By Kyle Couperus, MD, John Bass, MD, and Gregory Moore, MD, JD

Physician (Couperus and Bass) and Attending Physician (Moore), Madigan Army Medical Center, Tacoma, WA

Drs. Couperus, Bass, and Moore report no financial relationships relevant to this field of study.

Testicular torsion (TT) is a urologic emergency with potentially devastating consequences and costs for providers and patients alike. With an annual incidence of approximately 4.5 per 100,000 males aged 1-25 years, TT is an uncommon medical condition, yet is the third most common cause of medical malpractice suit in this demographic.1 Because of varying presentations and physical exam findings, along with diagnostic imaging subject to individual interpretation, ED providers may miss this time-sensitive diagnosis. Delays in identification and management of this surgical emergency significantly increase the morbidity associated with TT. Between 31.9% and 41.9% of such cases result in testicular loss.2 Accordingly, error in diagnosis is the most common major liability in paid TT malpractice suits, with an average reported settlement of $60,000.2 When encountering genitourinary and lower abdominal complaints in male patients, ED providers must maintain a heightened suspicion for TT. Below are medical-legal cases that highlight potential errors in the evaluation, work-up, and management of this high-risk condition.

Patient History and Age

Case 1. A 12-year-old boy was referred to the ED by his pediatrician for a testicular ultrasound after sliding into base during a baseball game, resulting in a swollen and painful testis. On exam, the ED physician noted the testicle was three times larger than the other testis, albeit without scrotal ecchymosis or evidence of hernia. An ultrasound was interpreted by radiology as showing testicular contusion with interstitial edema, an epididymal head cyst and hydrocele, and slightly decreased vascularity in the left testis pole. The ED physician discussed these results with a urologist, who recommended a follow-up ultrasound in two weeks. Four days later, the patient returned with increased testicular pain and swelling, and repeat ultrasound revealed no flow to the testis. Following orchiectomy, a lawsuit was filed for failure to diagnose TT on the first evaluation, and a settlement of $662,500 was reached.3 It is likely that the physicians providing care in this case anchored on the trauma present and did not consider TT.

Although classically associated with abrupt onset and excruciating scrotal pain, there is no standard presentation for TT. The TT presentation can resemble epididymitis. A significant number of proven TT cases present with gradual onset discomfort, whereas alternative causes of scrotal pain, such as epididymitis, can present with sudden discomfort in up to 51% of cases.1 Furthermore, nonspecific complaints, such as nausea or vomiting, offer little in differentiating the cause of scrotal pain. Approximately one-third of patients with confirmed TT complained of nausea or vomiting upon initial evaluation, compared to 12.5% of epididymitis patients.1 Finally, circumstances surrounding a presentation may not reveal the ultimate diagnosis. TT is attributed to direct trauma in only 4-8% of reported cases, and more frequently occurs during sleep because of spontaneous cremasteric contractions.4 Since there are varying symptoms and circumstances surrounding TT, it is imperative to maintain a high suspicion for this diagnosis, and not rely on historical features in isolation to guide further evaluation.

Case 2. A 53-year-old male presented to the ED initially complaining of right lower quadrant pain, and later right testicular pain. A genital exam performed by the intern and attending physician was believed to be normal. The patient was discharged after an abdominal CT scan for appendicitis was read by radiology as normal and the pain had resolved. The patient returned later that day with right testicular pain and swelling, and an ultrasound showed TT with infarction. An orchiectomy was performed. The plaintiff later claimed that an ultrasound should have been performed during the first visit, while the defendant stated that there was no evidence of TT on the first visit, which included a normal exam and pain abatement. The defense also asserted that no harm occurred as there was no effect on reproductive ability, sexual performance, or testosterone levels. A jury ruled for the defense.5

TT often is considered in a bimodal distribution, with a peak incidence during the perinatal period, and again during puberty. Most cases occur in males under the age of 25 years, and 65% of these cases involve males between the ages of 12 and 18 years.4 However, approximately one-third of torsion malpractice cases involve adult plaintiffs, which suggests a possibly higher rate of misdiagnosis in this demographic.6 In fact, one study showed that the odds of orchiectomy effectively doubled for every decade of patient life in TT cases.1 Although factors such as delayed evaluation and anatomic changes associated with age likely contribute to this likelihood of orchiectomy, ED providers must consider TT high in their differential diagnosis for acute scrotal pain, regardless of patient age.

