrasound. In the future emergency medical technicians and/or emergency room triage personnel may be able to calculate TWIST score to guide radiological evaluation and immediate surgical intervention at initial assessment long before urological consultation.