Author's Accepted Manuscript

Diagnosing Testicular Torsion before Urologic Consultation and Imaging: A

Validation of the TWIST Score

Kunj R. Sheth , Melise Keays , Gwen M. Grimsby , Candace F. Granberg , Vani S.

Menon , Daniel G. DaJusta , Lauren Ostrov , Martinez Hill , Emma Sanchez , David
Kuppermann , Clanton B. Harrison , Micah A. Jacobs , Rong Huang , Berk Burgu ,
Halim Hennes , Bruce J. Schlomer , Linda A. Baker

PII: S0022-5347(16)00224-X
DOI: 10.1016/j.juro.2016.01.101
Reference: JURO 13294

To appear in: The Journal of Urology

Accepted Date: 15 January 2016

Please cite this article as: Sheth KR, Keays M, Grimsby GM, Granberg CF, Menon VS, DaJusta DG,
Ostrov L, Hill M, Sanchez E, Kuppermann D, Harrison CB, Jacobs MA, Huang R, Burgu B, Hennes H,
Schlomer BJ, Baker LA, Diagnosing Testicular Torsion before Urologic Consultation and Imaging: A
Validation of the TWIST Score, The Journal of Urology® (2016), doi: 10.1016/j.juro.2016.01.101.

DISCLAIMER: This is a PDF file of an unedited manuscript that has been accepted for publication. As a
service to our subscribers we are providing this early version of the article. The paper will be copy edited
and typeset, and proof will be reviewed before it is published in its final form. Please note that during the
production process errors may be discovered which could affect the content, and all legal disclaimers
that apply to The Journal pertain.

Embargo Policy

All article content is under embargo until uncorrected proof of the article becomes available
online.

We will provide journalists and editors with full-text copies of the articles in question prior to the embargo
date so that stories can be adequately researched and written. The standard embargo time is
12:01 AM ET on that date. Questions regarding embargo should be directed to jumedia@elsevier.com.
 ACCEPTED MANUSCRIPT

Diagnosing Testicular Torsion before Urologic Consultation and Imaging: A

Validation of the TWIST Score
Kunj R. Sheth1, Melise Keays2, Gwen M. Grimsby3, Candace F. Granberg4, Vani S. Menon1,8,
Daniel G. DaJusta6, Lauren Ostrov8, Martinez Hill8, Emma Sanchez8, David Kuppermann7,
Clanton B. Harrison1,8, Micah A. Jacobs1,8, Rong Huang8, Berk Burgu5, Halim Hennes1,8, Bruce
J. Schlomer1,8, Linda A. Baker1,8

PT
1
Affiliations: University of Texas Southwestern Medical Center, Dallas, TX
2
Children’s Hospital of East Ontario, Ottawa, Ontario
3

RI
Phoenix Children’s Hospital, Phoenix, AZ
4
Mayo Clinic, Rochester, MN
5
Nationwide Children’s Hospital, Columbus, OH
6

SC
Harvard Medical School, Boston, MA
7
Ankara Üniversitesi Tıp Fakültesi, Ankara, Turkey
8
Children’s Health, Dallas, TX

Address Correspondence To:

U
AN
Linda A Baker, MD
Interim Chief of Pediatric Urology
Children’s Health, Center for Pediatric Urology
2350 Stemmons Freeway
M

4th Floor, F4.04

Dallas, TX 75207
P: 214 456 2480
D

F: 214 456 8803

Email: linda.baker@childrens.com
TE

Descriptive Runninghead (41 characters, max 50): Diagnosing Testicular Torsion with
TWIST score
EP

Keywords (up to 5): Diagnosis, Spermatic cord torsion, Scrotum, Ultrasound

C

Funding: This study was supported by an NIH grant, R21DK092654 (PI: Baker, LA).
AC

Financial Disclosures: None

Conflict of Interest: None

Word count:
Abstract (Limit 250): 250
Manuscript (Limit 2500): 2311

1
 ACCEPTED MANUSCRIPT

Abstract

PURPOSE: TWIST (Testicular Workup for Ischemia and Suspected Torsion) score uses
urologic history and physical exam to assess risk of testis torsion. The 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,

PT
its diagnostic accuracy amongst non-urologic providers is unknown. We assessed the
utility of the TWIST score when collected by non-urologic non-physician providers,
mirroring the ER evaluation of acute scrotal pain.

RI
MATERIALS AND METHODS: Pediatric patients with unilateral acute scrotum were
prospectively enrolled in a NIH clinical trial. After undergoing basic history and physical exam

SC
training, EMTs calculated TWIST score and determined Tanner stage per a pictorial diagram.
Clinical torsion was confirmed by surgical exploration. All data were captured into RedCap, and
receiver operating characteristic (ROC) curves evaluated the diagnostic utility of TWIST.

U
RESULTS: Of 128 patients (mean age 11.3), 44 (mean age 13.0) had torsion. TWIST score
cutoff values of 0 and 6 derived from ROC analysis identified 31 high, 57 intermediate, and 40
AN
low risk patients (positive predictive value 93.5%; negative predictive value 100%).
CONCLUSIONS: TWIST score assessed by non-urologists, such as EMTs, is accurate. Low risk
patients do not require ultrasound to rule out torsion. High risk patients can proceed directly to
M

surgery, avoiding the ultrasound in >50% of patients. In the future, EMTs and/or ER triage
personnel could calculate TWIST score to guide radiologic workup and immediate surgical
intervention at initial assessment long before urologic consultation.
D
TE
C EP
AC

2
 ACCEPTED MANUSCRIPT

Introduction
Testicular torsion is one of the few pediatric urologic emergencies, accounting for only

10-15% of acute scrotum presentations1, 2 with an annual incidence of 3.8 per 100,000 pediatric

patients.3 Intervention within 4-8 hours is critical to prevent permanent testicular loss or atrophy

PT
from compromised testicular arterial flow.4, 5 Thereafter, the testicle is often not salvageable

RI
resulting in orchiectomy rates of 32-41%.3, 6 While delayed ER presentation cannot be

controlled, prompt and accurate diagnosis upon arrival is essential to identify patients requiring

SC
surgical detorsion.

U
The classic presentation for testicular torsion in pubertal males is acute onset unilateral
AN
testicular pain with nausea and vomiting. An absent cremasteric reflex has been considered

specific for testicular torsion,7 although there are reports of torsion with present cremasteric
M

reflex.8 Testicular swelling, tenderness and high lie are nonspecific, often making diagnosis

solely on physical exam difficult.9 Therefore, testicular ultrasound with doppler is heavily relied
D

upon for confirmation.10, 11 Since awaiting any imaging constitutes a time delay, risk scoring
TE

systems based on signs and symptoms only, such as the TWIST (Testicular Workup for Ischemia

and Suspected Torsion) score, have been proposed.12

EP

Barbosa et al. devised and validated the TWIST scoring system, which assigns a summed
C

TWIST score (range 0-7 points) based on the absence (0 points) or presence of the following 5
AC

variables: testicular swelling (2 points), hard testicle (2), absent cremasteric reflex (1),

nausea/vomiting (1) and high riding testis (1). Their ROC analysis yielded all binary variables.

Thus, for the categories of testicular swelling and hard testis, patients could only receive a score

of 0 or 2 points (no option for 1 point). Per their initial validation, patients at high risk for

3
 ACCEPTED MANUSCRIPT

torsion (TWIST ≥ 5) could proceed straight to OR without imaging as the PPV was 100%.

Patients with intermediate risk (TWIST = 3-4) required ultrasound to evaluate for torsion, and

patients at low risk for torsion (TWIST ≤ 2) did not require scrotal ultrasound as the NPV was

100%.12 However, the TWIST score does not account well for physiologic differences in

PT
children, control for inter-observer variability, or substitute for medico-legal need of ultrasound

RI
documentation. In Barbosa et al. data were collected by urologists, but in practice, this would

first be obtained by an ER provider prior to urology consultation. In the present study we

SC
evaluate the utility of the TWIST score when measured by trained non-physician, non-urologic

personnel, specifically EMTs, who are often the first medical providers to encounter patients in

an emergency setting.
U
AN
Materials and Methods
M

Study Population (Inclusion and Exclusion Criteria)

