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Increasing utilization of the TWIST score in workup of patients with acute scrotal pain: Role in diagnosis and risk stratification

Published:September 27, 2022DOI:https://doi.org/10.1016/j.jpurol.2022.09.018

      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

      Summary Figure
      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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      References

        • Zhao L.C.
        • Lautz T.B.
        • Meeks J.J.
        • 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: 2009-2013https://doi.org/10.1016/j.juro.2011.07.024
        • Barbosa J.A.B.A.
        • Denes F.T.
        • Nguyen H.T.
        Testicular torsion-can we improve the management of acute scrotum?.
        J Urol. 2016; 195: 1650-1651https://doi.org/10.1016/j.juro.2016.03.066
        • Barbosa J.A.
        • Tiseo B.C.
        • Barayan G.A.
        • Rosman B.M.
        • Torricelli F.C.M.
        • Passerotti C.C.
        • et al.
        Development and initial validation of a scoring system to diagnose testicular torsion in children.
        J Urol. 2013; 189: 1859-1864https://doi.org/10.1016/j.juro.2012.10.056
        • Bayne C.E.
        • Villanueva J.
        • Davis T.D.
        • Pohl H.G.
        • Rushton H.G.
        Factors associated with delayed presentation and misdiagnosis of testicular torsion: a case-control study.
        J Pediatr. 2017; 186: 200-204https://doi.org/10.1016/j.jpeds.2017.03.037
        • 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; https://doi.org/10.1016/j.ajem.2020.11.023
        • Tanaka K.
        • Ogasawara Y.
        • Nikai K.
        • Yamada S.
        • Fujiwara K.
        • Okazaki T.
        Acute scrotum and testicular torsion in children: a retrospective study in a single institution.
        J Pediatr Urol. 2020; https://doi.org/10.1016/j.jpurol.2019.11.007
        • Huang A.
        • Delozier S.
        • Lauderdale C.J.
        • Zhao S.
        • Clayton D.B.
        • Pope J.C.
        • et al.
        Do repeat ultrasounds affect orchiectomy rate in patients with testicular torsion treated at a pediatric institution?.
        J Pediatr Urol. 2019; https://doi.org/10.1016/j.jpurol.2018.12.002
        • Schmitz D.
        • Safranek S.
        Clinical inquiries. How useful is a physical exam in diagnosing testicular torsion?.
        J Fam Pract. 2009; 58 ([pii]): 433-434
        • Sheth K.R.
        • Keays M.
        • Grimsby G.M.
        • Granberg C.F.
        • Menon V.S.
        • Dajusta D.G.
        • et al.
        Diagnosing testicular torsion before urological consultation and imaging: validation of the TWIST score.
        J Urol. 2016; 195: 1870-1876https://doi.org/10.1016/j.juro.2016.01.101
        • Cheng E.M.
        • Chui J.N.
        • Crowe M.
        • Cooke A.
        Improving testicular examinations on paediatric patients in the emergency department: a quality improvement study to improve early diagnosis of testicular torsion.
        Asian J Urol. 2021; https://doi.org/10.1016/j.ajur.2021.07.002
        • Barco-Castillo C.
        • Sánchez D.
        • Fernández N.
        Performance of the TWIST score in patients with testicular torsion that present to the emergency department.
        Urol Colomb. 2020; https://doi.org/10.1055/s-0040-1712937
        • Arevalo M.K.
        • Sheth K.R.
        • Menon V.S.
        • Ostrov L.
        • Hennes H.
        • Singla N.
        • et al.
        Straight to the operating room: an emergent surgery track for acute testicular torsion transfers.
        J Pediatr. 2018; https://doi.org/10.1016/j.jpeds.2017.09.009
        • Frohlich L.C.
        • Paydar-Darian N.
        • Cilento B.G.
        • Lee L.K.
        Prospective validation of clinical score for males presenting with an acute scrotum.
        Acad Emerg Med. 2017; https://doi.org/10.1111/acem.13295