Jabbar et al.

, Prensa Med Argent 2018, 105:3

DOI: 10.41720032-745X.1000346 La Prensa Medica
Argentina

Research Article A SCITECHNOL JOURNAL

Evaluation of TWIST Score in permanent ischemic damage to the testis [1]. The extent of testicular
ischemia depends on the degree of torsion. The testicular salvage rate
Predicting Testicular Torsion in hinges on the degree of torsion and the duration of ischemia. Almost
all testes are salvaged within the first 6 hours after the onset of
Children symptoms, with later treatment; the salvage rates rapidly decrease [2].
Maha Abdul-Jabbar Lattuf AL-Rudaini1, Omar AbdulQader Ajaj2 Testicular torsion is a surgical emergency that requires prompt
and Hayder Adnan Fawzi3* intervention. Although clinical diagnosis is recommended, scrotal
1Consultant Pediatric Surgeon, Pediatric surgery unit, Children Welfare Hospital, Doppler ultrasound is frequently ordered which shows decreased
Baghdad, Iraq blood flow and may detect coiling of the spermatic cord, indicating
2Pediatric surgery unit, College of Medicine, Al-Anbar University, Anbar, Iraq torsion, even with normal blood flow within the testis [3], ultrasound
3Clinical Pharmacy unite, Baghdad Medical Hospital, Baghdad, Iraq should only be used when the diagnosis is equivocal because imaging
*Corresponding studies will only delay scrotal exploration [1], therefore; Barbosa et al.
author: Hayder Adnan Fawzi, Clinical Pharmacy unite, Baghdad
Medical Hospital, Baghdad, Iraq, Tel: 009647722627943; E-mail: [4] devised and validated the TWIST (Testicular Workup for Ischemia
[email protected] and Suspected Torsion) score, which assigns a summed score (range 0
Received Date: June 21, 2018 Accepted Date: July 23, 2018 Published Date: to 7 points) to diagnose the testicular torsion in children as shown in
July 30, 2018 Table 1.

Finding Points

Abstract Testicular swelling 2

Hard testicle 2
Background: Torsion of the testis is a surgical emergency
because the likelihood of testicular salvage decreases as the Absent cremasteric reflex 1
duration of the torsion increases. TWIST (Testicular Workup for
Ischemia and Suspected Torsion) score had been validated for Nausea or vomiting 1
diagnosis of testicular torsion in children with acute scrotum.
High riding testicle 1