D

The study population was drawn from an NIH-funded prospective study evaluating the
TE

use of Near Infrared Spectroscopy (NIRS) in the diagnosis of torsion.13 Between March 2013

and March 2015, we prospectively evaluated males aged one month to 21 presenting to a tertiary
EP

care pediatric ER with acute scrotum, defined as painful scrotum or testis, abdominal pain,
C

and/or waddling gait ("Cowboy shuffle") from painful scrotum. Patients with synchronous
AC

bilateral testicular torsion or a previously known testicular or scrotal pathology were excluded in

the study protocol due to inability to use the contralateral testis as an internal control for NIRS

measurements. Additionally, we excluded patients with chronic respiratory, hematological or

vascular problems that could affect total body tissue oxygenation levels, and thus NIRS

measurements.
4
 ACCEPTED MANUSCRIPT

Study Design

Per the NIH study protocol, the ER was instructed to page the on-call EMT research personnel

upon arrival of any patients with acute scrotum. Potentially eligible study subjects were

PT
approached by the on-call EMT and screened for inclusion and exclusion criteria. Informed

consent and required study data were collected while patients were receiving care, ultrasound

RI
and/or surgery, avoiding any delay in care. Scrotal ultrasound was used as the gold standard for

SC
diagnosis of testicular torsion and was intended to be performed for all patients included in the

study, unless the physician's clinical suspicion was high enough to forego ultrasound and

U
proceed to the OR for urgent detorsion. Patients with no evidence of torsion on ultrasound were
AN
given a urology follow-up appointment in 2 weeks and ER warning signs.

For all enrolled study patients, the research EMTs evaluated the patient, assigning binary
M

components of the TWIST score and Tanner stage using a descriptive and pictorial table (see
D

Figure 1). The EMT received no training specific to the scrotal exam or TWIST scoring, but
TE

rather relied on basic history and physical exam training they learned during EMT certification.

Patients without complete TWIST score components were excluded from this study.
EP

Data Analysis
C

All collected data were entered into a RedCap database (CTSA NIH Grant
AC

UL1TR001105)14 and extracted as needed for analysis. T-tests, Fischer’s exact test and Wilcoxan

rank sum tests were used for comparisons. ROC curves were constructed to analyze and compare

the performance of the TWIST score as a diagnostic test for torsion.15 Optimal cutoff values for

low, intermediate, and high risk groups were chosen to maximize performance of the test, taking

into account clinically meaningful results to optimize NPV and PPV while limiting false
5
 ACCEPTED MANUSCRIPT

negatives and false positives. All statistical analysis was performed with Stata 12 (College

Station, TX).

PT
RI
U SC
AN
M
D
TE
C EP
AC

6
 ACCEPTED MANUSCRIPT

Results

Among the 316 patients assessed for eligibility, 115 did not meet study criteria and 47

declined to participate. One patient was taken straight to the OR for high suspicion of torsion

PT
without ultrasound and 2 patients without torsion did not receive an ultrasound. One of these

patients refused ultrasound and the other had low clinical suspicion and ultrasound was deferred

RI
per the ED. Both patients had Urology follow-up with no evidence of torsion at that time.

SC
128/154 enrolled patients had all TWIST data available (Figure 2). 44/128 (34.4%) patients were

diagnosed with torsion and surgically confirmed. Amongst those not diagnosed with torsion in

U
the ER, no patients presented with missed torsion, although only 45% returned for clinical
AN
follow-up. Demographic characteristics of all patients with and without torsion are demonstrated

in Table 1. Patients with torsion were older (13.0 vs 10.4 yrs, p = 0.001), were more likely to be
M

white or black (p = 0.003), had higher Tanner stage (p < 0.001), and had lower median hours of

pain prior to arrival (p = 0.01).

D
TE

The TWIST score components and total score (range 0-7) distribution is shown in Table

2. The median TWIST score for torsion patients was 6 and the median TWIST score of non-
EP

torsion patients was 1 (p < 0.001). The ROC curve using all points in the TWIST score had an

AUC = 0.95 (95% CI 0.91-0.98) (Figure 3a). Clinically meaningful TWIST score cutoff values
C

of 0 and 6 were used to categorize patients into low risk (TWIST = 0), intermediate risk (TWIST
AC

= 1-5), and high risk (TWIST ≥ 6) with an optimized AUC of 0.90 (95% CI 0.85-0.94) (Figure

3b). There were no patients with a TWIST score of 0 that had torsion, giving a negative

predictive value (NPV) of 100% and specificity of 47.6%. Of those with TWIST ≥ 6, 29/31 had

torsion for a positive predictive value (PPV) of 93.5% and a sensitivity of 65.9%. The two

7
 ACCEPTED MANUSCRIPT

torsion patients with a TWIST score of 1 for nausea/vomiting were manually detorsed at and

outside facility and operative room findings remained consistent with this.

