Recorded on: Thursday, March 26
Presenter: Janelle Fox, MD, MS-HQSM, FACS, Chief of Pediatric Urology, CHKD
Improving Outcomes for Boys with Testicular Torsion
At a recent CHKD Provider Relations Lunch & Learn, Janelle Fox, MD, Chief of Pediatric Urology at CHKD, shared insights into the urgent need for faster recognition and treatment of testicular torsion in boys across Hampton Roads. Her presentation highlighted local data, risk factors for delayed care, and CHKD’s ongoing quality improvement efforts to reduce orchiectomy rates through provider education, streamlined workflows, and community outreach.
Why Timely Recognition Matters
Testicular torsion is a true surgical emergency, and delays in diagnosis and treatment can quickly affect outcomes. CHKD’s hospital-level data showed that, before its quality improvement work began, patients spent about two hours in the emergency department before case booking. For patients transferred from outside hospitals, that timeline often increased by another three to three and a half hours, adding up to roughly five hours of ischemia time before reaching the operating room.
The strongest predictor of orchiectomy was delayed presentation. In CHKD’s analysis, patients who waited more than 24 hours from symptom onset had dramatically higher odds of orchiectomy, underscoring the need for same-day evaluation of acute scrotal pain.
Factors Associated with Delayed Presentation
Dr. Fox noted that boys who first presented to urgent care or primary care offices appeared more likely to have delayed presentation compared with those who went directly to the CHKD emergency department. This did not suggest that outpatient providers were causing delays, but rather that families may not recognize scrotal pain as an emergency and may seek care in settings that are not designed for definitive torsion management.
Other factors associated with worse outcomes included payer status, neurocognitive conditions, and geography. Medicaid patients had higher rates of delayed presentation and orchiectomy, while TRICARE patients appeared more likely to present earlier. Children with autism spectrum disorder, developmental conditions, or other neurocognitive differences also had higher rates of orchiectomy, in part because symptoms may be harder to communicate or localize. CHKD also found a relationship between distance from the hospital and delayed care.
A Regional Issue in Hampton Roads
One striking finding from the presentation was the reported local incidence of pediatric testicular torsion. According to CHKD data shared during the session, Hampton Roads appears to have a substantially higher incidence than what is commonly cited in the literature. While the reason for this remains unclear, the finding reinforces the need for increased awareness among providers, schools, families, and community partners throughout the region.
CHKD’s Quality Improvement Approach
To address these challenges, CHKD launched Project Torsion in June 2024. This ongoing quality improvement initiative focuses on reducing delays in recognition, transfer, and treatment through a phased approach. The work has brought together pediatric urology, emergency medicine, surgical process improvement, and community education partners.
Phase 1: Improve ED and transfer workflows
The first phase focused on creating emergency department torsion pathways, standardizing transfer processes, improving coordination with the operating room, and expanding CME and GME education throughout the pediatrics program and community settings.
Phase 2: Expand outpatient and parent education
The second phase included outreach to school nurses, outside hospital emergency departments, and pediatricians, along with parent education and website resources. CHKD Urology also expanded educational materials related to testicular conditions, self-exam guidance, and signs that warrant urgent evaluation.
Phase 3: Reach the broader community
The current phase aims to increase public awareness through educational videos, social media, and outreach to athletic trainers. CHKD is also exploring longer-term opportunities to incorporate testicular health education into broader community and school-based education efforts.
Clinical Takeaway for Referring Providers
For community providers, the message is straightforward: acute scrotal pain should be treated as an emergency. Early recognition, prompt triage, and rapid referral are essential to improving salvage rates. During the presentation, Dr. Fox emphasized the value of the TWIST score in helping guide urgent evaluation. In CHKD’s transfer pathway, outside hospitals are encouraged to calculate a TWIST score early, and for patients with a score of 5 or greater, initiate transfer without waiting for ultrasound, given the strong positive predictive value.
Moving Forward
Improving outcomes for boys with testicular torsion will require continued partnership across care settings. CHKD’s work highlights the importance of early recognition, efficient transfer pathways, provider education, and family awareness in reducing delays and protecting testicular viability. As Project Torsion continues, these efforts have the potential to make a meaningful difference for children and families across Hampton Roads.
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