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Assume nothing

01 September 2007

K was an active 14-year-old boy, keen on skateboarding and football. When he came home after a day’s skateboarding complaining of intense pain in his groin and abdomen, his father was alarmed and took him directly to his local A&E department. Four years earlier, K had developed testicular torsion resulting in the loss of his left testis; his father was understandably fearful that now K’s remaining testicle was also at risk.

When they saw Dr J, a junior doctor in the A&E department, K’s father recounted K’s previous history of testicular torsion and impressed on Dr J his concern that K’s remaining testicle might be at risk. Dr J reassured him on that score, telling him that when the surgeon removed K’s testicle he would have fixed the other in place, so there was no possibility that K’s current condition could be attributed to testicular torsion.

Dr J examined K, finding an oedematous scrotum tender to the touch. He elicited a history from K of scrotal and abdominal pain starting suddenly shortly after he had taken an awkward fall from his skateboard. He felt slightly nauseous, but had no other symptoms, apart from the residual effects of a recent upper respiratory-tract infection; in answer to Dr J’s question, he reported that he had no difficulty in passing urine.

Dr J considered epididymo-orchitis secondary to a viral infection as the most likely diagnosis, prescribing a course of antibiotics and some ibuprofen for the pain. He discharged K home without conducting any investigations, advising K to see his GP if the pain and swelling did not subside in a few days.

Three days after this, K returned to A&E with a hard, discoloured scrotum. His right testis was gangrenous and had to be removed. K brought negligence claims against Dr J and the surgeon, Mr L, who had performed the first orchidectomy and neglected to fix his remaining testicle in place. 

Expert opinion

We consulted an expert in emergency medicine and a general surgeon. Both were extremely critical of Dr J, who, on the basis of an assumption, had ignored both local protocols and generally accepted principles of best practice, namely, that when an adolescent boy presents with testicular pain, it should be treated as torsion until proved otherwise. One expert was particularly critical about Dr J’s failure even to carry out a urinalysis; moreover, he did not consider that the picture presented supported a diagnosis of epididymo-orchitis.

On looking through K’s earlier medical records, the expert in surgery was at a loss to explain to his own satisfaction why Mr L had failed to fix K’s remaining testicle during surgery. As Mr L was now living overseas and had no recollection of the case, it could only be concluded that it was due to an uncustomary lapse in his normal practice.

As it was clear that K’s infertility could have been avoided, had it not been for below-standard care from both Dr J and Mr L, the case was settled for a substantial sum.

Learning points

  • Torsion of the testis is a surgical emergency; the testicle will infarct if detorsion is not effected within a few hours of the onset of pain.
  • A high proportion of missed torsion cases referred to MPS as negligence claims have been erroneously diagnosed as epididymitis.
  • If the consequences for the patient would be profound if you are wrong, dismissing a diagnosis without confirmatory investigation results is an extremely risky undertaking.
  • It is axiomatic that if a boy or a young man present with a history of sudden testicular pain, it should be treated as testicular torsion until proved otherwise.

Further information

A table to assist in the differential diagnosis of testicular torsion, epidydimo-orchitis and testicular cancer can be found in Anthony, S, Scrotal Confusion: Focus on Diagnosis, Casebook 19: 5–11 (2002).