Testicular Torsion

Pathway Background and Objectives

Testicular torsion is an organ-threatening condition that requires prompt diagnosis and treatment. Connecticut Children’s currently provides excellent care for testicular torsion, supported by stellar National Surgical Quality Improvement Program (NSQIP) metrics, but this is accomplished without a standardized clinical pathway. We have set out to standardize our approach to testicular torsion to avoid variation and maintain our current standard of care as we grow as an institution. We also aim to formalize best practices for triaging patients by utilization of ultrasound and/or TWIST clinical score using suggestions from the United Kingdom National Health Service clinical pathway for testicular torsion1.

Color doppler ultrasound has excellent diagnostic accuracy for testicular torsion.2 The TWIST score is a clinical score which has high sensitivity for high risk patients and high specificity for low risk patients, and it can help triage which patients would most benefit from further attention.4 While our outcomes in terms of time to the operating room and orchiectomy rate are favorable when compared to NSQIP data, testicular torsion pathways are known to improve both metrics.3 Specific clinical pathway objectives are to:

The objectives of this pathway are to:

  • Standardize the current-state for testicular torsion care at Connecticut Children’s

  • Prevent delays of care when ultrasound is unavailable

  • Encourage use of the TWIST score to triage testicular torsion when appropriate

Algorithm  Educational Module

  • Percentage of patients receiving an ultrasound

  • Percentage of patients with a documented TWIST score

  • Percentage of patients going to the OR for testicular torsion procedure

  • Percentage of patients going to the OR for testicular torsion procedure based on TWIST score alone and no ultrasound

  1. Alexander CE, Warren H, Light A, Agarwal R, Asif A, Chow BJ, Clement K, Chan V, Zimmermann E, Khadhouri S, Eyskens PJ, Shah TT, Nathan A, Byrnes K, Bhatt N, Mani N, Yuhong Yuan C, Sidhu PS, Takwoingi Y, Kasivisvanathan V. Ultrasound for the Diagnosis of Testicular Torsion: A Systematic Review and Meta-analysis of Diagnostic Accuracy. Eur Urol Focus. 2026 Jan;12(1):96-108. doi: 10.1016/j.euf.2025.04.026. Epub 2025 May 13. PMID: 40368720.
  2. Barbosa JA, Tiseo BC, Barayan GA, Rosman BM, Torricelli FC, Passerotti CC, Srougi M, Retik AB, Nguyen HT. Development and initial validation of a scoring system to diagnose testicular torsion in children. J Urol. 2013 May;189(5):1859-64. doi: 10.1016/j.juro.2012.10.056. Epub 2012 Oct 24. Erratum in: J Urol. 2014 Aug;192(2):619. PMID: 23103800.
  3. GIRFT Children and Young People: Testicular torsion pathway. Published online January 2026. https://gettingitrightfirsttime.co.uk/wp-content/uploads/2025/12/Paediatric-testicular-torsion-pathway-guide-FINAL-V2-January-2026.pdf
  4. Richardson S, Huen K, Benga T, Fajardo B, Sturm R, Lerman SE, Singer JS. Reducing time from presentation to surgical intervention for testicular torsion: implementation of a quality improvement protocol. Front Urol. 2024 Jul 16;4:1383108. doi: 10.3389/fruro.2024.1383108. PMID: 40777106; PMCID: PMC12327294.

The clinical pathways in the above links have been developed specifically for use at Connecticut Children’s and are made available publicly for informational and/or educational purposes only. The clinical pathways are not intended to be, nor are they, a substitute for individualized professional medical judgment, advice, diagnosis, or treatment. Although Connecticut Children’s makes all efforts to ensure the accuracy of the posted content, Connecticut Children’s makes no warranty of any kind as to the accuracy or completeness of the information or its fitness for use at any particular facility or in any individual case.