title: Diagnosing Testicular Torsion before Urological Consultation and Imaging: Validation of the TWIST Score.
abstract: 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.
authors.affiliation: University of Texas Southwestern Medical Center, Dallas, Texas.
authors.forename: Kunj R
authors.initials: KR
authors.lastname: Sheth
authors.affiliation: Children's Hospital of East Ontario, Ottawa, Ontario, Canada.
authors.forename: Melise
authors.initials: M
authors.lastname: Keays
authors.affiliation: Phoenix Children's Hospital, Phoenix, Arizona.
authors.forename: Gwen M
authors.initials: GM
authors.lastname: Grimsby
authors.affiliation: Mayo Clinic, Rochester, Minnesota.
authors.forename: Candace F
authors.initials: CF
authors.lastname: Granberg
authors.affiliation: University of Texas Southwestern Medical Center, Dallas, Texas; Children's Health, Dallas, Texas.
authors.forename: Vani S
authors.initials: VS
authors.lastname: Menon
authors.affiliation: Harvard Medical School, Boston, Massachusetts.
authors.forename: Daniel G
authors.initials: DG
authors.lastname: DaJusta
authors.affiliation: Children's Health, Dallas, Texas.
authors.forename: Lauren
authors.initials: L
authors.lastname: Ostrov
authors.affiliation: Children's Health, Dallas, Texas.
authors.forename: Martinez
authors.initials: M
authors.lastname: Hill
authors.affiliation: Children's Health, Dallas, Texas.
authors.forename: Emma
authors.initials: E
authors.lastname: Sanchez
authors.affiliation: Ankara Üniversitesi Tıp Fakültesi, Ankara, Turkey.
authors.forename: David
authors.initials: D
authors.lastname: Kuppermann
authors.affiliation: University of Texas Southwestern Medical Center, Dallas, Texas; Children's Health, Dallas, Texas.
authors.forename: Clanton B
authors.initials: CB
authors.lastname: Harrison
authors.affiliation: University of Texas Southwestern Medical Center, Dallas, Texas; Children's Health, Dallas, Texas.
authors.forename: Micah A
authors.initials: MA
authors.lastname: Jacobs
authors.affiliation: Children's Health, Dallas, Texas.
authors.forename: Rong
authors.initials: R
authors.lastname: Huang
authors.affiliation: Nationwide Children's Hospital, Columbus, Ohio.
authors.forename: Berk
authors.initials: B
authors.lastname: Burgu
authors.affiliation: University of Texas Southwestern Medical Center, Dallas, Texas; Children's Health, Dallas, Texas.
authors.forename: Halim
authors.initials: H
authors.lastname: Hennes
authors.affiliation: University of Texas Southwestern Medical Center, Dallas, Texas; Children's Health, Dallas, Texas.
authors.forename: Bruce J
authors.initials: BJ
authors.lastname: Schlomer
authors.affiliation: University of Texas Southwestern Medical Center, Dallas, Texas; Children's Health, Dallas, Texas. Electronic address: linda.baker@childrens.com.
authors.forename: Linda A
authors.initials: LA
authors.lastname: Baker
mesh_terms: D000293:Adolescent; D002648:Child; D002675:Child, Preschool; D006801:Humans; D008297:Male; D010808:Physical Examination / Q000379:methods; D011237:Predictive Value of Tests; D011446:Prospective Studies; D012372:ROC Curve; D012017:Referral and Consultation; D018570:Risk Assessment / Q000379:methods; D012611:Scrotum / Q000473:pathology* / Q000601:surgery; D013086:Spermatic Cord Torsion / Q000175:diagnosis* / Q000601:surgery; D013737:Testis / Q000473:pathology* / Q000601:surgery; D014463:Ultrasonography / Q000379:methods
keywords: diagnosis; scrotum; spermatic cord torsion; ultrasonography