Physical Exam

Case 3. A 16-year-old male arrived at the ED complaining of right lower quadrant abdominal pain with some associated nausea and vomiting. The ED physician obtained labs and completed an abdominal exam, abdominal ultrasound, and a CT of the abdomen and pelvis. These were all unremarkable. Nevertheless, a surgical consultation was obtained to further evaluate for appendicitis. The surgeon did not believe appendicitis was present, and the patient was discharged without anyone performing a genital exam.

The following day, the patient returned with right testicular pain. He was immediately taken to the operating room for scrotal exploration and required a right orchiectomy. The patient sued for failure to perform a genital exam and failure to consider testicular torsion in the diagnosis. Before trial, the parties reached a settlement.7

Isolated abdominal pain is a frequent chief complaint associated with TT. In one review, failure to complete a testicular exam was associated with 19% of TT malpractice cases.2 It is imperative to consider this diagnosis and complete a scrotal exam any time lower abdominal pain is present.

Case 4. A 17-year-old male awoke in the middle of the night with testicular pain and came to the ED. The physician considered a TT diagnosis, but says he ruled it out based on physical exam. The patient was discharged with treatment for epididymitis. Five days later, the patient presented to his primary care physician with persistent pain. The patient was immediately referred back to the ED, where staff diagnosed TT. The patient subsequently underwent an orchiectomy. The patient sued, claiming an ultrasound should have been performed on the first visit. A medical review panel unanimously ruled that the standard of care was not met. The physician claimed he met the standard of care by conducting a thorough history and genital exam. The jury delivered a defense verdict.8 This physician was fortunate to obtain the jury outcome rendered.

ED physicians should be hesitant to decide the absence (or presence) of TT based solely on clinical exam. Presence or absence of cremasteric reflexes, scrotal edema/erythema, pain along the upper pole of the testicle or epididymis, enlarged epididymis, transverse lie, and retraction of testicle all fail to give a definitive answer.1 Even when experienced urologists combine all these exam findings, their initial impressions frequently are wrong.1

Historically, the presence of a cremasteric reflex has been cited to rule out TT. Unfortunately, this is a black pearl. Although mostly small case series, several have reported TT with intact cremasteric reflexes.1 Specifically, patients who were later diagnosed with TT exhibited intact cremasteric reflexes in 12-40% of cases.1 This percentage is unacceptably high; thus, cremasteric reflex is unreliable. Additionally, cremasteric reflexes are absent in 30% of males with normal testicles, and also absent in patients with other scrotal pathology such as hydatid torsion and epididymitis.1

Other physical exam features of TT exhibit much overlap with other diagnoses. Scrotal erythema, edema, and testicular swelling also are reported frequently in patients with TT at indiscernible rates from other causes.1 Isolated pain along the upper pole of the testicle or epididymis has been reported to occur in 18.7% of patients with TT and 40.8% of patients with torsion of the testicular appendage.1 Enlargement of the epididymis also has been seen in 40% of patients with TT and 77% of patients with epididymitis.1 A transverse testicular lie has been reported in 17-83% of TT cases, while a vertical lie has been observed in up to 54% of TT cases.1 Lastly, testicular retraction (high-riding testicle) is only present in 33-80% of TT cases.1 Sadly, it is not possible to rule TT in or out based on physical exam findings.1,6

Imaging

Case 5. A 14-year-old male was taken to the ED after awakening with abdominal pain. Laboratory studies, an abdominal CT scan, and a scrotal ultrasound were performed. The CT scan was read as suggestive of appendicitis; thus, ED staff called for surgical consultation. The surgeon did not believe that appendicitis was present. The radiologist reviewed the ultrasound and diagnosed epididymitis. Based on the studies, the ED physician discharged the patient on antibiotics. Three days later, the patient awoke with testicle pain and was taken to a different ED where he was diagnosed with testicular torsion and received an orchiectomy. A review of the original ultrasound revealed there was decreased blood flow to the testicle. The patient litigated, claiming that the diagnosis should have been made on the first visit and the testicle could have been salvaged. The case was solely against the ED physician and not the radiologist. There was testimony from the ED physician that he ordered the “gold standard” test and he relied on the interpretation by radiology. After trial, the jury awarded a $500,000 verdict.9 This case is typical of others. When a radiologist misreads the testicular ultrasound, often the radiologist pays out less than the ED physician, or the ED physician pays out alone. The thought process is that the ED physician had the ability to make a “clinical correlation” that the radiologist didn’t.