For Tanner stage 3-5 patients, a high risk TWIST score had a PPV of 100% and

PT
sensitivity of 65.6% (Figure 4a). In contrast, for Tanner stage 1-2 patients, a high risk TWIST

score had a PPV of 77.8% and sensitivity of 70.0% (Figure 4b). The two patients with high risk

RI
TWIST score without testicular torsion were a Tanner 1 and Tanner 2 patient with torsion of the

SC
appendix testis.

U
AN
M
D
TE
C EP
AC

8
 ACCEPTED MANUSCRIPT

Discussion

In this study, we assessed the TWIST score obtained by trained non-physician, non-

urologic providers. In our population, the TWIST score performed well as a diagnostic test for

PT
torsion, although not as well as previously reported and with different optimal cutoff values.12

Based on our results we have devised an algorithm to evaluate patients who present to the ER

RI
with an acute scrotum (Figure 5).

SC
In our population, no torsions were missed on follow-up and all patients taken to the

operating room had torsion or testicular ischemia in the absence of torsion, indicating recent

U
detorsion (spontaneous, manual by ER, or with anesthesia). In current practice, ultrasound is
AN
increasingly used to guide the diagnosis of testicular torsion,10, 11 with reported 100% sensitivity,

97.9% specificity and 98.1% diagnostic accuracy. 2 Thus, ultrasonography served as the gold
M

standard in our study population although constituting a 30-60 minute time delay in diagnosis.
D

Thus, there is a growing effort to return to traditional history and physical exam findings
TE

to diagnose torsion, decreasing the reliance on imaging, minimizing cost, and facilitating rapid

surgical intervention.16-19 The TWIST score is easy to calculate with a simple patient evaluation.
EP

In our study, 29/44 (65.9%) testicular torsions were detectable by a high risk TWIST score (≥ 6)
C

and only 2/31 (6.5%) in the high risk group without testicular torsion would undergo a negative
AC

unnecessary surgical exploration. Per our ROC analysis the high risk score cutoff was 6 rather

than 5, which was reported previously.12 In our population 4/12 (33.3%) patients with a TWIST

score of 5 did not have testicular torsion, which would lead to an unacceptably high negative

exploration rate. Alternatively, a high risk cutoff of 7 would yield a 100% PPV, but lower

sensitivity to 34.1%, leading to an optimal cutoff of 6. In addition, our low risk group cutoff of 0
9
 ACCEPTED MANUSCRIPT

was different than previously published. 40/128 (31.3%) comprised the low risk group with no

cases of testicular torsion (100% NPV). If the goal of a low risk TWIST score is to avoid use of

ultrasound, then a NPV of 100% is necessary as a missed torsion is unacceptable. A scrotal

ultrasound could be avoided in all low (31.3%) and high (24.2%) risk patients, comprising over

PT
50% of patients. In comparison, Barbosa et al. found ultrasound unnecessary in ~80% of

RI
patients.12

SC
Torsion has a bimodal age distribution with the first peak in the neonatal period and the

second peak around puberty.20 While post-pubertal children usually present with severe testicular

U
pain, identifying typical torsion symptoms and performing sonography to appropriately diagnose
AN
torsion is more challenging in prepubescent children.6, 21 In our study, the two patients without

torsion who were in the high risk group were Tanner stage 1 or 2 with a diagnosis of torsion of
M

the appendix testis that led to a high TWIST score.

D

In Tanner stage 3-5 patients, the high risk TWIST score had a PPV of 100%, signifying
TE

that the TWIST score performs better for peri-pubertal or post-pubertal children. TWIST also

performs well in Tanner 1-2 patients, but some of these children with torsion of appendix testis
EP

will be categorized as high risk for torsion. Therefore, ultrasound should be considered for these

patients to help confirm diagnosis.

