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CASE REPORT
Year : 2021  |  Volume : 24  |  Issue : 5  |  Page : 786-788

Testicular torsion: Losses from missed diagnosis and delayed referral despite early presentation


Department of Surgery, Edo University, Iyamho, Nigeria

Date of Submission09-Jul-2020
Date of Acceptance29-Sep-2020
Date of Web Publication20-May-2021

Correspondence Address:
Dr. F E Ogbetere
Department of Surgery, Edo University, KM 7, Auchi- Abuja Expressway, PMB 04, Iyamho, Auchi, Edo State
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njcp.njcp_432_20

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   Abstract 


Testicular torsion leads to loss of blood supply to the testes due to the twisting of the spermatic cord and its contents, necessitating urgent surgical intervention to salvage the affected testis. Testicular loss from missed diagnosis and delayed referral is preventable, especially when patients present early to first contact health care workers. This makes having the correct diagnostic knowledge for testicular torsion by these first contact healthcare providers a very essential determinant of its overall outcome. Two cases of testicular torsion are presented here. Their diagnoses were missed and referrals were delayed despite presenting within three hours of onset of symptoms. It led to the removal of the affected testis in both patients. This case series emphasizes the need to regard every testicular pain in children and young adults as testicular torsion until proven otherwise and highlights the importance of training the first contact health care providers on recognition and prompt intervention or referral of patients with testicular torsion.

Keywords: Delayed referral, missed diagnosis, testicular loss, testicular torsion


How to cite this article:
Ogbetere F E. Testicular torsion: Losses from missed diagnosis and delayed referral despite early presentation. Niger J Clin Pract 2021;24:786-8

How to cite this URL:
Ogbetere F E. Testicular torsion: Losses from missed diagnosis and delayed referral despite early presentation. Niger J Clin Pract [serial online] 2021 [cited 2022 Dec 3];24:786-8. Available from: https://www.njcponline.com/text.asp?2021/24/5/786/316470




   Introduction Top


Testicular torsion is a urological emergency presenting with acute scrotal pain. The annual incidence is one in 4000 males below 25 years of age.[1] It accounts for 10-15% of acute scrotum in children and young adults[2] with orchiectomy rate of 41.7%.[3] Early diagnosis and treatment are necessary to prevent testicular loss, and torsion must be excluded in patients with acute scrotum.

In this case series, testicular losses from missed diagnosis and delayed referral despite early presentation is explored with emphasis on the need for interventional programmes aimed at early recognition and immediate treatment or referral by first contact health professionals.


   Case Reports Top


Herein are two cases of patients who presented to first contact health care providers within three hours of onset of symptoms but eventually had orchidectomy due to missed diagnosis and delayed referral.

Case 1

Master AD, a 17-year old secondary school student who presented to our clinic with a history of left hemi-scrotal pain and swelling of 4 days duration. He developed scrotal pain of sudden onset while in class and was immediately taken to a comprehensive health centre where he was given some analgesics and discharged after observation for 24 hours following some relief. Two days later, he noticed a swollen left hemiscrotum with persistence of the scrotal pain necessitating presentation to our facility. He had no history of change in the colour of skin over the swelling, trauma or fever.

On clinical examination, he was anxious with stable vital signs. The left testis was swollen, tender and hanging high with thickened spermatic cord. The right testis was normal in size and shape. The doppler ultrasound done showed absence of blood flow in the left testis and epididymis. He had scrotal exploration and the left testis was black and necrotic with a 360-degree torsion of the spermatic cord [Figure 1]. A left orchiectomy was done and the right testis fixed. He was discharged 2 days after and has remained stable at follow up.
Figure 1: A gangrenous left testis following scrotal exploration

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Case 2

Mr ES, a 20-year-old construction worker referred from a private facility on account of the complain of 'vanishing' right testis. He has had testicular pain of sudden onset 2 months previously while at work. For the above he immediately visited the referring private hospital where he was managed as a case of orchitis and given some analgesics and antibiotics. He was discharged after 3 days of admission following 'improvement' in clinical condition. Subsequently, he noticed a progressive reduction in the volume of the affected testis. As a result of this, he presented again to the same private hospital two months after from where he was referred to us. Scrotal scan done in our facility showed untreated right testicular torsion with no demonstrable blood flow to the right testis and marked reduction in testicular volume. A shrunken necrotic right testis with about 450 degrees torsion was found at surgery [Figure 2]. He subsequently had right orchidectomy and left orchidopexy with no complications during convalescence. He was discharged on the third day and being followed up in the clinic.
Figure 2: A shrunken pale and necrotic right testis with about 450 degrees torsion on scrotal exploration

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   Discussion Top


Testicular loss from testicular torsion has a devastating effect. This is due to the fact that torsion leads to testicular ischemia within six hours.[1] Beyond the six hours, the chances of saving the testis is significantly reduced, and almost unlikely after 24 hours.[3] In addition, the extent of testicular twisting determines the time to total testicular loss.

