TWIST score

Last revised by Tom Foster on 20 Feb 2024

The Testicular Workup for Ischemia and Suspected Torsion (TWIST) score is a clinical decision tool used for the workup and management of acute scrotal emergencies where testicular torsion is suspected. It uses history and examination to estimate the likelihood of torsion. Currently, validation of the clinical score has only been conducted in the pediatric population. The TWIST score aims to reduce the number of unnecessary ultrasounds in cases of suspected torsion.


  • testicular swelling (two points)

  • hard testis (two points)

  • absent cremasteric reflex (one point)

  • nausea or vomiting (one point)

  • high riding testis (one point)


  • score 0-2: low risk

  • score 3-4: intermediate risk

    • ultrasound warranted

  • score 5 or above: high risk

    • 100% positive predictive value for torsion

    • ultrasound not required, urgent urological consultation and surgery required to salvage testis

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