In this article, Dr Karen Robinson, Clinical Risk Advisor in the State Claims Agency, looks at learning from testicular torsion claims and presents advice on mitigating the risk of these claims occurring.

What is testicular torsion?

Testicular torsion occurs when the testicle twists on the spermatic cord, constricting the vasculature and resulting in ischaemia, necrosis and loss of function of the testis unless detorsion occurs. It is a urological emergency and possible cases should be assessed promptly as the chances of testicular salvage are significantly reduced if treatment is delayed.¹

Through its routine analysis of incidents on NIMS (the National Incident Management System), the State Claims Agency (SCA) noted 55 incidents related to the diagnosis or management of testicular torsion in a five-year period between 2017 and 2021. This prompted a review of claims related to testicular torsion to identify learning.

Learning from testicular torsion claims

The SCA finalised nine claims involving testicular torsion in a five-year period from 2017-2021. These claims incurred total costs (damages and legal and other costs) of €2.2 million.

Patients’ ages at time of the incident that triggered the claim ranged from 4-31 years. Eight incidents had an incident severity rating of moderate when reported on NIMS, with one having a severity rating of major. Five of the nine claims reviewed were previously reported as an incident.

Claims occurred predominantly due to missed diagnosis of the condition, misdiagnosis of another condition (e.g., epididymo-orchitis or renal colic), delays in assessment and treatment, or a combination of these factors.

Some of the issues identified in relation to these claims included:

• Inadequate evaluation of presenting symptoms and/or documentation of history (e.g. the severity and location of pain), resulting in incorrect triage category or care pathway
• Failure to consider testicular torsion in the differential diagnosis and/or document the differential diagnosis, particularly in more complex cases (e.g. in patients with recurrent episodes of pain; past history of orchidopexy; or where there was a previous diagnosis of epididymo-orchitis, but the clinical picture had changed)
• Failure to give sufficient weight to the opinion of a referring doctor who had suggested a diagnosis of testicular torsion
• Lack of documented evidence that a full abdominal examination was performed, in particular, examination of the genitalia
• Where full abdominal examination was performed, lack of documented evidence of examination of the cremasteric reflex

Minimising the risk of claims

In order to mitigate the risk of the occurrence of claims related to testicular torsion, as well as to improve the outcome for the patients affected, the SCA, based on its analysis of testicular torsion claims, advises as follows:

• A full and detailed history should be taken in all males presenting with abdominal or scrotal pain, with particular attention to time of onset of symptoms and the history of previous similar episodes
• External genitalia and the cremasteric reflex should be examined in all males presenting with possible testicular torsion
• Testicular torsion should be included in the differential diagnosis in patients presenting with relevant symptoms, in particular where a potential diagnosis of testicular torsion has been suggested by another practitioner
• Where testicular torsion is considered, there should be urgent referral to senior/specialist staff for assessment and the development of the appropriate care plan
• Particular care should be taken where surgery on-site is not available, to ensure early transfer if required
• The history, findings on physical examination, differential diagnosis and care plan should be fully and carefully documented in the healthcare record.
• All patient safety incidents should be recorded on NIMS, in line with the HSE’s Incident Management Framework

References available on request.