RISK PREDICTION IN ADOLESCENT TESTICULAR TORSION - A

HAEMATOLOGICAL AID TO A CLINICAL DIAGNOSIS

2. Author ,Co-Author ,HOD and Guide details

Name type Name Designation Department Institution Name

Final year Government Stanley
1. Author Surabhi Sainath General Surgery
Postgraduate Medical College
Government Stanley
2. Guide Anandi A Professor of Surgery General Surgery
Medical College
Professor and Head of Government Stanley
3. HOD R Manivannan General Surgery
the Department Medical College
Government Stanley
4. Co-Author Vinoth Kumar Assistant Professor General Surgery
Medical College

3. Abstract and Keywords

Testicular torsion is an acute scrotal pathology which requires urgent surgical intervention. It is
a clinical diagnosis and relies on laboratory tests and imaging. However, there is no consensus about
the proper method for the exact diagnosis of torsion. As testicular torsion may initiate inflammatory
systemic processes, studies have shown Neutrophil-lympochyte ratio, Platelet-lymphocyte ratio as
novel inflammatory markers in its prediction. The Testicular Workup for Ischemia and Suspected
Torsion (TWIST) score represents an effort towards reducing the necessity of imaging exams and
hastening the diagnosis and treatment aspect of testicular torsion. A number of series have tested
the TWIST score in the pediatric population. In our study, we establish the validity of the TWIST
score in adolescent population diagnosed with testicular torsion both clinically and sonographically
with a high sensitivity, high PPV and an accuracy of 86% with the former. We also demonstrate the
significance of NLR and PLR as predictive markers with the TWIST score. It can,thus, be noted that
the TWIST score may be applied to adolescent population with testicular torsion for risk
categorization and early intervention. Furthermore, this score may be supported by basic
haematological parameters such as the NLR and PLR for confirmation of the same in order to deliver
optimal surgical care to the patient. Key words- Testicular torsion, Neutrophil-lympochyte ratio,
Platelet-lymphocyte ratio, TWIST score

4. Introduction

Testicular torsion is an acute scrotal pathology where there is a twisting of the spermatic cord
and its content and requires urgent surgical intervention. It is a clinical diagnosis and management
relies on physical examination, laboratory tests and imaging. However, physical examination is often
deceptive and with the large number of differential diagnoses for an acute scrotum. A delay in the
detection of torsion may result in compromised viability of the testis highlighting the prudence of an
early diagnosis.(1) Low cost blood investigations such as the complete haemogram contain values
such as neutrophil lymphocyte ratio (NLR), platelet lymphocyte ratio (PLR) and mean platelet
volume (MPV), which have been shown to aid in the diagnosis of infections and inflammatory
conditions.(2) Testicular torsion has also been known to incite an inflammatory reaction due to
hypoxic tissue damage there by allowing for the possibility of a rise in these markers. Multiple
studies investigating efficiencies of hematological parameters for the differential diagnosis of
testicular torsion are underway. (3,4,5) In our study we attempt to study the validity of the TWIST
score in adolescent population at a tertiary centre in South India and compare basic haematological
inflammatory markers in predicting a high risk for testicular torsion

5. Aim and Objectives

-To compare basic haematological inflammatory parameters with TWIST score in the prediction
of testicular tortion in adolescents -To assess the application of TWIST score in adolescent
population

