Closed Claims—Open Insights: Testicular Torsion Emergency

Background

Case #1: A 16-year-old male presented to the emergency department (ED) with sudden-onset right testicular pain that had begun the previous night and worsened throughout the day. He denied trauma but reported playing tennis earlier in the day. His medical history included left knee arthroscopy and drug allergies.

On examination, the patient rated his pain as 10/10. The right testicle lay normally but showed significant swelling and marked tenderness. No discoloration, bruising, or inguinal hernia was detected. The left testicle was normal. Laboratory studies, including a CBC and BMP, were unremarkable. Urinalysis showed +1 ketones.

The physician performed a manual counterclockwise detorsion maneuver, and the patient reported partial relief of pain (an important clinical clue suggestive of torsion). The patient received IV morphine, and a scrotal ultrasound was obtained. The ultrasound did not show torsion but showed epididymal thickening and a hydrocele.

The patient was diagnosed with epididymitis and discharged with antibiotics and anti-inflammatories, with instructions to return if symptoms persisted. The patient’s symptoms continued, and further evaluation confirmed right testicular torsion. By that time, the testicle was nonviable and required surgical removal.

Case #2: A 31-year-old man presented to the ED with sudden-onset lower abdominal and testicular pain that began one hour prior. Physical examination did not reveal visible testicular swelling. The ED physician ordered a CT scan to assess for kidney stones, and the imaging results were normal. Based on the absence of swelling and initial findings, the patient was diagnosed with torsion of the appendix testis (a benign condition) and discharged with instructions to return if symptoms worsened.

Three hours later, after the initial physician’s shift ended, the patient returned with escalating pain and new right testicular swelling. A different ED physician evaluated him and ordered an ultrasound, which showed diminished blood flow to the right testicle. The radiologist expressed concern for acute testicular torsion. The patient was taken emergently to surgery, but the testicle was nonviable and required surgical removal.

 Allegations

• Failure to diagnose testicular torsion despite classic symptoms (sudden severe pain, swelling, extreme tenderness)
• Overreliance on a negative ultrasound, without considering clinical suspicion or the partial relief after manual detorsion
• Inappropriate diagnosis of epididymitis despite red‑flag symptoms inconsistent with infection
• Failure to provide appropriate urologic consultation given persistent severe symptoms.
• Delayed recognition and treatment resulting in loss of the testicle

Case Review Insights

• Acute testicular pain must always prompt immediate evaluation for torsion, regardless of patient age or absence of swelling.
• Negative or inconclusive imaging does not rule out torsion—clinical suspicion should override ultrasound findings when symptoms strongly suggest ischemia.
• Partial pain relief after manual detorsion is a red flag, and should trigger urgent urologic consultation, not reassurance.
• Premature anchoring on benign diagnoses (epididymitis, appendix testis torsion) led to missed opportunities for timely intervention.
• Failure to reassess or escalate care when symptoms persisted or worsened contributed directly to loss of testicular viability.
• Timely urology involvement and scrotal Doppler ultrasound are essential and should not be delayed when torsion is suspected.
• Delays in diagnosing testicular torsion frequently lead to professional liability claims because torsion is a true urologic emergency in which testicular viability declines rapidly, often within hours. When clinicians fail to promptly recognize or rule out torsion, patients may suffer permanent injury—including loss of the testicle—that is both preventable and highly consequential.
• Because the standard of care requires immediate evaluation and intervention when torsion is suspected, any delay is closely scrutinized and commonly viewed as a deviation from expected emergency practice.

Resolution

Both cases were settled after expert reviews indicated deviation from standard care. Damages included pain and suffering, emotional distress, and physical deformity.

Lessons Learned

• Treat acute testicular pain as torsion until proven otherwise. Adopt a “torsion-first” mindset—any sudden testicular pain, even without swelling, should be assumed torsion until excluded by appropriate evaluation.
• Avoid anchoring on benign diagnoses (e.g., epididymitis, appendix testis torsion) before ruling out true torsion.

Risk Management Tips

• Use current, evidence-based clinical guidance—such as urology-endorsed pathways (e.g., TWIST scoring), and modern best practices that emphasize urgent surgical evaluation without delaying care for imaging—to ensure that testicular torsion is promptly identified and treated. Following the most up‑to‑date, validated decision tools and urological recommendations helps reduce diagnostic delays, supports timely surgical intervention, and minimizes preventable patient harm and subsequent liability risk.

• Good documentation demonstrates that torsion was considered and appropriately addressed—critical for defending care. Document thoroughly and clearly, recording:

• Onset and characteristics of pain
• Physical exam findings (testicular lie, tenderness, swelling)
• Clinical reasoning
• Why torsion is or is not suspected

• Give explicit, time-sensitive return precautions. If torsion is deemed unlikely and the patient is discharged, provide clear instructions to return immediately for worsening pain, swelling, nausea/vomiting, or any change in symptoms. Reinforce that deterioration can occur quickly and requires urgent reassessment.

Resource

• NHS England GIRFT (Getting It Right First Time) Testicular Torsion Pathway, Version 2 — Updated January 2026. This pathway was developed by a multidisciplinary group including urologists, pediatric surgeons, and emergency physicians, and reflects modern urological standards.

Disclaimer

Curi’s risk mitigation resources and guidance are offered for educational and informational purposes only. This information is not medical or legal advice, does not replace independent professional judgment, does not constitute an endorsement of any kind, should not be deemed authoritative, and does not establish a standard of care in clinical settings or in courts of law. If you need legal advice, you should consult your independent/corporate counsel. We have found that using risk mitigation efforts can reduce malpractice risk; however, we do not make any guarantees that following these risk recommendations will prevent a complaint, claim, or suit from occurring, or mitigate the outcome(s) associated with any of them.