Patients usually complain of severe acute scrotal pain, nausea, and vomiting.[3] Examination may show a high-riding testis with thickening of the spermatic cord at the point of torsion as well as absent cremasteric reflex. If history and physical examination suggest torsion, or if in diagnostic dilemma, immediate surgical exploration is indicated and should not be postponed to perform imaging studies. Given the painful nature of the condition the patient's healthcare seeking response is usually rapid with delays being observed at the first contact with the healthcare system.[1],[4]

In this case series, patients reported to the nearest health facility almost immediately due to the excruciating scrotal pain. However, the diagnosis was missed in both patients resulting in delayed referral and consequent testicular loss. This delay in referral to the health units where surgical intervention can be offered usually occur when the wrong diagnosis is made leading to the management of torsion as orchitis by the first healthcare provider.[5],[6] A good diagnostic knowledge of testicular torsion by the first contact healthcare provider is a very important factor in determining the outcomes of testicular torsion. The inclusion of torsion education as a mandatory content of continuing medical education programme of doctors, nurses and allied health care providers as recommended by Ugwumba and colleagues[3] can address this diagnostic knowledge gap. Other African researchers have also advocated for greater education of non-doctor health workers who are often more accessible and the first to have contact with these patients.[7],[8]

It is believed that efforts toward enlightening first-line health care professionals will help to reduce the testicular loss associated with delays in diagnosis, and treatment or referral of testicular torsion.


   Conclusion Top


This case series highlights the importance of training the first contact health care provider on recognition and prompt intervention or referral of patients with testicular torsion. The learning point is every case of testicular pain in children or young adults should be treated as testicular torsion until proven otherwise and this should be emphasized in the continuing medical education programmes of doctors and allied health professionals.

Declaration of patient consent

The author certifies that he has all appropriate patient consent forms. In the form, the patients have given consent for their photographs, and other clinical information to be reported in the journal. The patients understand that their names will not be published and due effort will be made to hide their identity.

Financial support and sponsorship

Nil.

Conflicts of interest

There is no conflicts of interest.



 
   References Top

1.
Kapoor S. Testicular torsion: A race against time. Int J Clin Pract 2008;62:821-7.  Back to cited text no. 1
    
2.
Romeo C, Impellizzeri P, Arrigo T. Late hormonal function after testicular torsion. J Pediatr Surg 2010;45:411-3.  Back to cited text no. 2
    
3.
Ugwumba FO, Okoh AD, Echetabu KN. Acute and intermittent testicular torsion: Analysis of presentation, management, and outcome in South East, Nigeria. Niger J Clin Pract 2016;19:407-10.  Back to cited text no. 3
[PUBMED]  [Full text]  
4.
Mangwiro TI. Testicular torsion: A review of clinical experiences. East Cent Afr J Surg 2006;11:94-98.  Back to cited text no. 4
    
5.
Ibingira C. Management of Testicular torsion in Mulago Hospital over a 5-year period. East Cent Afr J Surg 2001;6:101-5.  Back to cited text no. 5
    
6.
Ayman Nada MEA, Victor Labib. The value of time in the management of testicular torsion. Sci Med J 2006;18:35-40.  Back to cited text no. 6
    
7.
Baruga E, Guyton Munabi I. Case series on testicular torsion: An educational emergency for subSaharan Africa. Pan Afr Med J 2013;14-8.  Back to cited text no. 7
    
8.
Njeze GE. Testicular torsion: Needless testicular loss can be prevented. Niger J Clin Pract 2012;15:1824.  Back to cited text no. 8
  [Full text]  


    Figures

  [Figure 1], [Figure 2]



 

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  In this article
    Abstract
   Introduction
   Case Reports
   Discussion
   Conclusion
    References
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