6. Review of Literature

Testicular torsion was first described by Hunter in 1776. It occurs most commonly in the
pediatric age group, with a smaller peak in the neonatal age group.(6) This distribution results from
the different types of torsion. Testicular torsion in newborns results almost exclusively from
extravaginal testicular torsion. Neonates present with scrotal discoloration and swelling and a firm
painless mass. There is typical infarction and necrosis at birth. Pubertal boys develop intravaginal
torsion that occurs within the tunica vaginalis. The predisposing factors include a long and narrow
mesentery or a bell-clapper deformity. Testicular torsion is defined as a rotation of the longitudinal
axis of the spermatic cord, resulting in strangulation of testicular blood flow. The severity of
ischemia depends on the degree of torsion (180° to 720°). The testicular salvage rate depends on the
degree of torsion and the duration of ischemia. Almost all testes are savaged within the first 6 hours
after the onset of symptoms. Testicular recovery is more likely if the intervention begins in the first 6
hours after onset of symptoms. Viability decreases dramatically after 12 hours. With later treatment,
the salvage rates rapidly decrease.(2,3) Typically, Testicular torsion presents with a sudden onset of
severe pain followed by inguinal and/or scrotal swelling. Many patients also have gastrointestinal
symptoms with nausea and vomiting. Often, a high riding testis with a transverse orientation is
found. The absence of the cremasteric reflex in a patient with acute scrotal pain supports the
diagnosis of Testicular torsion.(7) Many clinical and experimental studies have been performed to
reduce the negative exploration rate and testicular loss (2,3,4). These studies have been based on
clinical variables and color Doppler ultrasonography findings. However, there is no consensus about
the proper method for the exact diagnosis of Testicular torsion. Most acute scrotal pathologies do
not require surgical intervention, except for scrotal trauma. Therefore, efforts are made to
distinguish Testicular torsion from other scrotal pathologies. The similarity of clinical findings
(scrotal swelling and erythema, testicular sensitivity) and radiological errors may result in
unnecessary scrotal explorations. Despite clinical and radiological advancements, challenges in the
diagnosis of Testicular torsion remain. Neutrophils play a crucial role in the inflammatory
processes.(8) Hematologic parameters, especially the NLR, have been shown to play a predictive
role in the prognosis of acute and chronic inflammatory processes. Testicular torsion is an acute
inflammatory process and testis viability is strictly related to the presenting time to the hospital.
Vascular complications in relation to thrombosis may be based on this increased activity]. MPV is
known as a basic indicator of platelet activity. Platelets with increased volume are supposed to have
more capacity to generate inflammatory agents and are more likely to aggregate . As pointed out in
the current literature, platelet activity and MPV are related to thrombosis and endovascular
processes. (9,10) Thus, they may be used to identify the inflammatory process in Testicular torsion.
NLR was introduced as a simple and practical inflammatory marker that may have a predictive role
in the diagnosis of systemic inflammatory processes. Thus, the potential significance of NLR as an
indicator of inflammation has been increasing. Testicular torsion may initiate inflammatory systemic
processes and thus the significance of NLR as a novel inflammatory marker was reported. Gunes et
al. found a significant relationship between NLR, PLR, and PLT and the diagnosis of Testicular
torsion. However, only NLR was found to be related to the duration of symptoms in patients with
Testicular torsion. Thus, in relation to the results of the linear regression analysis, only NLR seems
to be a helpful parameter in Testicular torsion prognosis. These results suggest NLR as an
accessible, inexpensive, predictive parameter for testicular viability in relation to Testicular
torsion.(2) The TWIST score (Figure 1) represents an effort towards reducing the necessity of
imaging exams and hastening the diagnosis and treatment aspect of Testicular torsion.(11) A
number of series have tested the TWIST score in the pediatric population. Baskovic et al. Showed
that for patients scoring 5 or more points, the tool reaches a PPV of 92.8%. Frohlich et al. conducted
a prospective study of 258 children presenting with acute scrotum. In their protocol the TWIST score
was applied by emergency pediatric attending physicians, residents or fellows. In this series, the
authors found a slightly lower performance and adjusted the score to 4. On the other hand, a score 2
or less remains consistent to rule out Testicular torsion(12) A number of factors should be taken into
account, including the level of expertise of the specialist,the population and also the setting and
resources available. As per the reported series, it appears that the accuracy of the score was the
highest when applied by urologists, and decreased when performed by non-expert physicians. (11)
Also of note, we hypothesize that, in adults, cases of epididymo-orchitis with longer duration of
symptoms may evolve with a hard testicle and hence lead to higher scores of TWIST. Furthermore,in
cases where USG is not readily available, the social burden of up to 10% of negative surgical
explorations does not exceed that of testicular loss due to prolonged waiting. Finally, Ridgway
et al.(13) reviewed the data from the four series that directly assessed the TWIST score. They found
consistent Sensitivity rates between 95%–100% for low-risk patients, whereas specificity reached
97–100% in the high-risk group. This further supports the TWIST score as a reliable resource for the
evaluation of patients with acute scrotum

7. Material and Methods

Place of Study: Department of General Surgery- Govt Stanley Medical College, Chennai
Duration: 2 months Study Design: Retrospective Observational Study Sample Size: n=57 Inclusion
criteria: All patients between the age group of 11-19 years diagnosed by a surgeon with testicular
torsion using USG doppler and operated on for the same. Exclusion criteria patients with any
malignancy; presence of another active infection; disease causing increased inflammatory
response hematologic diseases affecting blood count; and/or receiving chemotherapy Stastistical
Analysis: Descriptive statistical analysis for continuous and categorical data, with stastical
parametry Significance in categorical data- Fischer exact test Relationship between the variables-
Pearson's correlation Significance between bivariate samples- Independant sample t-test p value
= 0.05 Methodology: Case records from the Medical Records Department were obtained after
providing a letter with the required details. Cases from the department of General Surgery
admitted between June, 2020 and October, 2022 were selected Patient details, such as age,
presenting symptoms, history, clinical examination finding, CBC values and procedure done were
abstracted from the clinical records using a systematically prepared data form TWIST score was
applied to each case and risk categorization was done Primary analysis- Complete Blood Count
based Inflammatory marker parameters such as Neutrophil-Lymphocyte Ration, Platelet-Lymphocyte
Ratio and Mean Platelet Volume with the risk score of the patient Secondary analysis- Type of
surgery conducted, I.e. presence/absence of gangrene and correlation of the USG finding with the
risk score of the patient

