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Management of testicular swelling

01 September 2008

Mr F, a 20-year-old university student, found a swelling around his left testis while showering. He was in the middle of exams and therefore did not attend his own GP, Dr A, until two weeks later, by which time he had also developed some mild pain in the area. He had no other significant medical history and he told Dr A that he thought the swelling may have got larger in the intervening period.

Dr A recalled that he had no urinary symptoms, fever or urethral discharge, although none of these details were recorded in the notes. Dr A examined Mr F and felt a swollen area of tenderness behind the left testis, which he assessed at that time as being separate from the testis and most likely due to epididymitis. No additional investigations, such as urinalysis or blood tests, were arranged. Dr A prescribed doxycycline but did not arrange for any review with Mr F if symptoms did not settle, or become worse.

Over the next six months Mr F visited Dr A three more times with other, unrelated complaints. However, at each visit, Mr F’s family said that he mentioned the non-resolution of his testicular symptoms and ongoing pain in the same region. There were no records of any further investigations related to this problem and an examination of the area was carried out only once during the whole period. On one occasion another course of antibiotics (ciprofloxacin) was prescribed. Finally, on the fifth consultation by Mr F, he was examined by a different GP, Dr B, who felt the left testis to be “indurated” and irregular on palpation and at this stage arranged an urgent referral to the local urology clinic.

Mr F was diagnosed in hospital with a malignant teratoma and, despite chemotherapy and surgical intervention, he died two years later. Mr F’s family began a negligence claim.

Expert opinion

A GP expert was critical of the management of Mr F. He advised that if the patient’s condition had not resolved fully after two weeks, an urgent urological assessment should have been arranged at that time. The claim was settled for a moderate sum.

Learning points

  • Testicular germ cell tumours are rare (about 1,700 new cases reported in UK each year) meaning a GP can expect to see only one or two cases in a career, but they are the most common cancer in men aged 20–30.
  • Problems caused by delayed diagnoses of testicular problems are a common feature in MPS case files. Several years ago we published an extensive review of MPS experience, which provides much valuable information on the potential pitfalls. Anthony S, Scrotal Confusion, Casebook 19, 5–11 (2002).
  • In this case Dr A’s notekeeping was poor, and this did not help his defence. Relying on your memory to reconstruct consultations is unwise. When recording the details of a consultation, remember the importance of including relevant negative findings. This can provide valuable evidence of the diagnoses that you have considered, but excluded. Remember the importance of note making and including relevant negative findings in notes. See the booklet, MPS Guide to Medical Records, for more information.
  • If a patient returns to see you with the same unresolved complaint, this provides a good opportunity to revisit your diagnosis. It is vital to keep an open mind. In particular, consider serious diagnoses. Have you carried out appropriate investigations to rule them out?