Claims Case Studies: Testicular Torsion

Testicular torsion, the twisting of the spermatic cord and the blood supply to the scrotum, can cause severe pain and swelling that may subsequently result in loss of the affected testicle. This urologic emergency primarily occurs in adolescents and is the most common cause of testicular loss in that age group. However, torsion may still occasionally present in men of all ages. Early diagnosis and treatment are vital to saving the viability of the testicle, so torsion must always be excluded before considering other causes of acute scrotal pain.

When diagnosed, testicular torsion usually requires emergency surgery to untwist the organ and secure it in its new position. When treated quickly, the testicle can often be saved. However, when blood flow has been restricted for too long, a testicle might become so badly damaged that it has to be removed. In this study, we examine two patient cases resulting in the loss of testicle and offer tips about how to avoid this adverse outcome.

Case #1: 16-Year-Old Male

A 16-year-old male patient presented to the Emergency Department (ED) with a complaint of sudden-onset right testicular pain. The patient reported that the pain had started the night before and significantly worsened during the day. He noted no specific trauma but reported that he did play tennis earlier that day. His past medical history included a left knee arthroscopy and allergies to amoxicillin and sulfa drugs.

Upon examination by our insured physician, it was noted that the patient reported 10/10 pain, and no inguinal or abdominal hernias were identified. The scrotal lie was normal on the right but there was notable swelling and extreme tenderness on palpation. No bruising or discoloration was noted. The patient’s left testicular exam was normal, his CBC and BMP were normal, and his UA had +1 ketones.

When the physician performed a manual counter clockwise rotation of the right testicle, the patient reported some relief and was subsequently given morphine for pain management. An ultrasound of the testicle revealed no evidence of torsion, but there was a thickening of the epididymis and a right hydrocele, a collection of fluid in the sheath surrounding the testicle, was observed.

The patient received a diagnosis of epididymitis, or inflammation of the epididymis, after which he was given a dose of IV ceftriaxone and discharged home on Omnicef and Naprosyn. He was instructed to follow up with his primary care physician or return to the ED should he have continuing problems.

The patient continued to have problems and was ultimately diagnosed with right testicular torsion and underwent the surgical removal of his now non-viable testicle.

Case #2: 31-Year-Old-Male

A 31-year-old male presented to the ED with complaints of lower abdominal and testicular pain. He had no testicular swelling and told the physician that the pain had started suddenly about one hour prior to his arrival.

The insured emergency medicine physician ordered a CT scan to rule out kidney stones, and the imaging results were read as normal. The physician diagnosed the patient with torsion of the appendix testis, a non-vital area on the top of the testicle, and told the patient to return to the ED if the pain did not improve or became worse.

The patient returned to the ED three hours later, after the insured physician’s shift had ended. The patient complained of the same pain as before but said that now the right testicle was swollen and very painful. Another ED physician ordered an ultrasound, which showed diminished flow to the right testicle, and the radiologist shared a concern for torsion.

The patient was taken to surgery, where he underwent a surgical removal of the non-viable right testicle.

What Went Wrong?

In the case of the 16-year-old patient, our clinical experts were consistent in their feedback that the insured should have ordered a surgical or urological consult before making the diagnosis of epididymitis. Given the patient’s age and complaints, testicular torsion should have been high on index of suspicion. Although the ultrasound did not indicate torsion when it was performed in the ED, the physical twisting of the spermatic cord can happen at any time. In addition, the patient reported relief after the manual rotation of the right testicle, at which point the physician should have ordered additional testing and a surgical consult to ensure the untwisting was complete. The physician should also have noted the fact that the patient had been playing sports shortly before experiencing pain, another factor that may easily point to a probable testicular torsion. The loss of the testicle, along with pain and suffering, were considered in the settlement.

Regarding the case of the 31-year-old patient, our experts believe that the insured was faulted for failure to order an ultrasound during the first visit to the ED and, as a result, misdiagnosed the patient’s condition. Evaluation of presenting symptoms, a thorough history and physical exam, and performing a scrotal doppler ultrasound on the first ED visit could have determined whether torsion was a possible diagnosis. The majority of the claimed damages in this settlement were for emotional distress and physical deformity.

Risk Management Takeaways:

It is essential that emergency medical care providers follow accepted standard of care practices for ordering diagnostic testing for a thorough evaluation. Medical Mutual’s Risk Management team recommends the following to help prevent these types of cases:

• Physicians should complete a thorough ED patient assessment, including history, physical, and diagnostic imaging studies.
• Physicians should always order an ultrasound for patients with a history of testicular pain and a normal prior ultrasound, as they may have subsequently developed a torsion/detorsion.
• Physicians should provide the patient with discharge instructions that highlight symptoms requiring immediate return to the ED, as timing is critical for prompt intervention in torsion cases.
• Departments should develop a process for a post-ED discharge follow-up call to evaluate the status of high-risk patients and their compliance with the discharge plan.

For further guidance on this issue, Curi members are encouraged to reach out to our Claims and Risk Management Departments at 800.662.7917.