A young man presents to an ED with vague complaints of abdominal pain. If testicular torsion is missed, whether the EP performed a genital exam, obtained a scrotal ultrasound, or involved urology all will become important questions.

“Everybody knows about [testicular torsion]. There are tests to diagnose it, but yet we still keep missing it,” says Gregory Moore, MD, JD, an attending physician at Madigan Army Medical Center in Tacoma, WA. Cases with “classic” presentation usually do not end up in litigation. “We get the straightforward ones, but the occasional one is still missed,” says Moore, who co-authored a recent paper on this topic.1

Testicular torsion is a highly time-sensitive diagnosis that presents with inconsistent histories, physical exam findings, and imaging findings, says co-author Kyle Couperus, MD, emergency medicine clinical faculty at Madigan Army Medical Center. The classic case presents with sudden onset, severe pain, scrotal swelling/edema, a high-riding testicle, transverse lie, and an absent cremasteric reflex. “However, every single one of these factors can vary significantly,” Couperus notes. The pain may come on gradually. The edema may be minimal. Rarely, a cremasteric reflex can be present. There are some other common fact patterns in missed testicular torsion cases:

The patient experienced severe pain at one point, but it has since resolved. This can be falsely reassuring to EPs who considered the diagnosis but believe it can now be ruled out.

“‘The patient is not hurting, so it can’t be that’ is the mindset,” Moore says. In these cases, Moore suggests the EP consider an ultrasound and consulting with the urologist instead of simply discharging the patient.

Radiologists mistakenly read the ultrasound as normal. One 14-year-old patient who presented with abdominal pain was discharged from an ED on antibiotics. However, paramedics brought the patient to another ED days later. There, the diagnosis of testicular torsion was made after a scrotal ultrasound showed decreased blood flow to the testicle.

“The EP was the sole defendant in the case and testified that he had ordered the correct test and relied on radiology’s interpretation,” Moore says. However, the jury ruled against the EP and awarded the plaintiff $500,000.

The patient does not report testicular pain. Diagnostic errors were present in all 62 closed ED malpractice claims analyzed in a recent study. Five cases involved misdiagnosis of testicular torsion.2 Notably, two patients presented with vomiting and abdominal pain but without testicular pain.

If testicular pain is listed as the chief complaint by ED triage nurses, it is an obvious possibility. “But it is easy to forget when evaluating ‘abdominal pain,’” Couperus adds.

This is especially important for children and adolescents who may be either confused or embarrassed by the location of discomfort. “Performing a good history and genitourinary exam on patients with abdominal pain can help mitigate this risk,” Couperus says.

In one case, a 16-year-old patient complained of abdominal pain, nausea, and vomiting but reported no testicular pain. A CT of the abdomen and pelvis was unremarkable. The patient was discharged without anyone ever performing a genital exam. The following day, the patient returned with right testicular pain and required a right orchiectomy. The family sued the EP for failing to consider testicular torsion. The case settled for $300,000.

An abnormal ultrasound is misread as normal. The average time window for possible testicular salvage is six to eight hours, with a steady decline in outcomes every hour after, Couperus notes. “If you are still concerned after a normal ultrasound, consult urology.” A negative ultrasound decreases the likelihood of testicular torsion, says Couperus, “but errors in radiology reads and intermittent torsion can still occur.”

Couperus says there are two steps providers can use. If suspicion is high after a workup, consult urology. If suspicion is low after a workup, discuss the continued risk of intermittent torsion, its potential complications, and strict return precautions with the patient and family.

Even if the radiologist misinterprets the ultrasound, the EP still is not off the hook legally. “The ED doctor almost universally pays out some of the award — in multiple cases I’ve reviewed, about two-thirds,” Moore says.

One study revealed that of 52 cases of litigation involving testicular torsion, EPs were the most commonly sued medical providers (48%) and were significantly more likely to make indemnity payments than urologists.3 The authors of another recent paper with similar findings reported that in 53 malpractice cases involving testicular torsion, EPs were the most common provider sued (35% of the time). Atypical presentations were common, with 31% presenting with abdominal pain only.4

Jurors’ reasoning for holding EPs liable instead of radiology or urology seems to be, at least in part, the fact that the EP was physically present to evaluate the patient.

“The logic is the radiologist is looking at a machine, the urologist may have talked with the ED doctor on the phone — but the ED doctor was there,” Moore offers.

REFERENCES

  1. Bass JB, Couperus KS, Pfaff JL, Moore GP. A pair of testicular torsion medicolegal cases with caveats: The ball’s in your court. Clin Pract Cases Emerg Med 2018;2:283-285.
  2. Lemoine N, Dajer A, Konwinski J, et al. Understanding diagnostic safety in emergency medicine: A case-by-case review of closed ED malpractice claims. J Healthc Risk Manag 2018;38:48-53.
  3. Colaco M, Heavner M, Sunaryo P, Terlecki R. Malpractice litigation and testicular torsion: A legal database review. J Emerg Med 2015;49:849-854.
  4. Gaithere TW, Copp HL. State appellant cases for testicular torsion: Case review from 1985 to 2015. J Pediatr Urol 2016;12:291.e1-291.e5.