Efficiency Matters When Managing Testicular Torsion

Every moment counts when managing cases of testicular torsion. A delay in surgical treatment can result in permanent loss of the testicle.

“It's a very time-sensitive situation where you have this window of up to six hours from the onset of symptoms to the time that you get that surgically managed, after which the rates of salvaging the testis drop substantially,” explains Jessica Hannick, MD, a pediatric urologist at Cleveland Clinic.

Most patients with testicular torsion present with severe scrotal pain. The condition can occur at any age, but is most common among adolescents, with an estimated incidence of 1 in 4,000 males under age 25. Testicular torsion is caused by spontaneous twisting of the spermatic cord, ultimately compromising the testis’ blood supply and causing ischemia.

Though testicular torsion is considered relatively rare, Dr. Hannick and her Cleveland Clinic urology colleagues encounter approximately five cases per month. They recently led a quality improvement (QI) initiative and published systemwide guidelines to expedite the time from presentation in the emergency department (ED) to arrival in the operating room.

Finding opportunities to improve care

When she joined the Department of Urology in 2023, Dr. Hannick was determined to gain a clear picture of the operational flow and identify opportunities to improve efficiency and standardize case management for testicular torsion. The team analyzed three years of institutional data to identify existing bottlenecks in the patient journey from initial presentation to treatment—and at each touchpoint in between.

Implementing the TWIST score in electronic medical records

Dr. Hannick worked closely with adult and pediatric emergency medicine colleagues to define the initial workup and communication practices when a patient presents to the ED. Together, the teams implemented the TWIST score, an evidence-based tool with defined parameters, into patients’ electronic medical records. This tool assesses their level of risk as either low, intermediate or high and prompts urologic involvement.

This strategy gets the urology service on board immediately, rather than after the ultrasound has been ordered and interpreted. “If the tool indicates high risk, we recommend bypassing the ultrasound as a first step and involving the pediatric urology team immediately,” she says. “Even if it’s intermediate risk, and we’d like an ultrasound, we are now aware and can initiate multiple aspects of care concurrently to speed up the process.”

Pediatric emergency medicine physician Arjun Sarin, MD, collaborated with Dr. Hannick on this initiative. He says, anecdotally, it has improved time from ED presentation to OR arrival. In some cases, patients are there in less than 45 minutes.

“This is significant,” he says. “Treating testicular torsion is incredibly time sensitive, and there are so many unpredictable factors. The time from onset of symptoms to time of ED presentation can vary from case to case, so prioritizing timeliness to definitive care is of utmost importance” he says.

Redefining the transfer process

The transfer system was another area the team identified as an opportunity for improvement. While the overall goal was to reduce transfers, which were found to add up to an hour of additional time in getting patients to the OR, they were able to increase the triage status of testicular torsion cases, thus expediting ambulance transfers when necessary. In most cases of testicular torsion, however, a parent or family member-led transfer is a safe and viable option.

“Typically, these are otherwise stable patients, and so if the parent or family is comfortable, and many often are, it’s faster to have them drive the child directly between hospitals,” says Dr. Hannick. In addition to Cleveland Clinic Main Campus, Hillcrest and Fairview Hospitals are each equipped with resources to manage these emergent cases and may be more convenient locations for patients and families. Part of this initiative has been educating providers and the community about transfer options.

Evaluating the impact

It’s been just over a year since the process improvements were implemented in July 2024. Dr. Hannick notes that there has been a slight decrease in the average time of ED presentation to OR arrival, shifting from 3.5 to 3.1 hours. They also found a 75% documentation rate of the TWIST score. She says the team is eager to continue promoting, refining and evaluating the process as needed.

Establishing a blueprint for colleagues

Importantly, through this project, Dr. Hannick authored a systemwide guideline to operationalize and streamline the care for emergency department providers and urologists managing adult and pediatric testicular torsion.

This has become a focus area for many centers nationally, she notes, adding that it’s often a topic at national meetings. While specific actions may be unique and institution-dependent, incorporating evidence-based tools, such as the TWIST score, and improving the transfer process are somewhat universal change ideas.

“Our exact approach may not work for every center, but we are hopeful that some aspects may be successful elsewhere and implemented locally depending on what works for your institution,” concludes Dr. Hannick.