Objective: establish the validity and applicability of using

TWIST score in the diagnosis of testicular torsion in children. Table 1: TWIST (Testicular Workup for Ischemia and Suspected
Torsion) score [4].
Methods: The study includes 53 patients presented with acute A score of (1-2) corresponds to a low risk of testicular torsion with
scrotum, TWIST score obtained for all patients and classifies
no recommendation for Doppler Ultrasound. A score of (3-4)
the patients into 3 groups of testicular torsion: Low risk (1-2),
Intermediate risk: (3-4) and high risk (5-7). determines the intermediate risk of testicular torsion, for which
Doppler Ultrasound would be indicated. A score of (5-7) indicates a
Results: TWIST Score analysis shows that the low-risk score high risk of testicular torsion with the recommendation of surgical
patients are (8, 15.1%), the intermediate risk score patients are exploration [4]. We aimed to establish the validity and applicability of
(21, 39.6%) and high-risk score patients are (24, 45.3%). using TWIST score in the diagnosis of testicular torsion in children.
Torsion group have significantly high-risk score compared to
the non-torsion group. There was a high level of agreement
Patients and Methods
between initial and final diagnosis, but there are 6 patients with
false positives among the high-risk patients with no false
negative patients among the low and intermediate risk patients. Study design
The parameters that show high accuracy in testicular torsion
diagnosis are: Hard testis (100.0% vs 11.4%), absent A prospective cohort study was conducted in the pediatric surgery
cremasteric reflux (83.3% vs 28.6%), nausea/vomiting (77.8% department of Children Welfare Teaching Hospital/Medical City;
vs 45.7%) and high riding testis (61.1% vs 20.0% ). Baghdad-Iraq from June 2015 till October 2016. The study includes 53
patients aged from (1 month-13 years) referred from the pediatric
Conclusions: TWIST score is a useful tool in the diagnosis of emergency unit or outpatient clinic with acute scrotum. Patients with
testicular torsion especially in the peripheral hospitals with the previous history of scrotal pathology were excluded from the study. All
unavailability of Doppler ultrasound at night. The TWIST score the obtained data were analyzed using (TWIST) score, a summed score
at point 6 provides enough indicator of high suspicion of (range 0 to 7 points) to diagnose the testicular torsion in children
testicular torsion and need of emergency surgical intervention.
which classifies the patients into 3 groups: Low risk of testicular
torsion: Patients with scoring (1-2), Intermediate risk of testicular
Keywords: Testicular torsion; TWIST scores; Risk assessment
torsion: Patients with scoring (3-4) and high risk of testicular torsion:
Patients with scoring (5-7). All patients of high risk of testicular
torsion were admitted to the surgical ward and underwent surgical
Introduction interventions, while patients of the low and intermediate risk of
testicular torsion were admitted to the surgical ward for conservative
The term acute scrotum refers to acute scrotal pain with or without treatment and followed up (clinical and scrotal Ultrasound) except one
swelling and erythema. This presentation should always be treated as patient of intermediate group underwent surgical intervention.
an emergency because of the possibility of testicular torsion and

All articles published in La Prensa Medica Argentina are the property of SciTechnol and is protected by copyright laws.
Copyright © 2018, SciTechnol, All Rights Reserved.
Citation: Jabbar MA, AL-Rudaini L, Ajaj ABK, Fawzi HA (2018) Evaluation of TWIST Score in Predicting Testicular Torsion in Children. Prensa Med Argent
105:3.

doi: 10.41720032-745X.1000346

Doppler Ultrasound was done for all patients of the intermediate and Results
low risk of testicular torsion. During operation, the data of each
patient was recorded, and the removed testicle was sent for Patient’s distributions according to TWIST score are classified into 3
histopathology. groups:
Group I: A scoring (1-2) includes 8 patients with low risk of
Statistical analysis testicular torsion who were admitted to the hospital for conservative
treatment and followed up accordingly.
Anderson darling test was done to assess if continuous variables
follow a normal distribution. Chi-square test was used to analyze the Group II: A scoring (3-4) includes 21 patients with intermediate risk
discrete variable. To test the agreement level between initial and final of testicular torsion who were admitted to the hospital for conservative
diagnosis kappa test was used (more than 0.8 indicate strong treatment and followed up accordingly, except one patient who
agreement). Receiver operator curve was used to see the validity of underwent surgical exploration for drainage of the scrotal abscess.
different parameters in separating patients with torsion from non-
Group III: A scoring (5-7) includes 24 patients with high risk of
torsion and area under the curve (AUC), and its p-value prescribes this
testicular torsion who were admitted to the hospital and treated by
validity (if AUC ≥ 0.9 means excellent test, 0.8-0.89 means good test,
surgical exploration accordingly.
0.7-0.79 fair test otherwise unacceptable). Trapezoidal method was
used to calculate the curve. In a ROC curve, the true positive rate There is a high level of agreement between initial and final
(Sensitivity) is plotted in function of the false positive rate (100- diagnosis. In those with with initial diagnosis of testicular torsion,
Specificity) for different cut-off points. Reliability tests (Sensitivity, there is some degree of false positive in which 24 patients initially
Specificity, positive predictive value (PPV), negative predictive value diagnosed as testicular torsion, but only 18 patients of them had
(NPV) and accuracy) were calculated. SPSS 20.0.0 (Chicago, IL), testicular torsion, 3 patients had obstructed inguinal hernia, and
MedCalc Statistical Software version 14.8.1 (MedCalc Software bvba, another 3 patients had hydrocele as illustrated in Table 2.
Ostend, Belgium; 2014) we used for performing the statistical analysis,
p-value considered when appropriate to be significant if less than 0.05

