Validation and comparison of clinical predictive scores for testicular torsion in children with acute scrotum
DOI:
https://doi.org/10.18203/2349-2902.isj20253447Keywords:
Testicular torsion, Acute scrotum, Scoring systems, Diagnosis, ChildrenAbstract
Background: Testicular torsion scoring systems, based on a combination of clinical and imaging factors, have been developed to improve the diagnostic accuracy of testicular torsion in patients presenting with acute scrotum. This study aimed to validate and compare two current testicular torsion scores the Boettcher Alert Score (BAL) and the Testicular Workup for Ischemia and Suspected Torsion (TWIST)-in a retrospective cohort of pediatric patients with acute scrotum.
Methods: We conducted a retrospective study of all pediatric patients admitted to our institution for acute scrotum between January 2010 and December 2022. Patients were categorized into the testicular torsion (TT) group and the non-testicular torsion (NTT) group. Collected data were used to calculate the scoring systems and perform statistical analyses.
Results: A total of 241 patients were included, of whom 80 (33.2%) had testicular torsion. The mean age in the TT group was 13 years. The optimal individual cut-off value for the BAL score was >1 (sensitivity 90%, specificity 80.75%), and for the TWIST score >4 (sensitivity 82.5%, specificity 80.75%). A high-risk TWIST score >5 had a specificity of 80.75% and a negative predictive value (NPV) of 90.28%, while a BAL score of 4 showed a specificity of 98.48% and NPV of 94.2%. The area under the ROC curve was slightly higher for the BAL score (0.917; 95% CI, 0.875–0.949) than for the TWIST score (0.897; 95% CI, 0.851–0.932). The difference between the two scores was not statistically significant.
Conclusion: The TWIST and BAL clinical scores have significant diagnostic value and may assist in the evaluation of testicular torsion in children. Both scores could be incorporated into a standardized approach for assessing pediatric acute scrotum, potentially reducing time to definitive diagnosis, and minimizing ischemia duration.
Metrics
References
Kapoor S. Testicular torsion: a race against time. Int J Clin Pract. 2008;62:821–7. DOI: https://doi.org/10.1111/j.1742-1241.2008.01727.x
Lewis AG, Bukowski TP, Jarvis PD, Wacksman J, Sheldon CA. Evaluation of acute scrotum in the emergency department. J Pediatr Surg. 1995;30:277–81. DOI: https://doi.org/10.1016/0022-3468(95)90574-X
Zhao LC, Lautz TB, Meeks JJ, Maizels M. Pediatric testicular torsion epidemiology using a national database: incidence, risk of orchiectomy and possible measures toward improving the quality of care. J Urol. 2011;186:2009–13. DOI: https://doi.org/10.1016/j.juro.2011.07.024
Frohlich LC, Paydar-Darian N, Cilento BG Jr, Lee LK. Prospective validation of clinical score for males presenting with an acute scrotum. Acad Emerg Med. 2017;24:1474–82. DOI: https://doi.org/10.1111/acem.13295
Zvizdic Z, Aganovic A, Milisic E, Jonuzi A, Zvizdic D, Vranic S. Duration of symptoms is the only predictor of testicular salvage following testicular torsion in children: A case-control study. Am J Emerg Med. 2021;41:197-200. DOI: https://doi.org/10.1016/j.ajem.2020.11.023
Boettcher M, Krebs T, Bergholz R, Wenke K, Aronson D, Reinshagen K. Clinical and sonographic features predict testicular torsion in children: a prospective study. BJU Int. 2013;112:1201–6. DOI: https://doi.org/10.1111/bju.12229
Liang T, Metcalfe P, Sevcik W, Noga M. Retrospective review of diagnosis and treatment in children presenting to the pediatric department with acute scrotum. Am J Roentgenol. 2013;200:444–9. DOI: https://doi.org/10.2214/AJR.12.10036
Davenport M. ABC of general surgery in children. Acute problems of the scrotum. BMJ. 1996;312:435–7. DOI: https://doi.org/10.1136/bmj.312.7028.435
Barbosa JA, Tiseo BC, Barayan GA, Rosman BM, Torricelli FC, Passerotti CC, et al. Development and initial validation of a scoring system to diagnose testicular torsion in children. J Urol. 2013;189:1859–64. DOI: https://doi.org/10.1016/j.juro.2012.10.056
