Testicular Torsion: A Case Study

By Gordon Muir, Consultant Urological Surgeon

Case Scenario:

An 18 year old man awoke at 5am one morning with severe left testicular pain. This did not ease over the next hour so he went to the local A&E, where he was seen for triage and assessed by the accident and emergency doctor within one hour. A presumptive diagnosis of testicular torsion was made and referral made to the surgical registrar, who saw the patient at 08.17 am.

A history was obtained that the patient had just returned from a music festival where he had penetrative intercourse with two separate female partners. The clinical findings were consistent with inflammation of the epididymis (collecting tubules behind the testicle) and he was sent home with analgesia and antibiotics. No urine tests or blood tests were ordered.

Over the following three hours the pain became unbearable, with the patient representing to the same hospital at 2.34pm. An ultrasound of the scrotum was ordered which was carried out at 6.25pm. The ultrasound found no evidence of blood flow in the testis and torsion was queried.

Arrangements were made to take the patient to surgery and scrotal exploration at 7.20pm revealed a  torted and dead left testicle which was removed. A prophylactic fixation of the right testicle was carried out. The patient is on the waiting list to have a prosthetic testicle placed on the left side.

Testicular Torsion; A Case Study 3 (2)

The clinical problem:

Torsion of the testis occurs in young men, usually between puberty and 30 years of age. If not treated within six hours there is a high risk of testicular damage or death.

In this case, a mistaken diagnosis of an infection was made. Had the surgical trainee taken a more in depth history he would have heard that the patient had never had unprotected intercourse, making genital infection extremely unlikely.

The misdiagnosis and the delays led directly to the loss of a testicle in a healthy man.

A Urological Expert’s View:

Although it should never happen nowadays, young men lose salvageable testicles on most weeks in the NHS. Broadly, if a man is taken to surgery within six hours of the torsion occurring the great majority of testicles will survive. A delay of over twelve hours is usually fatal to the testicle. A delay of 6-12 hours may lead to a salvageable testis.

There is NO diagnostic test to exclude testicular torsion. In departments with very experienced ultrasound doctors, a number of conditions may be diagnosed which can mimic torsion. However even in this situation there should be no delay to surgery if an absolute diagnosis cannot be made – the ultrasound should be done on the way to the operating theatre. If there remains any doubt, emergency surgical exploration should be carried out.

National and international guidelines are unanimous in advising this management pathway.

Thus there were two clear breaches here.

The first was misdiagnosis in the face of a classical presentation of torsion. The second was to delay further the surgical exploration waiting for an unnecessary test. On the balance of probabilities the testis would have survived had these errors not been made.

Once the decision had been made to remove the dead testis, the surgery itself was of an acceptable standard and the fixation of the remaining testis (to avoid that side torting) was entirely correct. Deferred insertion of a testicular prosthesis is what most specialists would recommend in the presence of testicular loss due to torsion.

Loss of a Testicle:

Most healthy men will not notice a difference in their hormone levels should a testicle be removed for torsion, trauma or cancer. Normally fertile men will similarly not see a major difference in their fertility.

For young men the loss of a testis for whatever reason can cause significant psychiatric and body image problems. Most younger men will choose to have a prosthetic testis implanted in this situation although that is a cosmetic procedure, and men who are offered this option are generally happy with whichever choice they make.

Urology Experts

The majority of men who lose a testis in their youth will choose to bank sperms in case there is a damage to the other testis. This has an initial cost and there is then an ongoing need for payment and reconfirmation of the desire to continue storing the sperms.

Probably around fifteen per cent of healthy men will develop late onset hypogonadism or infertility in later life. While the data on this is still developing as we see the late survivors of testicular cancer growing into old age, it is reasonable to expect this risk to be doubled due to loss of a testicle.

The Medico-Legal Case:

The hospital was sued for damages claiming negligence in not immediately taking the patient to the operating theatre for exploration, and for delaying surgery by ordering ultrasound on the second presentation.

Expert advice was that the case was indefensible.

The case was settled out of court with an award being made to cover:

  • Pain and suffering
  • Potential loss of fertility and later need for hormone replacement
  • Sperm freezing and storage
  • Psychological stress
  • The cost of a prosthetic testis being implanted as a private patient.

The total quantum was in the order of £35,000

About the Author:

Mr. Gordon Muir is a Consultant Urological Surgeon working at King’s College Hospital, and Honorary Senior Lecturer in Surgery at King’s College London. He qualified in medicine at the University of Glasgow and spent time in active service as an Army medical officer, his training in surgery and urology was in London at St George’s and the Royal Marsden Hospitals. He has worked in clinical practice and research in France, Egypt, the USA and Italy.

He has been providing medicolegal reports for more than 10 years. He currently provides reports in a ratio of approximately 50% claimant, 40% defendant and 10% joint.

His areas of specialist interest include;

  • Diagnosis and minimally invasive treatment of Urological Cancer
  • Male Sexual Dysfunction and infertility, including testicular torsion
  • Prostatic Diseases and complications of treatment
  • Training and consent issues in medical negligence
  • Defective Diagnostic and Surgical Processes leading to poor outcomes
  • Urological trauma including operative injuries to bladder and ureters

Mr Muir can be contacted for all medico-legal work and to request his CV at gordonmuir@inneg.co.uk

Request Mr Muir’s CV & Terms