Professional Diagnosis Definitive diagnosis

Testicular Obstructed inguinal Epididymitis Idiopathic scrotal Testicular Hydrocele

hernia edema abscess
Torsion

Testicular Torsion (24) 18 3 0 0 0 3

Epididymitis (24) 0 0 24 0 0 0

Idiopathic scrotal edema 0 0 0 3 0 0

(3)

Testicular abscess (1) 0 0 0 0 1 0

Hydrocele (1) 0 0 0 0 0 1

Kappa = 0.853, p value <0.001.

Table 2: Agreement between professional and definitive diagnosis.

The torsion group has significantly high-risk score compared to the TWIST score at the cut point 6 had an excellent rule (since
non-torsion group as illustrated in Figure 1. AUC>0.9) for predicting testicular torsion (100% specificity, 94.44%
sensitivity, PPV 100% and NPV 97.2%), as illustrated in Table 3 and
Figure 2.

Figure 1: boxplot of TWIST score for each group (p-value <0.001).

Volume 105 • Issue 3 • 1000346 • Page 2 of 4 •

Citation: Jabbar MA, AL-Rudaini L, Ajaj ABK, Fawzi HA (2018) Evaluation of TWIST Score in Predicting Testicular Torsion in Children. Prensa Med Argent
105:3.

doi: 10.41720032-745X.1000346

AUC 95%CI Cut off Sensitivity Specificity Accuracy PPV NPV

0.996 0.925-1.0 >5 94.44% 100% 98.1% 100% 97.2%

AUC: area under the curve, CI: confidence interval, PPV: positive predictive value, NPV: negative predictive value

Table 3: ROC test for predicting the TWIST score point in predicting testicular torsion.

