Pedemy All toolsTap the findings. The TWIST score and the next step update at once. Torsion is a time-critical surgical emergency — never let scoring or imaging delay a urology call.
This tool helps clinicians assess a child or teenager with acute scrotal pain for testicular torsion using the TWIST score (Testicular Workup for Ischemia and Suspected Torsion). It asks how long ago the pain started, then which of five findings are present, and gives a risk group with the next step at once. The clinician taps findings; anything left untapped counts as absent.
TWIST gives 2 points each for testicular swelling and a hard testis, and 1 point each for an absent cremasteric reflex, nausea or vomiting, and a high-riding testis, for a total of 0 to 7. A score of 0–2 is low risk, 3–4 intermediate risk (urgent Doppler ultrasound and urology review), and 5–7 high risk (call urology for surgical exploration without waiting for imaging). Later validation studies used stricter high-risk cutoffs (6 or more, or 7), so a high score supports but does not replace urology judgment.
The page also lists the main other causes of an acute scrotum — torsion of the appendix testis, epididymitis, incarcerated hernia, IgA vasculitis, trauma and neonatal torsion — and red flags at any score. It is based on Barbosa et al. (J Urol 2013), with pediatric validation by Sheth et al. (J Urol 2016) and Frohlich et al. (Acad Emerg Med 2017).
TWIST adds 2 points for testicular swelling, 2 for a hard testis, and 1 each for an absent cremasteric reflex, nausea or vomiting, and a high-riding testis. Totals of 0–2 are low risk, 3–4 intermediate and 5–7 high risk for torsion.
No. In the original study every child scoring 5 or more had torsion, so the tool advises calling urology for exploration at once and using ultrasound only if it will not delay surgery.
Not on its own. A score of 0–2 had a 100% negative predictive value in the derivation study, but a pediatric emergency department validation found a few torsions at low scores, and young children, very early pain and intermittent torsion can score low. Image if there is any doubt and give clear return advice.
Free to use on clinic, school, blog or hospital pages. Copy this code into your page: