The BAL-Score Almost Perfectly Predicts Testicular Torsion in Children: A Two-Center Cohort Study

Abstract

Introduction: Testicular torsion (TT) is a common emergency that warrants immediate exploration to prevent infertility or testicular loss. To improve diagnostic reliability, various scoring systems have been published. The aim of this study was to evaluate and validate different testicular torsion scores in a large cohort of children with acute scrotum.Methods: Retrospective analysis of all male children that were admitted for acute scrotum at the Pediatric Surgery Department of the Altonaer Kinderkrankenhaus and University medical Center Hamburg-Eppendorf from 01/2013 to 03/2019. Two testicular torsion scores (Boettcher Alert Score, Testicular Workup for Ischemia and Suspected Torsion Score) were applied to all data sets. Furthermore, an artificial intelligence (AI)-based score was developed and compared to the two current scores.Results: In total, 460 boys were included in the study. Of those, 48 (10.4%) had TT. Children with TT suffered most often from short duration of pain, nausea and vomiting, high riding testicle and absent cremasteric reflex. The BALS and the AI-based score had excellent predictive values and all patients with TT would have been detected.Conclusion: The BAL and the AI score show excellent predictive capabilities and may be used to identify all cases of TT in a pediatric population. The scores are easy to apply. As the BALS was slightly better, we advocate to use this score but to validate our findings in prospective multicenter studies.

Should haematological inflammatory markers be included as an adjuvant in the differential diagnosis of acute scrotal pathologies?

“…In addition, NLR, PLR, MER and RDW were found to be statistically significantly higher in all scrotal pathologies compared to the control group. In current studies, CBC‐obtained inflammatory markers were found to be statistically higher in ASPs than the control group but scrotal pathologies and particularly TT and EO could not be distinguished according to these markers (Arikan et al, 2021; Klinke et al, 2020; Ozbir et al, 2020; Patel et al, 2013; Rachidi et al, 2014). In the aforementioned studies, we think that this may be primarily associated with the systemic inflammatory response and inflammatory markers like PLR and RDW that increase in vascular pathologies in studies using varicocele patients as the control group is greater compared to our healthy control group and the smaller number of cases.…”

“…Complete blood count (CBC) and biochemical parameters obtained from the peripheral blood had to be within the 1‐week period before the diagnosis and had to be obtained during the preoperative period from surgical candidates (Shah et al, 2016). For blood sampling and reference ranges, local laboratory techniques and parameters complying with current literature data and methods were taken into consideration (Klinke et al, 2020; Patel et al, 2013). NLR, PLR and MER values were obtained from the proportion of absolute neutrophils/absolute lymphocytes, absolute platelets/absolute lymphocytes and absolute monocytes/absolute eosinophils respectively.…”

“…In addition to the clinical variables for the differential diagnosis of ASPs and research based on DU signs, recent studies have focussed on inflammatory haematological parameters derived from CBC demonstrating an adjuvant role in the differential diagnosis of ASPs (Arikan et al, 2021; Klinke et al, 2020; Konishi et al, 2017; Liu et al, 2021; Ozbir et al, 2020; Patel et al, 2013; Rachidi et al, 2014).…”

Testicular Torsion in the Absence of Severe Pain: Considerations for the Pediatric Surgeon

“…Additionally, when classical symptoms appear inconsistently, pain is intermittent and non-specific symptoms occur, diagnosis and treatment may be delayed [ 11 ]. Two common scores for evaluating the probability of testicular torsion—TWIST (testicular workup for ischemia and suspected torsion) and BAL (Boettcher alert score)—have shown high sensitivity and specificity for predicting testicular torsion [ 11 , 16 , 17 , 18 ]. However, they rely on classical clinical symptoms (pain, nausea/emesis, displacement of the testicle, abnormal cremasteric reflex, swelling and hardened testicle), the majority of which were not present in our case.…”

Delayed Care Seeking and Outcomes of Testicular Torsion among Children during the COVID-19 Pandemic: A Systematic Review and Meta-Analysis

“…3 Evaluated clinical scores for assessing the probability of testicular torsions, such as the Testicular Workup for Ischemia and Suspected Torsion (TWIST) score and the Boettcher Alert (BAL) score, have proven excellent sensitivity and specificity. 4,5 Doppler ultrasonography of the scrotum can also help in determining the proper diagnosis.…”