Delayed Diagnosis of Testicular Torsion Mistaken for Epididymitis

A 34-year-old male presented to the emergency room with sudden onset left sided groin pain that he rated as an 8/10 in intensity. The pain was constant and was described to be sharp in character but did not radiate anywhere. The ER worked the patient up for possible kidney stones which were ruled out with a CT-abdomen and pelvis. It should be noted that this was the only imaging study performed during this ER visit. The patient was discharged with pain medications and antibiotics and given the diagnosis of “pain of unknown etiology” and referred to his primary doctor for a follow-up appointment. One week later the patient’s pain did not resolve and he was seen by his primary care doctor who started to suspect epididymitis and wanted to rule out testicular torsion. An ultrasound was performed the day after and it showed findings compatible with left sided torsion with severely decreased blood flow to the left testicle. The patient was scheduled for a left orchiectomy and right testicular fixation, which was now considered to be non-emergent in nature due to the delayed diagnosis. The patient has a past medical history significant for Factor V Leiden mutation and was taking coumadin with his INR level at a 3. The patient is also a Jehovah’s witness and would refuse whole blood products if needed.

Question(s) For Expert Witness

1. Did the ER physicians do everything within their power to rule out a testicular torsion in this patients case?

2. Had the ER physicians actually identified the torsion at the initial time of presentation, would the urologist be able to operate emergently given that this patient has a Factor V mutation and is a Jehovah witness that would refuse blood products?

Expert Witness Response E-000066

Scrotal exploration for testicular torsion is a relatively minor procedure. Furthermore, if surgery is not performed within 12 hours, there is a 50% chance of losing the testicle. This surgery could be undertaken even with an INR of 3, but counseling about an increased risk of bleeding would need to be discussed. Even if bleeding occurred, it would be unlikely to be severe or life-threatening or require blood transfusion since it is not a major abdominal cavity. Also, depending on the patient, some Jehovah's Witness will accept certain blood components that can reverse anticoagulation, but this would obviously need discussion with the patient. I would likely leave a drain in place if I was to do this procedure to prevent hematoma formation.