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The Whirlpool Sign Revisited: Limited Additional Predictive Value When Screening For Testicular Torsion at a Stand-Alone Pediatric Institution
Emily May, MD1, Corey Shafer, MD1, Lindsey Webb, MD1, Kelly White, BS2, Arianna Matz, MD1, Oluwadamilola Egbewole, BDS, MPH3, Daniel Herz, MD3, Anne Dudley, MD3, Courtney Rowe, MD3.
1University of Connecticut, Farmington, CT, USA, 2University of Connecticut Medical School, Farmington, CT, USA, 3Connecticut Children's Medical Center, Hartford, CT, USA.
Background - Early or partial testicular torsion may present with preserved blood flow on ultrasound (US), delaying diagnosis and risking testicular loss. The “whirlpool sign” is a spiral twist of the spermatic cord with preserved blood flow and has been proposed as a marker of early or partial torsion. Since June 2018, our institution has mandated spermatic cord sweeps on all scrotal US to assess this finding. We evaluated diagnostic performance, hypothesizing a low predictive value.
Methods - We performed a retrospective review of patients undergoing scrotal US for testicular/abdominal/scrotal pain or scrotal/groin swelling between 9/1/23 and 9/1/24. Radiology reports were reviewed, and a TWIST score retrospectively calculated. Abnormal operative findings were defined as testicular torsion ≥180°.
Results - A total of 482 ultrasounds met inclusion (
Figure 1). There were no patients with missed torsion (follow-up months mean 11.6, median 11.3). As a stand-alone indicator, the whirlpool sign had poor positive predictive value (
Table 1). Adding the whirlpool sign to traditional markers of torsion improved sensitivity at the expense of specificity. All patients with whirlpool signs and torsion had abnormal exams by urology leading to surgery.
Conclusions - Although the whirlpool sign may indicate early torsion, reliance on this finding alone can result in unnecessary intervention. In this cohort, it did not provide meaningful additional diagnostic value and may increase uncertainty. Clear interpretive guidelines are needed before widespread adoption.
Figure 1. 482 ultrasounds were included from 9/1/23 - 9/1/24. Patients were excluded for testicular cancer, lack of exam, or surgery > 1 month after ultrasound. Isolated whirlpool sign (twisted cord with preserved blood supply) was found in 5 patients with torsion and 12 without; 7 underwent surgery.
Table 1. Diagnostic Performance of Ultrasound Findings for Testicular Torsion | Sensitivity | Specificity | PPV | NPV |
| Whirlpool sign alone | 83.3% | 97.3% | 29.4% | 99.8% |
| Clear testicular torsion on US | 78.6% | 100% | 100% | 98.7% |
| Clear testicular torsion + whirlpool sign | 96.4% | 97.4% | 69.2% | 99.8% |
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