Enhancing diagnostic accuracy in acute scrotum in the pediatric emergency department: A combined diagnostic model integrating the TWIST score and systemic inflammatory markers

Objective: Timely and accurate differentiation of testicular torsion (TT) from epididymo-orchitis (EO) in pediatric patients presenting with acute scrotum is crucial to prevent testicular loss. The Testicular Workup for Ischemia and Suspected Torsion (TWIST) score is widely used, but lacks laboratory markers. We aimed to evaluate whether combining systemic inflammatory markers with the TWIST score improves diagnostic accuracy. Materials and Methods: We retrospectively evaluated 99 pediatric patients diagnosed with TT (n=50) or EO (n=49). Clinical findings, TWIST scores, and inflammatory markers (NLR, SII, PLR) were recorded. Receiver operating characteristic (ROC) analysis was used to assess diagnostic performance. Multivariable logistic regression was performed to build a combined diagnostic model using TWIST score and the single most predictive inflammatory marker (NLR) to avoid potential collinearity between collinear biomarkers. Results: A total of 99 pediatric patients were included in the study; TT was diagnosed in 50 (50.5%) and EO in 49 (49.5%) of them. Patients with TT had significantly higher TWIST scores, NLR, and SII values compared to those with EO. While individual ROC analyses demonstrated high discriminatory performance for both NLR (AUC: 0.871) and SII (AUC: 0.866), the model combining the TWIST score and NLR yielded a higher AUC (0.915) than the TWIST score alone (AUC: 0.795), suggesting improved diagnostic discrimination. Conclusion: Integrating NLR with the clinical TWIST score may enhance diagnostic accuracy in pediatric acute scrotum, providing a simple and robust clinical decision-support tool to guide early surgical decision-making.