C

One key difference and asset in this validation of the TWIST score that may explain the
AC

differences in group stratification is that all the involved components were collected by non-

physician, non-urologic personnel. At presentation, a urologist is typically not immediately

available in the ER and the initial evaluation and decision to obtain an ultrasound or not is quite

often done by non-urologists. Thus, we suggest the cutoff values seen in our study are more valid

10
 ACCEPTED MANUSCRIPT

for use in the ER. Implementation and evaluation of the TWIST score by ER providers and triage

nurses following our diagnostic algorithm will be the next step to potentially expedite urologic

consultation and minimize time to the OR. Taking this one step further, validating EMT-

generated TWIST scoring opens the door to early risk stratification in the field or during transit

PT
to the hospital, analogous to Glasgow Coma Scale use. Such rapid triage could allow for

RI
expedited care on arrival for patients with TWIST ≥ 6, bypassing the ER with direct transport to

the OR. Of course, this time-saving approach would require further investigation and evaluation

SC
prior to routine implementation.

U
Limitations
AN
The NIH study was powered for NIRS performance to diagnose testicular torsion. Thus, this

secondary outcome sub-analysis evaluating TWIST score performance is limited by the small
M

number of patients. Similarly, patients without torsion in the ER had poor follow-up, which
D

could lead to misclassification of non-torsion patients. Furthermore, the TWIST score does not
TE

account for time since initial symptom onset. Generally, as torsion progresses, more signs and

symptoms associated with the TWIST score will be present. Our tertiary care center is often a
EP

referral center for pediatric patients with testicular pain, and our torsion rate in this study of

34.4% is much higher than reported in the literature (10-15%).1, 2 Many patients are transferred
C

from outside hospitals, prolonging their duration of symptoms. Thus, our study cohort may
AC

represent a biased group of patients with prolonged torsion, enabling the TWIST score to be

more diagnostic. Furthermore, the TWIST score does not incorporate severity of pain in risk

stratifying patients. While this may be hard to quantify for patients, clinical suspicion tends to be

higher when a patient presents with sudden onset severe pain. Lastly, the results are only

11
 ACCEPTED MANUSCRIPT

applicable to the group of patients that were not excluded in our study due to prior testicular

pathology or other medical co-morbidities. However, strengths of this study include the

prospective internally controlled study design and the patient evaluation with TWIST scoring by

non-physician, non-urologic staff.

PT
Conclusion

RI
The TWIST score was highly predictive in our population when evaluated by EMTs, especially

SC
in Tanner 3-5 patients where both the PPV and NPV were 100%. Therefore, our proposed

algorithm can potentially guide emergency room physicians and staff to triage patients

U
presenting with acute scrotum. Due to difficulty in definitive torsion diagnosis in Tanner 1 and 2
AN
patients, we recommend obtaining an ultrasound even in high risk TWIST patients. Since low

risk patients do not require ultrasound to rule out torsion and high risk patients Tanner 3-5 can
M

proceed directly to surgery, ultrasound is safely avoided in >50% of patients.

D
TE
C EP
AC

12
 ACCEPTED MANUSCRIPT

References

1. McAndrew HF, Pemberton R, Kikiros CS et al: The incidence and investigation of

acute scrotal problems in children. Pediatric surgery international 2002, 18(5-
6):435-437.
2. Liang T, Metcalfe P, Sevcik W et al: Retrospective review of diagnosis and treatment

PT
in children presenting to the pediatric department with acute scrotum. AJR
American journal of roentgenology 2013, 200(5):W444-449.
3. Zhao LC, Lautz TB, Meeks JJ et al: Pediatric testicular torsion epidemiology using a

RI
national database: incidence, risk of orchiectomy and possible measures toward
improving the quality of care. The Journal of urology 2011, 186(5):2009-2013.
4. Visser AJ, Heyns CF: Testicular function after torsion of the spermatic cord. BJU

SC
International 2003, 92(3):200-203.
5. Kapoor S: Testicular torsion: a race against time. International journal of clinical
practice 2008, 62(5):821-827.
6. Cost NG, Bush NC, Barber TD et al: Pediatric testicular torsion: demographics of

U
national orchiopexy versus orchiectomy rates. The Journal of urology 2011, 185(6
AN
Suppl):2459-2463.
7. Rabinowitz R: The importance of the cremasteric reflex in acute scrotal swelling in
children. The Journal of urology 1984, 132(1):89-90.
8. Nelson CP, Williams JF, Bloom DA: The cremasteric reflex: a useful but imperfect
M

sign in testicular torsion. Journal of Pediatric Surgery 2003, 38(8):1248-1249.