Srinivasan A, Cinman N, Feber KM, Gitlin J, Palmer LS. History and physical examination findings predictive of testicular torsion: an attempt to promote clinical diagnosis by house staff. J Pediatr Urol. 2011;7:470– 4. DOI: https://doi.org/10.1016/j.jpurol.2010.12.010
Nelson CP, Williams JF, Bloom DA. The cremasteric reflex: a useful but imperfect sign in testicular torsion. J Pediatr Surg. 2003;38:1248–9. DOI: https://doi.org/10.1016/S0022-3468(03)00280-X
Yazbeck S, Patriquin HB. Accuracy of doppler sonography in the evaluation of acute conditions of the scrotum in children. J Pediatr Surg. 1994;29:1270-72. DOI: https://doi.org/10.1016/0022-3468(94)90822-2
Sheth KR, Keays M, Grimsby GM, Granberg CF, Menon VS, DaJusta DG, et al. Diagnosing testicular torsion before urological consultation and imaging: validation of the TWIST score. J Urol. 2016;195:1870–6. DOI: https://doi.org/10.1016/j.juro.2016.01.101
Qin KR, Qu LG. Diagnosing with a TWIST: Systematic Review and Meta-Analysis of a Testicular Torsion Risk Score. J Urol. 2022;208(1):62-70. DOI: https://doi.org/10.1097/JU.0000000000002496
Pinar U, Duquesne I, Lannes F, Bardet F, Kaulanjan K, Michiels C, et al. The use of Doppler ultrasound for suspected testicular torsion: Lessons learned from a 15-year multicentre retrospective study of 2922 patients. Eur Urol Focus. 2022;8(1):105–11. DOI: https://doi.org/10.1016/j.euf.2021.02.011
Wright HG, Wright HJ. Ultrasound use in suspected testicular torsion: an association with delay to theatre and increased intraoperative finding of non-viable testicle. N Z Med J. 2021;134(1542):50–5.
Chan EP, Wang PZT, Myslik F, Chen H, Dave S. Identifying systems delays in assessment, diagnosis, and operative management for testicular torsion in a single-payer health-care system. J Pediatr Urol. 2019;15(3):251-7. DOI: https://doi.org/10.1016/j.jpurol.2019.03.017
Shah MI, Chantal Caviness A, Mendez DR. Prospective pilot derivation of a decision tool for children at low risk for testicular torsion. Acad Emerg Med. 2013;20:271–8. DOI: https://doi.org/10.1111/acem.12086
Choi JB, Han KH, Lee Y, Ha US, Cho KJ, Kim JC, et al. The incidence of testicular torsion and testicular salvage rate in Korea over 10 years: A nationwide population-based study. Investig Clin Urol. 2022;63(4):448-54. DOI: https://doi.org/10.4111/icu.20220122
Huang WY, Chen YF, Chang HC, Yang TK, Hsieh JT, Huang KH. The incidence rate and characteristics in patients with testicular torsion: a nationwide, population-based study. Acta Paediatr. 2013;102(8):363-7. DOI: https://doi.org/10.1111/apa.12275
Nöske HD, Kraus SW, Altinkilic BM, Weidner W. Historical milestones regarding torsion of the scrotal organs. J Urol. 1998;159(1):13-6. DOI: https://doi.org/10.1016/S0022-5347(01)63997-1
Ashcraft KW, Murphy JP, Ostlie DJ. Ashcraft’s Pediatric Surgery. 6thed. New York: Saunders/Elsevier. 2014: 821-6.
Seng YJ, Moissinac K. Trauma induced testicular torsion: a reminder for the unwary. J Accid Emerg Med. 2000;17:381–2. DOI: https://doi.org/10.1136/emj.17.5.381
Lrhorfi H, Manunta A, Rodriguez A, Lobel B. Trauma induced testicular torsion. J Urol. 2002;168:2548. DOI: https://doi.org/10.1097/00005392-200212000-00056
Pan P. Validation of the TWIST score in the diagnosis of testicular torsion in children with acute scrotum. Indian Pediatr. 2020;57(10):926-8. DOI: https://doi.org/10.1007/s13312-020-1992-6
Manohar CS, Gupta A, Keshavamurthy R, Shivalingaiah M, Sharanbasappa BR, Singh VK. Evaluation of Testicular Workup for Ischemia and Suspected Torsion score in patients presenting with acute scrotum. Urol Ann. 2018;10(1):20-3. DOI: https://doi.org/10.4103/UA.UA_35_17
Klinke M, Elrod J, Stiel C, Ghadban T, Wenskus J, Herrmann J, et al. The BAL-score almost perfectly predicts testicular torsion in children: A two-center cohort study. Front Pediatr. 2020;8:601892. DOI: https://doi.org/10.3389/fped.2020.601892
Downloads
Published
How to Cite
Issue
Section
