Time-Critical Diagnosis of Pediatric Testicular Torsion in a Tertiary Pediatric Emergency Setting: Integrating...

Acute scrotum is a frequent pediatric emergency encompassing a heterogeneous spectrum of conditions, among which testicular torsion (TT) represents the most time-critical diagnosis.

The aim of this study was to evaluate the diagnostic performance of clinical predictors and ultrasound in children presenting with acute scrotum, and to identify factors associated with TT.

We conducted a prospective observational cohort study including consecutive children presenting with non-traumatic acute scrotum between January 2022 and December 2025 at a tertiary pediatric surgical center.

During the 4-year study period, 189 children were prospectively enrolled. The median age was 11 years. Testicular torsion was confirmed in 41 patients. Scrotal Doppler ultrasound was performed in 72 patients (38.1%) with an overall accuracy of 94%. The accuracy of the Testicular Workup for Ischemia and Suspected Torsion (TWIST) score was 82%. On multivariable analysis, three independent predictors of TT were identified: pain duration < 24 h (OR = 19.251, 95% CI 5.355-69.210, p < 0.001), TWIST score ≥ 3 (OR = 35.987, 95% CI 2.49-370.7, p < 0.001), and scrotal erythema (OR = 6.277, 95% CI 1.572-25.061, p = 0.009).

In pediatric acute scrotum, scrotal Doppler ultrasound demonstrates excellent diagnostic accuracy when performed, while structured clinical assessment remains crucial for early risk stratification and time-critical decision-making. These findings support an integrated, probability-based diagnostic approach in which clinical predictors guide the selective and timely use of ultrasound, without delaying surgical exploration.