Written by Megan Hilbert
Spoon Feed
The TWIST Score can be used for risk stratification of an acute scrotum, but POCUS (point-of-care ultrasound) should be used to rule out testicular torsion in pediatric patients, particularly in intermediate risk patients.
Twist and shout (well… not if you’ve de-torsed the testicle)
The testicular workup for ischemia and suspected torsion (TWIST score) has previously been used by urologists to risk-stratify whether a patient has testicular torsion or not. This score has not traditionally been used or studied by Emergency Physicians (EPs). The primary aim of this retrospective observational study was to see the diagnostic accuracy of TWIST score and POCUS when performed by EPs. All patients underwent POCUS no matter their TWIST score with the goal of identifying “reduction and/or absence of intratesticular blood flow and the presence of the whirlpool sign”. The accuracy of the TWIST score as calculated by EPs was comparable to urologists with sensitivity 91% (95%CI 80% to 97%), specificity 95% (95%CI 93% to 97%), positive predictive value 63% (95%CI 50% to 75%), and negative predictive value 99% (95%CI 97% to 100%). The sensitivity is low for a rule-out test, but is appropriate for use in risk stratification.
How will this change my practice?
Acute scrotum is not an etiology that I am willing to miss in my workup, particularly since the rate of testicle salvage decreases precipitously after 6 hours. I may decide to discuss the TWIST score with parents who present with children in testicular pain, but I suspect I will continue to pursue testicular ultrasound to ensure that we are not concerned for active torsion as presenting etiology.
Source
Evaluating the TWIST score and point-of-care ultrasound for paediatric testicular torsion. Emerg Med J. 2026 Feb 23:emermed-2025-215067. doi: 10.1136/emermed-2025-215067. Epub ahead of print. PMID: 41730670.