found that nausea/vomiting in testicular torsion group versus non-

torsion group of about (33.3% vs 2%), (29% vs 2-8%) and (69% vs
26%) respectively.
In this series the high riding testis, absent cremasteric reflux and
hard testis are significantly associated with testicular torsion group of
(61.1% vs 20.0% , 83.3% vs 28.6% and 100.0% vs 11.4%) respectively.
These results resemble Michael Boettcher et al. [8] and Teresa Liang et
al. [10] who found that high riding testis was significantly associated
with torsion group (41.7% vs 3.3%) and (86% vs 27%) respectively, and
absent cremasteric reflux also was significantly associated with torsion
group of (50.0% vs 2.2%) and ( 91% vs 19%) respectively.
In this study, there is overall good level of agreement between the
initial and final diagnosis (Kappa=0.853, p-value <0.001). In testicular
Figure 2: ROC curve for TWIST score showing the optimal cut torsion group, 18 out of 24 boys were initially diagnosed as testicular
point and each point of the score criteria. torsion proved to have testicular torsion in final diagnosis, while there
are 6 false-positive results (3 boys have obstructed inguinal hernia, and
3 boys have hydrocele). This result in agreement with Mehran
Surgical explorations were done for 25 patients. Testicular torsion Peyvasteh et al. [11] who found good agreement between the initial
was proved in (18/53, 33.96%) patients with acute scrotum after and final diagnosis of testicular torsion but 3 patients of the false
surgical exploration, (9,36%) patients were rescued and underwent negative result (Initial diagnosis: 69 boys, final diagnosis: 72 boys).
bilateral orchiopexy, while another (9,36%) patients underwent
orchiectomy (histopathological result shows necrotic infarction of all In this study, the testicular torsion group has significantly higher
excised testis) with contralateral orchiopexy. The other 7 patients (3 risk score compared to the non-torsion group. In testicular torsion
patients underwent herniotomy, 3 patients underwent hydrocelectomy, group, the median is 6 while in the non-torsion group the median is 3
and the last patient drainage of a testicular abscess was done). which goes with Baker et al. [12] who found that the median was 6 in
Timeframe to presentation of torsion group, (58.7 ± 55.1) hours the torsion group and 1 in the non-torsion group.
mean time for patients underwent orchiopexy while (74.7 ± 58.1) In this study; none of the patients with low and intermediate risk
hours the mean time for patients underwent orchiectomy. The median score had testicular torsion. There are 18 out of 24 patients with higher
follow up of patients after discharge 14 days (range 7-90 days), Two risk score have testicular torsion. This result contradicts to Barbosa et
patients with salvaged testis have testicular atrophy after one month. al. [4] who found that no one of 234 lower risk score patients have
testicular torsion, but 12 out of 65 patients of intermediate risk score
Discussion have testicular torsion and all the 39 patients with high-risk score have
testicular torsion, this can be explained by the number and age of
Management of acute scrotum in pediatric age group mainly
patients in the current series comparing to number (338 boys) and age
depended on history and scrotal examination. The immediate surgical
of patients (3 months to 18 years) in Barbosa series [4].
intervention was indicated when testicular torsion was suspected, but
this type of management policy lead to high rate of false positive In this study, according to ROC analysis result TWIST score is
diagnosis of testicular torsion in about 2/3 of patients [5]. sensitive and highly specific for the diagnosis of testicular torsion and
good for confirmation and exclusion of testicular torsion with very
In this study, the median age was lower in torsion group which was
good predicting value for testicular torsion diagnosis at TWIST score
1.3 year compared to 5 years for the non-torsion group; this result
point of 6 (specificity 100%, sensitivity 94%, PPV 100% and
contradicts Feilim Murphy et al. [6] in their studies of 121 children
NPV=97.2%). TWIST score point 5 (PPV=98.4%, NPV=100.0%,
who found that the median age of torsion group was 12 years and 10
sensitivity 100% and specificity 85.7%) this means that the TWIST
years for the non-torsion group. This might be because the last series
score at point 5 had excellent for exclusion but increase likelihood of
includes patients with acute scrotum up to 15 years old while the
missing positive patients with testicular torsion, so the TWIST score at
former series with patients' age is up to 13 years old. Knowing that
point 6 provides enough indicator of high suspicion of testicular
there is a second peak incidence of testicular torsion in adolescent boys
torsion and need of emergency surgical interventions. This result is
aged (13-16) years [7].
consistent with Baker et al [12] who found that the optimal cut point
In this series, nausea/vomiting are significantly associated with was 6 (AUC=0.90, PPV 93,5% and sensitivity 65.9%), while Barbosa et
testicular torsion group (77.8% vs 45.7%). This result resembles to al [4] found that the optimal cut point was 5 (AUC=0.98, sensitivity
Michael Boettcher et al [8], Gregory J et al [9] and Ciftci et al [5] they 76%, specificity 100%, PPV 100% and NPV 96%) this might be because

Volume 105 • Issue 3 • 1000346 • Page 3 of 4 •

Citation: Jabbar MA, AL-Rudaini L, Ajaj ABK, Fawzi HA (2018) Evaluation of TWIST Score in Predicting Testicular Torsion in Children. Prensa Med Argent
105:3.

