Gastroenteritis is a common urgent care diagnosis, but clinicians tend to default to it because they lack a better explanation for a patient's GI symptoms. Don’t fall into the same trap as a fellow urgent care provider from New York who missed a case of testicular torsion masquerading as a benign GI complaint.
Patient Presentation and Legal Case:
The case in question involves a 12-year-old boy who visited an urgent care facility with his mother, complaining of epigastric abdominal pain. The patient was diagnosed with gastroenteritis and pharyngitis. Notably, there was no genitourinary exam documented, nor was there mention of whether the child stated they had testicular pain. However, within 24 hours, he was diagnosed with testicular torsion in the emergency room.
The crux of the legal complaint was the allegation that the urgent care clinician failed to examine the genitourinary (GU) area adequately and subsequently failed to order an ultrasound and make the diagnosis. The lawsuit highlighted the physical injuries suffered by the patient, including testicular torsion, removal of the affected testicle, and associated psychological distress. The settlement reached in the case totaled $299,000.
Medical Overview of Testicular Torsion:
Diagnosing testicular torsion presents several challenges, particularly in cases with atypical symptoms or presentations. While testicular pain is a hallmark symptom, it may not always be present, leading to potential misdiagnosis or delayed treatment. Moreover, relying solely on physical examination findings can be inconclusive, as testicles can appear normal early in the disease process, and the presence/absence of cremasteric reflex is unreliable.
It occurs in approximately 4.5 per 100,000 males under the age of 25. Testicular salvage rates decline significantly beyond the first 12 hours, with only 54.0% survival from 13 to 24 hours and 18.1% survival beyond 24 hours. This emphasizes the critical importance of prompt recognition and intervention to maximize patient outcomes.
Tools like the Twist Score have been developed to aid diagnosis, although they may not definitively exclude torsion. Additionally, the high variability in clinical presentation underscores the importance of maintaining a high index of suspicion, especially in patients with abdominal pain or nausea.
Malpractice Data:
In a study by Glerum et al. looking at closed pediatric malpractice claims, testicular torsion represented 4% of all claims, 5.5% of paid claims, and, when filed, was 41.4% likely to result in a payment to a plaintiff. The average indemnity was $253,756, with average defense fees of $36,896. Claims related to male genitalia disorders, including testicular torsion, rank among the most common in pediatric and adolescent populations.
Conclusion:
In our discussion on Urgent Care RAP, Matt Delaney and I highlight the high malpractice risk and impact on patient livelihood associated with testicular torsion. We stress that nearly every testicular pain case that presents to the urgent care should undergo an ultrasound, or at the very least, your notes should document a thorough conversation with the patient about your recommendations to do so. We also highlight how easy this can be to miss in a patient who you think is old enough to tell you they have testicular pain, how we need to be asking every pediatric patient with abdominal pain if they’re having testicular pain, and checking the younger pediatric patients if you’re not sure if they’re reliable. Learn more by listening to the "Legal Lessons: Testicular Torsion" segment on Urgent Care RAP.