title: Development and initial validation of a scoring system to diagnose testicular torsion in children.
abstract: OBJECTIVE
  Testicular torsion is a surgical emergency requiring prompt intervention. Although clinical diagnosis is recommended, scrotal ultrasound is frequently ordered, delaying treatment. We created a scoring system to diagnose testicular torsion, decreasing the indication for ultrasound.
  
  
  METHODS
  We prospectively evaluated 338 patients with acute scrotum, of whom 51 had testicular torsion. Physical examination was performed by a urologist, and all patients underwent scrotal ultrasound. Univariate analysis and logistic regression were performed, and a scoring system for risk stratification of torsion was created. Retrospective validation was performed with 2 independent data sets.
  
  
  RESULTS
  The scoring system consisted of testicular swelling (2 points), hard testicle (2), absent cremasteric reflex (1), nausea/vomiting (1) and high riding testis (1). Cutoffs for low and high risk were 2 and 5 points, respectively. Ultrasound would be indicated only for the intermediate risk group. In the prospective data set 69% of patients had low, 19% intermediate and 11.5% high risk. Negative and positive predictive values were 100% for cutoffs of 2 and 5, respectively (specificity 81%, sensitivity 76%). Retrospective validation in 1 data set showed 66% of patients at low, 16% intermediate and 17% high risk. Negative and positive predictive values for cutoffs of 2 and 5 were 100% (specificity 97%, sensitivity 54%). The second retrospective data set included only torsion cases, none of which was misdiagnosed by the scoring system.
  
  
  CONCLUSIONS
  This scoring system can potentially diagnose or rule out testicular torsion in 80% of cases, with high positive and negative predictive values for selected cutoffs. Ultrasound orders would be decreased to 20% of acute scrotum cases. Prospective validation of this scoring system is necessary.
authors.affiliation: Department of Urology, Boston Children's Hospital, Boston, Massachusetts 02115, USA. jbrunhara@gmail.com
authors.forename: João A
authors.initials: JA
authors.lastname: Barbosa
authors.forename: Bruno Camargo
authors.initials: BC
authors.lastname: Tiseo
authors.forename: Ghassan A
authors.initials: GA
authors.lastname: Barayan
authors.forename: Brian M
authors.initials: BM
authors.lastname: Rosman
authors.forename: Fábio César Miranda
authors.initials: FC
authors.lastname: Torricelli
authors.forename: Carlo C
authors.initials: CC
authors.lastname: Passerotti
authors.forename: Miguel
authors.initials: M
authors.lastname: Srougi
authors.forename: Alan B
authors.initials: AB
authors.lastname: Retik
authors.forename: Hiep T
authors.initials: HT
authors.lastname: Nguyen
mesh_terms: D002648:Child; D006801:Humans; D008297:Male; D010808:Physical Examination; D011446:Prospective Studies; D013086:Spermatic Cord Torsion / Q000175:diagnosis*