doi: 10.41720032-745X.1000346

the slight difference in inclusion criteria (patients age up to 18 years) 2. Fritsche GR, Gruetzkau A, Noske A (2010) Therapeutic potential
and exclusion criteria (age below 3 months and symptoms more than 7 of CAMPATH-1H in skeletal tumours. Histopathology 57:
days) with difference in sample size and patients characteristics. 851-861.
In this series testicular torsion was proved in (18, 33.96%) patients 3. Karmazyn B, Steinberg R, Kornreich L (2005) Clinical and
with acute scrotum after surgical exploration, (9, 36%) patients were Sonographic criteria of acute scrotum in children: A
rescued and underwent bilateral orchiopexy, while another (9, 36%) Retrospective study of 172 boys. Pediatr Radiol 35: 302-310.
patients underwent orchiectomy with contralateral orchiopexy. This 4. Barbosa JA, Tiseo BC, Barayan GA (2013) Development and
result is not consistent with Wael Mohammed et al. [13] in their initial validation of a scoring system to diagnose testicular
studies of 76 children who found that torsion group was (26, 34.2%) torsion in children. J Urol 189: 1859-1864.
patients, 10 patients of them underwent orchiopexy while 16 patients 5. Ciftci AO, Senocak ME, Tanyel FC (2004) Clinical predictors for
underwent orchiectomy. This might be because of the late presentation differential diagnosis of acute scrotum. Eur J Pediatr Surg 14:
(mean duration=63.3 hours) in the last series while in the former series 333-338.
(median duration=48 hours) in torsion group. 6. Murphy FL, Fletcher L, Pease P (2006) Early scrotal exploration
in all cases is the investigation and intervention of choice in the
In this series the timeframe to presentation of torsion group,
acute paediatric scrotum. Pediatr Surg Int 22: 413-416.
(58.7±55.1 hours) the mean time for patients underwent orchiopexy
while (74.7±58.1) hours the mean time for patients underwent 7. Hutson JM (2012) Undescended testis, torsion and varicocele, In:
orchiectomy. This result is not consistent with Wael Mohammed et al. Pediatric surgery, Coran AG, Adzick NS, Krummel TM (7th
[13] in their studies who found that (13.9 +- 6.1 hours) the mean time edtn), Elsevier Saunder, Philadelphia, USA.
for patients underwent orchiopexy while (94.1 +- 43.9) hours the mean 8. Boettcher M, Krebs T, Bergholz R (2013) Clinical and
time for patients underwent orchiectomy. This might be because of the Sonographic features predict testicular torsion in children: A
late presentation in the last series. prospective study. BJU Int 112: 1201-1206.
9. Nason GJ, Tareen F, McLoughlin D (2013) Scrotal exploration for
In this series the median follow up of patients after discharge 14
acute scrotal pain: A 10-year experience in two tertiary referral
days (range 7-90days), two patients with salvaged testis have testicular
paediatric units. Scand J Urol 47: 418-422.
atrophy after one month. This result is consistent with Feilim Murphy
et al. [6] in their studies who found that one patient with a salvaged 10. Liang T, Metcalfe P, Sevcik W (2013) Retrospective review of
testis had testicular atrophy after one month. Our study has some diagnosis and treatment in children presenting to the pediatric
limitations. Evaluation of TWIST score is limited by the low sample department with acute scrotum. Am J Roentgenol 200:
number of patients and Patients were poor compliance to complete W444-449.
follow up after discharge. 11. Peyvasteh M, Askarpour S, Javaherizadeh H (2011) Etiology of
acute scrotal pain in children and adolescent patients admitted in
Ahvaz Educational Hospitals. Ann Pediatr Surg 7: 148-151.
Conclusions
12. Sheth KR, Keays M, Grimsby GM (2016) Diagnosing Testicular
TWIST score is a useful tool in the diagnosis of testicular torsion Torsion before Urological Consultation and Imaging: Validation
especially in the peripheral hospitals with the unavailability of Doppler of the TWIST Score. J Urol 195: 1870-1876.
ultrasound at night. The TWIST score at point 6 provides enough 13. Saad WMTM, Mohamadain AA, Hamza AA (2015) Acute
indicator of high suspicion of testicular torsion and need of emergency Scrotum in Paediatric: Clinical Profile and Management. Sch J
surgical intervention. App Med Sci 3: 558-561.

References
1. Holcomb GW, Murphy JD, Ostlie DJ (2014) Ashcraft's Pediatric
Surgery E-Book. Elsevier Health Sciences, Philadelphia. USA.

Volume 105 • Issue 3 • 1000346 • Page 4 of 4 •