Safety of care
Scrotal pain may point to testicular torsion
An article for physicians by physicians
Originally published September 2006 / Revised May 2008
It is important to consider testicular torsion in young males presenting with abdominal or scrotal pain.
Of interest to physicians dealing with emergencies
The CMPA originally published this review of closed legal actions involving testicular torsion in 1997.
The statistics have been updated to include an analysis of the closed legal actions between 2001 and 2005 for which there was an allegation of a delay in the diagnosis of testicular torsion. The standards of medical practice are properly set by the practitioners of medicine, regulatory authorities (Colleges) and specialty sections. However, this CMPA information is presented again to remind physicians to consider the diagnosis of torsion of the testicle in young men who present with pain of relatively sudden onset in the scrotum or lower abdomen.
Around 9 p.m., a 17-year-old otherwise healthy young man developed an uncomfortable feeling in his scrotum and took one extra strength acetaminophen. The discomfort progressed to outright pain over the next four hours in spite of additional doses of acetaminophen. He awakened his mother, a nurse, and they proceeded to the hospital emergency department. By then, his pain was quite severe and steady, and it was uncomfortable to walk.
The physician in the emergency department examined the youth, palpated his scrotum and testes, and ordered blood and urine tests plus an injection of an analgesic with an antiemetic. While awaiting the results of the tests, the patient continued to experience severe pain and brought this to the attention of the physician.
When the test results were available, the physician stated the blood work was normal and diagnosed the condition as epididymitis. The physician discharged the patient on antibiotics and analgesics, with advice to see the family practitioner in one week. He also told the patient the pain would subside.
When the pain persisted and swelling developed, the youth saw the family practitioner (about 40 hours after the visit to the emergency department) and was referred to an urologist. The urologist surgically explored the scrotum, identified the problem as testicular torsion and performed an orchidectomy because the testicle could not be salvaged.
The lawyer for the physician sought expert opinion from three physicians: two general practitioners and a surgeon. All felt the initial physician should have suspected a testicular torsion based on the age of the patient (17 years), and the relatively rapid progression to acute pain which was not relieved by an injection of a narcotic analgesic. Furthermore, they felt that in these circumstances a surgical opinion should have been requested. They were critical of the medications prescribed on discharge and the delay in follow-up recommended even if the diagnosis had been epididymitis. Without peer support, settlement of this claim was paid by the CMPA on behalf of the physician.
As opposed to the usual CMPA experience in which two-thirds of the cases are dismissed, and less than 30 per cent settled, 55 per cent of the closed legal actions involving testicular torsion between 2001 and 2005 were settled as expert support could not be obtained. In this updated review, 73 per cent of the testicular torsion cases occurred in patients between the ages of 10 and 30. Primary-care physicians were involved in 57 per cent of these cases; urologists and general surgeons were involved in 37 per cent. The most common misdiagnoses were epididymitis and orchitis and the most common patient physical outcome was loss or atrophy of the testicle. Seventy-five per cent of the cases occurred exclusively in the emergency department.
Analysis of these closed claims suggests physicians may need to consider testicular torsion in the differential diagnosis of scrotal or lower abdominal pain of relatively sudden onset occurring in young men. There is often a very short "window of opportunity" in which the testicle can be saved.