9. Kadish HA, Bolte RG: A retrospective review of pediatric patients with epididymitis,
testicular torsion, and torsion of testicular appendages. Pediatrics 1998, 102(1 Pt
D

1):73-76.
10. Liguori G, Bucci S, Zordani A et al: Role of US in acute scrotal pain. World journal of
TE

urology 2011, 29(5):639-643.

11. Gunther P, Schenk JP, Wunsch R et al: Acute testicular torsion in children: the role of
sonography in the diagnostic workup. European radiology 2006, 16(11):2527-2532.
12. Barbosa JA, Tiseo BC, Barayan GA et al: Development and initial validation of a
EP

scoring system to diagnose testicular torsion in children. The Journal of urology

2013, 189(5):1859-1864.
13. Schlomer B, Keays M, Grimsby G et al: Trans-scrotal Near Infrared Spectroscopy in
C

the Emergency Department to Diagnose Testicular Torsion in Pediatric Patients

Presenting with Acute Scrotum. The Journal of urology 2015, 193(4s):e464.
AC

14. Harris PA, Taylor R, Thielke R et al: Research electronic data capture (REDCap)--a
metadata-driven methodology and workflow process for providing translational
research informatics support. Journal of biomedical informatics 2009, 42(2):377-
381.
15. DeLong ER, DeLong DM, Clarke-Pearson DL: Comparing the areas under two or
more correlated receiver operating characteristic curves: a nonparametric
approach. Biometrics 1988, 44(3):837-845.
16. Boettcher M, Bergholz R, Krebs TF et al: Clinical predictors of testicular torsion in
children. Urology 2012, 79(3):670-674.
13
 ACCEPTED MANUSCRIPT

17. Boettcher M, Krebs T, Bergholz R et al: Clinical and sonographic features predict
testicular torsion in children: a prospective study. BJU Int 2013, 112(8):1201-1206.
18. Srinivasan A, Cinman N, Feber KM et al: History and physical examination findings
predictive of testicular torsion: an attempt to promote clinical diagnosis by house
staff. Journal of pediatric urology 2011, 7(4):470-474.
19. Beni-Israel T, Goldman M, Bar Chaim S et al: Clinical predictors for testicular torsion
as seen in the pediatric ED. The American journal of emergency medicine 2010,

PT
28(7):786-789.
20. Sharp VJ, Kieran K, Arlen AM: Testicular torsion: diagnosis, evaluation, and
management. American family physician 2013, 88(12):835-840.

RI
21. Patriquin HB, Yazbeck S, Trinh B et al: Testicular torsion in infants and children:
diagnosis with Doppler sonography. Radiology 1993, 188(3):781-785.

U SC
AN
M
D
TE
C EP
AC

14
 ACCEPTED MANUSCRIPT

Table 1: Patient characteristics

Torsion (n=44) No torsion (n=84) p-value
Mean age (SD) 13.0 (4.0) 10.4 (4.4) 0.0011

Race

PT
White 11 (25.0%) 16 (19.1%) 0.0032
Hispanic 18 (40.9%) 58 (69.1%)
Black 14 (31.8%) 9 (10.7%)

RI
Asian 1 (2.3%) 0
Other 0 1 (1.2%)

Tanner stage (mean age)3

SC
1 (6.3 yrs) 6 (14.3%) 28 (33.3%) <0.0014
2 (10.8 yrs) 4 (9.5%) 31 (36.9%)
3 (13.7 yrs) 12 (28.6%) 11 (13.1%)

U
4 (15.3 yrs) 17 (40.5%) 10 (11.9%)
5 (15.0 yrs) 3 (7.1%) 4 (4.8%)
AN
Median hours of pain prior to 17.3 (0.6-129.3) 29.2 (0.9-346.1) 0.024
arrival (range)
1
Two-tailed t-test
M

2
Fischer exact test used
3
Tanner stage missing in two patients with torsion
4
Wilcoxan rank sum test used due to non-normal distribution
D

Table 1: Patient characteristics: This table describes patient demographics and characteristics in the
TE

torsion and non-torsion groups. The patients with torsion were found to be significantly older, more
likely to be black or white, had a higher Tanner stage and shorter duration of pain.
C EP
AC
 ACCEPTED MANUSCRIPT

Table 2: TWIST score results

Torsion (n=44) No torsion (n=84) p-value
TWIST Score
0 0 40 (47.6%) <0.001
1 3 (6.8%) 16 (19.1%)

