pem pearl: testicular torsion scoring
During conference recently the focus has been on GU topics and just a few weeks ago Dr. Norozian gave a great talk that reviewed testicular torsion. There are several clinical scoring tools out there that are validated for use in pediatric patients suspected of having testicular torsion. Here we have an article that compares 2 of them, albeit in adults (whomp). Mostly, I just like the name of the article, so we have to talk about it.
The TWIST score gives a score out of 7 for the following: hard testis (2), swelling (2), nausea/vomiting (1), absent cremasteric reflex (1) and high-riding testis (1). The Boettcher Alert Score (BAL) provides a score out of 4 for the following: duration of pain <24 h (1), high-riding testis (1), nausea and vomiting (1) and absent cremasteric reflex (1).
The researchers retrospectively identified 54 patients to be included in the study given the complete clinical data available, 13 of whom went on to have torsion confirmed by US. The study specifically excluded kids and those with incomplete data set, as well as those with a diagnosis made prior to transfer to their ED.
Bottom Line: The TWIST score performed slightly better. A TWIST score ≥3 had a 92% sensitivity, and a score of 6-7 had 80% PPV. A BAL score ≥2 also had a sensitivity of 92% with a slightly lower specificity. The negative predictive value of each of these was 97% and 95%, respectively.
Clinical relevance? We are all going to get an US of the child coming in with testicular pain or abnormal findings on exam. I think these scoring systems are going to be more beneficial for use in the child with a concerning story (high score) and "normal" US. This will give you some objective data to say to your consultant "I know there's flow but I still want you to come see this patient because my concern is that high," as this could be intermittent torsion or incomplete obstruction of flow.
The TWIST score gives a score out of 7 for the following: hard testis (2), swelling (2), nausea/vomiting (1), absent cremasteric reflex (1) and high-riding testis (1). The Boettcher Alert Score (BAL) provides a score out of 4 for the following: duration of pain <24 h (1), high-riding testis (1), nausea and vomiting (1) and absent cremasteric reflex (1).
The researchers retrospectively identified 54 patients to be included in the study given the complete clinical data available, 13 of whom went on to have torsion confirmed by US. The study specifically excluded kids and those with incomplete data set, as well as those with a diagnosis made prior to transfer to their ED.
Bottom Line: The TWIST score performed slightly better. A TWIST score ≥3 had a 92% sensitivity, and a score of 6-7 had 80% PPV. A BAL score ≥2 also had a sensitivity of 92% with a slightly lower specificity. The negative predictive value of each of these was 97% and 95%, respectively.
Clinical relevance? We are all going to get an US of the child coming in with testicular pain or abnormal findings on exam. I think these scoring systems are going to be more beneficial for use in the child with a concerning story (high score) and "normal" US. This will give you some objective data to say to your consultant "I know there's flow but I still want you to come see this patient because my concern is that high," as this could be intermittent torsion or incomplete obstruction of flow.
