Summary
Introduction
The TWIST score is a 5-component physical examination score used to aid in diagnosis
of testicular torsion (TT) and could lessen need for radiologic testing in certain
clinical scenarios.
Objective
TWIST use was not previously widespread at our institution. The primary objective
of this quality improvement study was to achieve 100% compliance in TWIST utilization
among urology and ED residents and to assess for score concordance between ED and
urology assessments. Secondary goals were correlation of TWIST components with need
for orchiectomy.
Methods
ED staff were educated about the TWIST score and asked to complete assessment for
patients presenting with acute scrotal pain. Simultaneously, an electronic medical
record-based dot phrase was introduced for urology trainees to complete an independent
TWIST evaluation. Spearman correlation was performed to assess association between
ED and Urology TWIST scores. Multivariable logistic regression was performed to assess
association of TWIST score components and need for orchiectomy.
Results
103 patients presented to the ED from 3/2018–11/2020 with a complaint of acute scrotal
pain; 47 were diagnosed with torsion. As compared to our retrospective cohort, the
documentation rate of complete TWIST score components on exam rose from 9% to 98%
(P < 0.001) on ED evaluation and 16%–66% on urology evaluation (P < 0.001). Rates
of repeat ultrasound for patient’s transferred between facilities was similar (58%
vs. 63%; p = 0.66) as was median time to OR (160 min vs. 145 min; p = 0.5). Using
TWIST cutoff of >5 yielded a specificity of 94.5% for diagnosis of torsion, with corresponding
strong correlation between ED and urology scores (rho = 0.71). A firm testicle was
noted on urology evaluation in 100% of orchiectomy patients (vs. 61% of salvage patients)
with persistent association after controlling for duration of symptoms (OR 28.1; P = 0.016).
Discussion
Through two-pronged quality improvement efforts, we significantly improved utilization
of the TWIST score by ED and urology staff for workup of patients with acute testicular
pain. We confirmed the high sensitivity and specificity of the TWIST score and demonstrated
inter-rater reliability between ED and urology assessments. On prospective analysis,
testicular firmness on exam was predictive of need for orchiectomy.
Conclusion
Graphical AbstractTWIST Component Physical Examination findings stratified by need for orchiectomy at
time of surgery for children presenting with testicular torsion following introduction
of TWIST score into practice. N is the number of non-missing values. Counts expressed
as N (%). Tests used: 1Fisher’s Exact or Chi-Squared test 2Wilcoxon test.
Keywords
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Article info
Publication history
Published online: September 27, 2022
Accepted:
September 20,
2022
Received in revised form:
August 25,
2022
Received:
February 14,
2022
Identification
Copyright
© 2022 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.
