Decision Rule - TWIST Score for Pediatric Testicular Torsion

TWIST Score for Pediatric Testicular Torsion:

-Testicular swelling . . . . . . . . . . . . . .  [Yes (+2 points)/No (0 points)]
-Hard testicle . . . . . . . . . . . . . . . . . . .  [Yes (+2 points)/No (0 points)]
-Absent cremasteric reflex  . . . . . . . .  [Yes (+1 point)/No (0 points)]
-Nausea or vomiting  . . . . . . . . . . . . .  [Yes (+1 point)/No (0 points)]
-High-riding testicle   . . . . . . . . . . . . .  [Yes (+1 point)/No (0 points)]

A score of >5 points had a positive predictive value for testicular torsion in the original derivation study, suggesting consideration of immediate urological consultation.
A score of <2 points had a negative predictive value of 100% in the original derivation study, suggesting these patients may be clinically cleared if they lack other concerning features.
Scores of 2-5 points should be considered for further evaluation with ultrasound in the appropriate clinical setting.

https://thesgem.com/2018/02/sgem205-twist-shout-testicular-torsion/

Caution should be used with this score, as it has not performed well on subsequent attempts at validation.  The only reason I consider it at all is that a high score would prompt me to consult a Pediatric Urologist earlier in the course of care, and this score MAY help convince them to see a patient emergently and prior to ultrasound.  I would not delay getting an ultrasound, and would be very cautious with a "low risk" score.

MDM - Testicular Torsion

[##]-year-old male with history and exam consistent with [right-sided/left-sided] testicular torsion.

Initial considerations in this patient included testicular torsion, epididymitis, orchitis, hematocele, hydrocele, spermatocele, hernias, scrotal abscess, sexually transmitted infections, urinary tract infection (UTI), scrotal abscess and cellulitis, and Fournier gangrene among others.  

Patient presented with report of [right-sided/left-sided testicular/scrotal] pain with report of onset of pain [## minutes/hours] prior to presentation concerning for torsion.  Patient [reported/denied] preceding trauma [describe].  Urology was consulted early in the course of care due to strong suspicion for testicular torsion [based on TWIST score greater than 5/with recommendation for emergent testicular ultrasound/evaluation in the ED].  A testicular ultrasound was obtained with evidence of torsion of the [right/left] testicle [as noted above].  A urinalysis was obtained and [noted to be unremarkable/notable for evidence of abnormal findings].

[Manual detorsion was considered/performed in this patient as a temporizing measure due to urologist not being immediately available.  The patient was given parenteral analgesic and the affected right/left testicle was twisted outward and laterally ("open the book") 180° with noted improvement in pain (if pain improves consider 2-3 rotations/if pain worsens consider twisting in opposite direction).]

Patient evaluated in the ED by Dr. [Name] of [Pediatric] Urology with plan for [admission to the OR for operative management/admission for serial examinations and likely operative management].  Patient reported [some/minimal/significant] improvement in pain after treatment with [analgesic] in the ED.  We discussed planned admission and treatment plan with the [patient/patient’s mother/father/parents], and they demonstrated understanding and agreement with this plan.

https://thesgem.com/2018/02/sgem205-twist-shout-testicular-torsion/