A systematic review and meta-analysis to inform the management of children and young people with acute testicular pain.

Abstract

To perform a systematic review to determine the effect of the duration of pain on early and late testicular survival after testicular torsion, and on the performance of diagnostic adjuncts for torsion, including the Testicular Workup for Ischemia and Suspected Torsion (TWIST) score and ultrasonography (US) performance, to inform the development of the 'Getting it Right First Time' (GIRFT) national testicular pain pathway for children and young people (CYP). The study was registered on the International Prospective Register of Online Systematic Reviews (CRD42023412619) and four databases were searched. Study inclusion criteria: all participants aged <25 years or where data for these patients could be extracted; studies including <20% neonates and <20% of undescended testes. The decision for inclusion in the study was made independently by two reviewers and conflicts resolved by a third. A weighted random-effects model was used for meta-analysis and results are shown as the test statistic (95% CI). Included studies were used to analyse the effect of duration of pain on testicular salvage (studies = 26), on the sensitivity and specificity of the TWIST score (studies = 10), and of US (studies = 34). The TWIST score performs best in its extremes, with a sensitivity of 94.2% (95% CI 72.8-99%) and specificity 98% (95% CI 91.5-99.5%), when comparing a high-risk score of 5-7 with a low-risk score of 0-2. The diagnostic sensitivity and specificity of US for testicular torsion has likely improved with time, with papers published after 2010 showing a sensitivity of 94.8% (95% CI 88.3-97.8%) and specificity 97.3% (95% CI 89.4-99.4%) compared to all-time published studies showing a sensitivity 92.6% (95% CI 87.8-95.6%) and specificity of 97.8% (95% CI 94.7-99.1%). These findings demonstrate the up-to-date literature on the effect of duration of pain on salvage of torted testes and on the performance of TWIST scores and US when evaluating CYP with testicular pain. They have been used within the development of the GIRFT testicular pain pathway.