Since 2016, across England there have been more 3,500 hospital admissions each year with suspected testicular torsion. A proportion of these patients suffered complications due to misdiagnosis and delay.

Testicular torsion is a condition where the testicle twists, cuts off the blood supply and results in significant pain. If not treated in time it can result in the loss of a testicle.

Testicular torsion can affect males at any age, but young adults aged between 12 to 18 years are at greater risk of torsion than other age groups.

Reference event

The investigation focuses on the case of a 20-year-old student. He suffered a testicular torsion and lost his right testicle due to a delay in diagnosis and treatment .

Investigation summary

This healthcare safety investigation reviews the management of acute onset testicular pain. It looks at GP referral pathways into hospitals, primary care telephone consultation and diagnosis of time-critical conditions.

The investigation reviews the diagnostic and treatment pathway for testicular torsion. There was a focus on delays and the human factors associated with the care pathway. The impact a missed testicular torsion has on patients, their family and carers, and on the clinicians involved in diagnosis and treatment was also explored.

Download and read the full report.

Safety recommendations

We made safety recommendations to the National Institute for Health and Care Excellence (NICE) and NHS England/NHS Improvement as a result of this investigation.

We have now received responses to all three safety recommendations set out in the investigation report.

The National Institute for Health and Care Excellence (NICE)

Safety recommendation

It is recommended that the National Institute for Health and Care Excellence revises the content and accessibility of its Clinical Knowledge Summary on testicular torsion.

Response

NICE welcomes the recommendations made in the HSIB investigation report on the management of acute onset of testicular pain dated September 2019.

We have completed several actions in August and September 2019 that address recommendation 2019/43, that the “National Institute for Health and Care Excellence revises the content and accessibility of its Clinical Knowledge Summary [CKS] on testicular torsion”.

The relevant CKS topic name has now been amended from Scrotal swelling to Scrotal pain and swelling and the torsion management scenario has been renamed testicular torsion. The testicular torsion scenario (along with other management scenarios within the Scrotal pain and swelling topic) are now returned as a result in the CKS site search. Testicular torsion is also the first scenario listed in the Scrotal pain and swelling topic list of management scenarios.

These changes make the torsion management topic more findable via the CKS site search and in NICE evidence search. Users of search engines such as Google are now directed to the topic when simple searches such as “testicular pain” are conducted.

NICE also asked Clarity Informatics Ltd, the authors of CKS topics, to conduct a review of the scrotal swelling topic which has resulted in updates to the content, references and recommendations.

These changes have resulted in the evidence highlighted by HSIB being added into the CKS topic. The update to the scrotal swelling topic has been highlighted to users through NICE’s promotional channels, which in this case is a monthly e-newsletter aimed at primary care staff.

This response was received on 20 November 2019.

NHS England and NHS Improvement

Safety recommendation

It is recommended that the NHS England/Improvement ‘Getting It Right First Time’ (GIRFT) programme ensures that testicular torsion/acute testicular pain is included on the checklist of emergency pathways to be considered by the newly established Urology Area Networks across England.

Response

GIRFT has now published a follow-up public document to its Getting It Right First Time in Urology National Report. This can be found at www.gettingitrightfirsttime.co.uk/good-practice-handbooks/.

This document offers a number of good examples to trusts wishing to improve different elements of their urological services. One of the key ways in which they can do this is through the establishment and effective management of a ‘Urological Area Network’ (UAN), whereby several geographically contiguous trusts work together to provide higher quality services.

This document provides guidelines for setting up and managing a UAN, including suggested UAN service specifications which should consider: ‘A specific description of arrangements for managing patients with testicular torsion. Such provision should cover all age groups and ensure that surgical exploration of the scrotum can be performed with no inappropriate delays.’

Combined with our ongoing work with trusts and with NHS commissioners, GIRFT is working to ensure that all UANs have a clear pathway for testicular torsion/acute testicular pain.

This response was received on 23 December 2019.

Safety recommendation

It is recommended that NHS England/Improvement works with relevant stakeholders to develop guidance for handling telephone advice/triage in primary medical care settings.

Response

NHS England/Improvement will work with the Royal College of General Practitioners to develop guidance for handling telephone advice/triage in primary medical care settings.

This response was received on 4 February 2020.

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