8. Results (Including Observations)

The data from 57 patient records were obtained and analysed. The reported clinical features,
duration of symptoms and diagnosis of testicular gangrene are summarized in table 1. TWIST score
was applied to each case and stratification was done based on a cut off of 4 obtained from published
literature. The median age of the study population was 15 years (range 11-19)and the average
duration of complaints was 1.7 days.(Table 1) With there being a 5 hour door-to-scalpel time,
institutional and logistical error were eliminated. The TWIST score showed that 76.1% of the
patients fell in the high risk category ( Figure 2). Haematological parmaters such as the Neutrophil-
Lymphocyte Ratio, Platelet-lyphocyte ratio and Mean platelet volume were charted. (Table 2) Using
bivariate analysis an independent T test was applied and the mean NLR was 7.8(SD=4.9, p=0.001)
while the mean PLR was 21.04(SD=17.4, p= 0.0001) and mean MPV was 8.2 (SD=1.1, p=0.005).
(Table 3) On comparing the surgical outcomes with the TWIST score(Table 4), 83.% of the high risk
(n=36) and 7.1% (n=1) of low risk patients were found to have undergone orchidectomy (p=0.001)
while 92.9% (n=13) of low risk patients underwent orchidopexy with testicular salvage. In this
series, a score of 4 or less points yielded a 92.9% NPV for testicular torsion in patients who
underwent orchidectomy. As all 57 patients with a score≥4 had TT in this series, sensitivity of the
clinical diagnosis correlation with TWIST score was 97.3% while it was 73.6% with USG based
diagnosis.The PPV with clinical correlation was 83.7% while it was 90.7% with USG confirmation.
Figure 3 summarizes accuracy measures including sensitivity and predictive values for different
cutoffs for the high-risk category definition

9. Discussion

Most acute scrotal pathologies do not require surgical intervention, except for scrotal trauma.
Therefore, efforts are made to distinguish Testicular torsion from other scrotal pathologies. The
similarity of clinical findings (scrotal swelling and erythema, testicular sensitivity) and USG/
testicular doppler errors may result in unnecessary scrotal explorations. Many studies have been
reported to introduce distinctive clinical and radiological features of Testicular torsion.(2,3,4)
However, challenges in the diagnosis of Testicular torsion remain. While the TWIST score was
initially designed for the pediatric population, in our study, we found that the score remained
applicable in the adolescent population as well with high sensitivity, positive predictive value and
accuracy in the diagnosis of torsion. Whereas Ridgway et al showed 97% sensitivity of the TWIST
score in adult population with acute scrotum, our study showed that the correlation of the TWIST
score with testicular viability, based on intraoperative observation, had a high sensitivity (97%) and
a positive predictive value (83%) suggesting its applicability in the adolescent population. On
comparing the validitry of the score with radiological diagnosis, we noted a lower sensitivity (73%)
but a higher positive predictive value (90%) compared to intraoperative diagnosis of testicular
ischemia. Neutrophils play a crucial role in the inflammatory processes. Hematologic parameters,
especially the NLR, and from multiple studies, the platelets as well have been shown to play a
predictive role in the prognosis of acute and chronic inflammatory processes. Crucial to the
inflammatory process, neutrophils, lymphocytes and platelets have been shown to be indications of
chronic inflammation in the body. In the process of studying their predictive role in testicular
torsion, we noted that Neutrophil-Lymphocyte Ratio(p=0.001), Platelet-Lymphocyte Ratio(p=0.0001)
were found to be significant. Testicular torsion may initiate inflammatory systemic processes and
thus the significance of NLR, PLR & MPV as inflammatory markers were examined in this study. We,
thus conclude that a significant relationship between NLR, PLR, and MPV and the diagnosis of
Testicular torsion based on the applied TWIST score may be used as an additional marker for
testicular ischemia that are also accessible and inexpensive, in the predicting testicular viability. The
drawbacks of the paper are that the duration of symptoms and door-to-scalpel time were averaged
and equal variance was assumed as all cases selected had undergone scrotal exploration. The
present study is retrospective nature and has a relatively small sample size. Systemic inflammatory
markers such as NLR, PLR, and MPV are more valuable for the differential diagnosis of Testicular
torsion and acute inflammatory diseases such as epididymo-orchitis. Also, the lack of some acute-
phase reactants such as the C-reactive protein level and erythrocyte sedimentation rate is a
limitation of the study.
10. Summary and Conclusion

Despite these limitations, our clinical observations showed that the NLR, PLR& MPV may be
used in addition to clinical indicators to detect testicular torsion in the adolescent age group.
However, large-scale, prospective, randomized studies evaluating the role of NLR in the differential
diagnosis of testicular torsion and the viability of the testis are needed. Additionally, The TWIST
score, although initially designed for the pediatric age group, may also be applicable to adolescents
with clinical suspicion of torsion testis in order to plan further management.

11. Bibliography

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12. Tables and Charts

12.1 Table Patient Descriptives

12.2 Table Haematological Parameters

12.3 Table Correlation of Haematological Parameters with TWIST score

12.4 Table Correlation of TWIST with Testicular Ischemia

12.5 Chart TWIST Score

12.6 Chart Risk Stratification

12.7 Chart Statistical Parameters of TWIST Score