Testicular torsion is a surgical emergency

Testicular torsion is a surgical emergency. It happens when the spermatic cord, which provides blood flow to the testicle, rotates and becomes twisted. The twisting cuts off blood supply to the testicular blood vessels and causes sudden pain and swelling. Without treatment, it rapidly leads to ischaemia (inadequate blood supply to organs) and the testicle can become necrotic and require surgical removal.

The most important factor in determining whether the testicle can be saved is the time between the onset of symptoms and surgical intervention. There is a very small window of opportunity to save the testicle once torsion occurs. The literature suggests the testicle can be saved in 90-100% of cases if surgical correction occurs within six hours of onset of pain. But those odds drop dramatically if surgery takes place later than that. If surgery does not take place for 24 hours or more, it will often be too late. For that reason, clinicians are advised to have a very low threshold for suspecting testicular torsion in males presenting with acute, painful scrotal swelling, particularly if they are younger than 25 years of age.

Testicular torsion is most common in children, with peak incidence in boys aged 13 to 16 years old.

Typical presentation includes:

  • sudden, severe pain in one testis
  • lower abdominal pain
  • nausea and vomiting
  • reddening of the scrotal skin
  • swelling

In a boy presenting with an acute scrotum, it is imperative to rule out testicular torsion. Examination of the testes should be performed in all male patients presenting with abdominal pain. However, it is important to know that the above symptoms are not always present and even a normal testicular examination should not preclude further investigation. If testicular torsion is suspected, one is advised to attend A&E without delay. If a GP suspects torsion, an immediate referral must be made to the emergency urology or surgical team for further investigation or surgery.

Sadly, there are often occasions where clinicians fail to recognise cases of torsion or manage them correctly, which leads to considerable pain and ultimately the loss of a testicle. As well as physical and emotional distress for the victim and their family, there will be questions about why this happened and concerns about the future: Will it cause infertility? What if there is long-lasting psychological damage? Will further surgery be required? 

David’s case

We acted for young boy (whose name has been changed to protect his identity), represented by his mother. David suffered from a sudden onset of pain in his testicular and abdominal area with vomiting. His mother acted promptly and took him straight to an Emergency Treatment Centre. The doctor made a diagnosis of ‘non-specific abdominal pain’ and discharged him. David continued to suffer from pain into the next day and then became acutely unwell.  David’s mother telephoned her GP surgery and was correctly advised to go straight to A&E. By this point, the testicle was necrotic and required removal by orchidectomy. There was an independent investigation which was quite critical of the care afforded to David, but the doctor involved denied any wrongdoing. His mother decided to consult solicitors.

We obtained our client’s medical records and sought independent medical opinion. Once a clear case of negligence was advised, we wrote to the hospital in question, whose claim was handled by its insurer. The hospital trust did not accept liability for the harm suffered by David and maintained that position throughout the case. It became necessary to issue court proceedings to litigate the matter. Ultimately, we won the case for our client without our client having to go to trial.

Arjun’s case

Arjun was 4 years old when his mother took him to the GP. He had suffered a sudden onset of abdominal pain with vomiting. The first consultation was by video. The second consultation was face-to-face later that day. The GP failed to carry out a testicular examination or take a history of pain or swelling in the testicular/scrotal area. The GP diagnosed constipation and did not provide any safety-netting advice to his mother. The pain worsened and she called 111 the next morning who advised her to go straight to A&E. By this point, the testicle was no longer viable and required surgical removal.

Arjun’s mother complained to her GP however they advised her that the care was appropriate. His mother reached out to our firm.  

We obtained an expert opinion from an independent GP who considered Arjun had received negligent care. We also obtained an independent report from a paediatric surgeon about Arjun’s prognosis, which gave peace of mind to his mother that fertility would not be impacted. We wrote to the GP whose claim was handled by her insurer. It was denied that urgent referral to hospital was required following the video consultation. Whilst it was admitted that the GP had breached her duty of care at the face-to-face consultation, liability was denied on the basis that the ‘die was cast’ by then. In other words, it was alleged that even if the GP had acted appropriately, the testicle was already unsalvageable, a point that was vehemently disputed by the expert paediatric surgeon.

We continued to fight our client’s corner and ultimately, the insurer chose to settle the case before it became necessary to issue court proceedings.

Summing up both cases

As David and Arjun were both children, the court had to determine whether we had agreed fair settlements for them. The settlements were approved by a judge and the compensation will be invested until both children turn 18 years old. It will allow both David and Arjun to have prosthetic implants and any counselling required on a private basis when they reach puberty. Both mothers’ perseverance in holding the doctors to account hopefully improves standards in treatment and may prevent avoidable harm to someone else in future.  

Arjun’s Mum:

Natalie Hirst was my main point of contact. I still feel embarrassed for crying on the phone the first day of our conversation. She helped us throughout this process in the best possible manner. I can’t thank Natalie and her team enough for holding the GP accountable for negligence and hopefully it will prevent this from happening to someone else in the future.

Arjun’s Mum

I have been very satisfied from start to finish with Natalie’s care and determination to get justice for my son. He suffered during his ordeal which led Natalie to pursue the case despite the denial of the other party and the technicalities that made this case difficult. Natalie was meticulous throughout the process and gave clear instructions relating to weakness and strengths of the case and always looked to secure our position with detailed narrative which was very reassuring.

David’s Mum