Testicular torsion

The patient was a 17-year old man who presented to his GP, an MDU member, the day after a football match. He reported that he had tackled an opponent but slipped and landed astride the other player's leg. He was aware of hurting his testicle but the pain did not seem severe. On waking that morning, his testicle felt more sore than before but the pain was intermittent and not severe.

On examination, both testicles were normal in size and position. The right testicle was tender in the lower half. The GP noted that there was no evidence of a torsion and suspected that the pain was as a result of the injury. She advised the patient to seek urgent medical assistance if the pain got worse.

The following day, a Saturday, he returned to the surgery and saw a different GP who noted that there was a large swelling on the right side. He sent the patient to the emergency department with a referral letter which queried testicular rupture. On admission the patient was noted to be suffering from intermittent testicular pain and the diagnosis was unclear. Arrangements for a Doppler ultrasound could not be made over the weekend and so the patient was discharged with painkillers. Over the next four days, the pain became more severe and constant. Four days after the initial admission, a Doppler ultrasound scan was performed which showed no flow in the testicle. A surgical exploration was performed which showed a necrotic right testicle which was removed and a left orchidopexy performed.

A claim was received which alleged that the torsion had occurred shortly before the patient was seen by his GP and that, if she had referred the patient that day, an immediate exploration and fixation could have prevented the loss of the testicle.

The MDU obtained reports from independent GP and urology experts.

The GP expert was supportive of the MDU GP's management. He pointed out that the pain at first presentation was not severe and was intermittent. The records were good and the GP had carefully noted her findings at examination. She had also made appropriate arrangements for follow-up.

It was clear from the claimant's witness statement that he had suffered a very severe emotional response to his illness and orchidectomy.

The urology expert commented on the difficulties in determining when the torsion occurred. He thought that it was most likely that the initial problem was a bruising injury to the testicle. The reasons for this included the intermittent, relatively mild pain and the fact that the GP recorded that the testicle was easily palpable and only tender in the lower pole. The urology expert considered that it was likely that the testicle was intermittently torting and then untwisting following the initial injury. The findings in casualty suggested that a full torsion had occurred and the expert considered that it was possible that if a Doppler ultrasound had been performed, it would have shown impaired circulation and the testicle could, at that point, have been saved. It is generally stated that in order to salvage the testicle, an operation should take place within six hours; however, it was impossible to say when the torsion occurred.

It was clear from the claimant's witness statement that he had suffered a very severe emotional response to his illness and orchidectomy. He suffered depression and panic attacks and attempted suicide. However, his account of the events after his injury accorded with the evidence from the MDU GP. As a result of this, the MDU solicitor proposed to the claimant that, if he discontinued his claim, the MDU would not seek their legal costs from him. This was accepted and the claim discontinued.

Both experts commented that this was a difficult case. However, the excellent records, which included examination findings and follow-up arrangements, assisted the experts in supporting the MDU member's care.

Dr Frances Szekely
Senior medical claims handler

This guidance was correct at publication 04/12/2013. It is intended as general guidance for members only. If you are a member and need specific advice relating to your own circumstances, please contact one of our advisers.

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