Adapted from an article by Mr Ramesh Thurairaja, Consultant Urological Surgeon, Guy’s & St Thomas’ Hospital, London
What is it, and how to establish if there is potential clinical negligence for failing to diagnose it
In very young boys the testicles (testis) lie inside the abdomen and during childhood, they descend through a ‘tunnel’ to occupy the scrotum.
Each testicle is connected to structures within the abdomen, such as the tubes along which sperm are transported which join the urethra, as well as blood and nerve supply. These vessels are collectively called the spermatic cord.
Clincal features of torsion of the testis
Torsion means that the testis twist – also causing the vascular and spermatic cord attachments to twist, to such an extent - that the vascular supply to the testis is compromised which can result in it dying.
Testicular torsion occurs in approximately 1 in 4000 males per year. There are two peaks in age, the first is during the neonatal period when the prognosis is usually poor with a salvage rate of about 9%. The second peak is typically between the ages of 12-16, but it should be considered a potential diagnosis for someone presenting with abdominal pain, up to the age of 40 years old. Any history should include any previous scrotal surgery, family history of torsion or undescended testis.
Testicular torsion typically presents with sudden onset of severe unilateral testicular pain often associated with nausea and vomiting. Some patients may also have non-specific symptoms such as fever or urinary problems. Many patients do describe a recent history of trauma or strenuous activity that could have resulted in torsion.
Some patients may present with intermittent torsion, ie recurrent episodes of acute pain in the groin. This presentation should also be taken seriously and warrants urological expert opinion.
The various causes for pain within the groin are :
- Inguinal hernia.
- Acute hydrocele
- Torsion of testis
- Torsion of the appendix of the testis
- Epididymitis (inflammation of the epidydimis)
- Acute inguinal lymphadnopathy
- Idiopathic scrotal oedema
- Testicular injury
- Mumps orchitis
As it can be seen clearly the incarcerated inguinal hernia, acute inguinal lymphadnopathy (enlarged lymph glands), idiopathic scrotal oedema (oedema meaning increased fluid in the wall of the scrotum) and mumps can be ruled out by history or examination. There is no history of testicular injury either, therefore this may be excluded.
The differential diagnoses therefore remain with acute hydrocele (a hydrocele is a collection of fluid in the scrotum surrounding the testis) which is usually painless, torsion of the testis, torsion of the appendix of the testis or epididymitis. An ultrasound helps to exclude hydrocele and can help to confirm in many cases the two forms of torsion. A urine sample would be mandatory in terms of supporting a diagnosis of epididymitis as there may be white cells in the urine, arising as a consequence of infection of the epididymis.
Part two of this article can be seen here.
To establish if you or someone you know may have a potential claim for clinical negligence following Torsion of the Testis, please do not hesitate to contact the Clinical Negligence Team at Dutton Gregory Solicitors in Bournemouth on 01202 315005, or email firstname.lastname@example.org.