PT
2 0 9 (10.7%)
3 2 (4.6%) 9 (10.7%)
4 2 (4.6%) 4 (4.8%)

RI
5 8 (18.2%) 4 (4.8%)
6 14 (31.8%) 2 (2.4%)
7 15 (34.1%) 0

SC
TWIST Score Risk Category
Low (0) 0 40 (47.6%) <0.001
Intermediate (1-5) 15 (34.1%) 42 (50.0%)

U
High (6-7) 29 (65.9%) 2 (2.4%)
Wilcoxan rank sum test used to compare groups due to non-normal distribution
AN
Table 2: TWIST score results: The individual components of the TWIST score are identified for all
patients with and without torsion, and the break-up of patients in the low (0), intermediate (1-5), and
M

high risk groups (6-7) are shown. There was no significant difference in the break-down of TWIST score
components for patients with torsion when sub-stratified by Tanner stage.
D
TE
C EP
AC
 ACCEPTED MANUSCRIPT

PT
RI
U SC
AN
M
D
TE
C EP
AC

Figure 1:Tanner stage chart used by EMTs to identify patient Tanner stage at time of evaluation
 ACCEPTED MANUSCRIPT

Figure 2: Study Consort Diagram

Excluded (n=162)

PT
Assessed for eligibility (n = 316) ♦ Not meeting inclusion criteria (n= 115)
• Consent not properly obtained (n=16)
• Comorbid conditions (n=23)

RI
• Obvious bug bites (n=11)
• Bilateral scrotal pain (n=10)
• Age less than 1 month (n=1)

SC
• No scrotal pain on assessment (n=21)
• Did not follow study protocol (n=20)
• Previous scrotal surgery (n=6)

U
• Prior or chronic testis pain (n=7)

AN
Enrolled (n= 154) ♦ Declined to participate (n= 47)
♦ Other reasons (n = 0)

M
TWIST data unavailable (n = 26)

D
Analysed for primary endpoint (n= 128)

TE
EP
Underwent scrotal ultrasound (n = 125) No scrotal ultrasound (n = 3)
C
AC

No testicular torsion on Testicular torsion – Refused US (n = 1) Low clinical suspicion,

US – given clinical confirmed on surgical Low suspicion for US deferred (n = 1);
follow-up (n=82) exploration (n=44) torsion, even at f/u No torsion at f/u appt.
 ACCEPTED MANUSCRIPT

PT
RI
U SC
7

AN
M
D
TE
Figure 3: ROC curve for TWIST score demonstrates an AUC of 0.95 (95% CI 0.91-0.98) (A). ROC curve for TWIST score risk categories
demonstrates an AUC of 0.90 (95% CI 0.85-0.94) (B).
C EP
AC
 ACCEPTED MANUSCRIPT

1 1

PT
RI
SC
7
7

U
AN
M
D
TE
Figure 4: ROC curve for TWIST score in Tanner 2-5 patients demonstrates an AUC of 0.95 (95% CI 0.91-0.99) (A). The ROC curve for TWIST score
in Tanner 1 patients demonstrates an AUC of 0.96 (95% CI 0.91-1.00) (B). The cutoff risk category cutoff points (0 and 6) are circled in both ROC
curves.
C EP
AC
 ACCEPTED MANUSCRIPT

Figure 5: Proposed Diagnostic Algorithm for

Pediatric Patient with Acute
Testicular Torsion in the Acute Scrotum Scrotum

PT
RI
Calculate TWIST Score (0-7) and Tanner Stage (1-5)

U SC
AN
Low Risk Intermediate Risk High Risk
(TWIST score = 0) (TWIST score = 1-5) (TWIST score ≥ 6)

M
D
TE
No Testicular Torsion Obtain Scrotal US to evaluate Tanner 3-5 Tanner 1-2
(No US necessary) for testicular torsion
C EP

Testicular torsion, Consider Scrotal US prior to

AC

proceed to OR (No US) surgical exploration

 ACCEPTED MANUSCRIPT

List of abbreviations:

TWIST Testicular Workup for Ischemia and Suspected Torsion

ER Emergency Room

EMT Emergency Medical Technician

PT
ROC Receiver Operating Characteristics

PPV Positive Predictive Value

RI
NPV Negative Predictive Value

SC
NIRS Near Infrared Spectroscopy

OR Operating Room

U
MRI Magnetic Resonance Imaging AN
M
D
TE
C EP
AC