The clinical problem
Torsion of the testis occurs in young men, usually between puberty and 30 years of age. If not treated within six hour 'window of opportunity' there is a high risk of testicular damage or death.
The importance of taking an in-depth history is essential to diagnose and discount other causes. Misdiagnosis and delays can lead directly to the loss of a testicle in a healthy man.
There is a very low threshold for suspicion for a patient presenting with acute, painful scrotal swelling, particularly if they are younger than 30 years of age. The National Institute for Health and Care Excellence Guidelines for scrotal pain and swelling state:
- Examination of the testes should be performed in all male patients presenting with abdominal pain.
- History and physical examination alone does not rule out testicular torsion.
- Surgical exploration may be necessary.
What should my doctor be asking me?
- Is there presence of pain - painful scrotal swellings are more likely to need urgent intervention.
- If pain is present, ask about site (torsion is usually unilateral), speed of onset (torsion is usually of rapid onset) duration, and severity (usually severe in testicular torsion), and any associated swelling (torsion does not always cause swelling).
- Have there been previous episodes of severe, self-limiting pain and swelling (described by some people with testicular torsion).
- Are there any associated symptoms, including:
- Nausea or vomiting (common with torsion, may occur with epididymo-orchitis).
- Symptoms of a lower urinary tract infection, or urethral discharge (suggesting epididymo-orchitis).
- Parotid swelling (suggesting mumps orchitis).
- Back pain, breathlessness, or weight loss (may occur in metastatic testicular cancer).
- Sexual history (if appropriate).
- History of trauma (in haematocele and, rarely, testicular torsion), or strenuous physical activity.
What should my doctor be examining me for?
- Position of the swelling in relation to the testis (testicular, extra-testicular).
- Testicular lie (suspect testicular torsion if high-riding or transverse).
- Size of the testis (may be enlarged with a testicular tumour).
- Symmetry of the testes, (in torsion the epididymis may be located anteriorly).
- Tenderness (present in torsion and epididymo-orchitis).
- Consistency of the swelling (for example, solid with testicular cancer, soft with a hydrocele).
- Lymphadenopathy or an abdominal mass.
- Prehn sign (relief of pain with elevation of the testes) - may suggest epididymitis but does not rule out testicular torsion.
- Transillumination (indicative of hydrocele).
- Features of inguinal hernia (examine the person both lying and standing), including:
- A positive cough impulse.
- Palpable bulge in the inguinal canal.
- Skin changes:
- A raised papule, plaque, or ulcer suggests scrotal cancer, although this is extremely rare.
- Erythema of the scrotal skin (associated with epididymo-orchitis).
- A blue dot sign, where an inflamed and ischaemic torsed appendage can be seen through the scrotal skin.
If testicular torsion is suspected, you should be admitted immediately to urology or paediatric surgery.
- Acute testicular pain, often with abdominal pain and sometimes vomiting has a high predictive value for testicular torsion. The patient should be kept fasted and a surgical referral should be made without delay
A Urological Expert's View
Broadly, if a man is taken to surgery within six hours of the torsion occurring the great majority of testicles will survive. A delay of over twelve hours is usually fatal to the testicle. A delay of 6-12 hours may lead to a salvageable testis.
As evidenced above there is no diagnostic test to exclude testicular torsion, and a number of conditions can mimic torsion. The crux is, time is of the essence, if in doubt explore in theatre. The ultrasound should be done on the way to the operating theatre to avoid delay.
The NICE guidelines support entirely this management pathway.
How will my life be impacted if I lose a testicle?
Loss of a testicle in a healthy male does not often greatly alter hormone level or fertility. Each case must be looked at on its own facts.
Loss of a testis can cause significant psychiatric and body image problems. Most younger men will choose to have a prosthetic testis implanted in this situation although that is a cosmetic procedure.
There is a choice to bank sperm in case there is a damage to the other testis. There is a cost associated with this decision that needs to be considered.
Potential heads of claim for testicular torsion
- Pain and suffering
- Potential loss of fertility and later need for hormone replacement
- Sperm freezing and storage
- Psychological stress
- The cost of a prosthetic testis being implanted as a private patient.
For more information contact Leonie Millard in our Clinical Negligence department
via email or phone on 01254 770517.
Alternatively send any question through to Forbes Solicitors via our online Contact Form.
Learn more about our Clinical Negligence department here
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