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Delayed diagnosis of testicular torsion | Signal

Reference number
1104 B
Issue date24 September 2009

This 'Signal' is about the risk of misdiagnosis or delay in treatment for young men with testicular pain leading to orchidectomy.


Extract from incident reported to the RLS: “….. Patient presented [to A&E] with abdominal pain of sudden onset. No history of vomiting, urinary or bowel problems. Pain described as colicky intermittent pain in right iliac fossa. On examination was not found to have signs of appendicitis. After analgesia pain settled and patient was sent home. Patient again presented to his GP for same pain after 5 days and was sent to hospital with query appendicitis to be assessed by the surgeons. It was found out that patient had testicular torsion and an orchidectomy was performed as there was no blood flow detected.” 


Testicular torsion is a relatively rare condition affecting mainly teenagers and young boys in which the cord providing blood supply is twisted, requiring immediate surgery. 


Following the trigger incident, the National Reporting and Learning Service (NRLS) identified 17 reports, of which 13 resulted in the loss of the testicle. Most of these patients were initially diagnosed with epididymitis or orchiditis, but some were diagnosed with UTIs or appendicitis.


Four further reports described some delay in treatment after diagnosis resulting in loss of the testicle; two of these were in neonates. There were also issues around confusion in who should manage the patient (for example, between paediatric and surgical teams). 


While diagnostic error is a complex issue that cannot usually be solved by advice in a Rapid Response Report (RRR), the NRLS is exploring the issue further with clinical experts. It was discussed with the College of Emergency Medicine and the Clinical Board for Surgical Safety, who confirmed that, although rare, given the narrow window for action this might warrant some kind of `fast-track’ tagging of patients, as for asthma crises, by frontline clinicians.  


We would like to hear from you – please contact us  with anonymised copies of local investigations or information about your initiatives to reduce risks in any of these areas.


Signals are notifications of key risks emerging from review of serious incidents reported and shared by the NRLS.

NOTES: relevant to: patient assessment/diagnosis, emergency medicine, surgery, medicine


Relevant to: patient assessment/diagnosis, emergency medicine, surgery, medicine.



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