The test of choice, a scrotal ultrasound, can be very helpful, although it is not failproof. First, the fact “one simple test” could make the diagnosis factor is hard to contest. Nevertheless, and perhaps more importantly, upon review of cases that were involved in litigation, obtaining an ultrasound did not correlate with a more successful defense.2,6 This possibly is because most of these associated cases produced false-negative results.2,6 Specifically, they were read by a resident, technician, or ED physician as (inaccurately) negative. The ultrasound is only as good as the user. Generally, high-resolution ultrasonography has a sensitivity of 96% but is not perfect.6 When a provider obtains an ultrasound in search of TT, it is important to ensure the individuals reading the exam are skilled at such a task. If a negative ultrasound is reported, in the situation that a high clinical suspicion remains, a urologist should be consulted. Historically, involving a consultant has created a very defensible position.6

Prognosis

Case 6. A 12-year-old male presented to the ED with lower abdominal and testicular pain. His exam was normal, and he was treated with morphine and ondansetron. A CT of the patient’s abdomen and pelvis was normal, and he was subsequently discharged. The following day, he presented to his pediatrician’s office with an edematous left testicle. The physician referred him for an immediate ultrasound, which revealed TT. A detorsion was completed in the operating room. One month later, the same patient returned with progressive pain. A testicular ultrasound revealed no flow, and an orchiectomy was performed. A claim was placed indicating an ultrasound should have been obtained on the first visit. A jury awarded the plaintiff $2 million.10

TT is a time-sensitive diagnosis. Testicular salvage rates are 85-97% — if intervention is initiated within six hours of symptom onset.2 If suspicion for TT is high, a urology consult should be obtained before (or concurrently) with the ultrasound. If a patient presents with symptoms greater than six hours, they should be managed just as urgently.1 Several case series have described good salvage rates up to 12 hours after symptom onset, and other isolated cases even several days out.1

In conclusion, TT is an uncommon, time-sensitive diagnosis, with high rates of successful litigation against emergency physicians.2,6 The use of history, physical, and imaging stand as diagnostic pillars; however, they are fallible. Care must be taken when relying on ultrasound findings. If there is any doubt in the diagnosis, consulting a urologist has been shown to allow for a more defensible position in court.6

REFERENCES

  1. Mellick LB. Torsion of the testicle: Is it time to stop tossing the dice? Pediatr Emerg Care 2012;28:80-86.
  2. Gaither TW, Copp, HL. State appellant cases for testicular torsion: Case review from 1985 to 2015. J Pediatr Urol 2016;12:291.e1-291.e5.
  3. Anonymous Boy v. Anonymous Hospital, Case No. 2008 CA 008290, District of Columbia Superior Court.
  4. Nicks BA, Manthey DE. “Male Genital Problems.” In: Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 7th edition. New York, NY: McGraw-Hill Companies; 2011, 645-651.
  5. King v. University of Chicago Medical Center, Case No 08L-4708, Cook County (IL) Circuit Court.
  6. Colaco M, Heavner M, Sunaryo P, Terlecki R. Malpractice litigation and testicular torsion: A legal database review. J Emerg Med 2015;49:849-854.
  7. Medical Malpractice Verdicts, Settlements, & Experts. Vol. 31, Number 9, Page 7, September 2015.
  8. Lavalais v. Ritter MD, No. 15-1340, Avoyelles Parish (LA) Judicial District Court.
  9. Graham v. Noreldin MD, Case No. WPCV2003-00099, Worcester County (MA) Superior Court.
  10. Simpson v. Mobile Infirmary Medical Center, Case No. 12-901184, Mobile County (AL) Circuit Court.