Testicular Torsion Missed in the Emergency Room — How These Malpractice Cases Get Built

A teenager or a young man comes to the emergency department with sudden, severe pain in one testicle. It came on fast, maybe woke him from sleep, and it is bad enough that he feels sick to his stomach. The scrotum is swollen and tender. He is told it is probably an infection — epididymitis — given antibiotics and pain medicine, and sent home with instructions to follow up. Hours later the pain is worse, and by the time anyone looks again the testicle cannot be saved. The diagnosis was testicular torsion the whole time: the cord that carries blood to the testicle had twisted and cut off its own blood supply, and the clock that decides whether the testicle survives had been running since the pain began.

Testicular torsion is one of the true time-critical emergencies in medicine, and it is also one of the most litigated diagnoses in emergency care — because the window to save the testicle is measured in hours, the workup is well defined, and the delay is usually measurable to the minute in the chart. This guide explains what torsion is, what separates a genuinely hard case from a diagnostic error, the examination and imaging the standard of care is built around, why a “normal” ultrasound can be a trap, why the surgical clock matters so much, and the records that decide these cases.

What Testicular Torsion Is

Testicular torsion occurs when the spermatic cord — the bundle that carries blood to and from the testicle — twists on itself, choking off the testicle’s blood supply. Deprived of blood, the tissue becomes ischemic and begins to die. It is most common in adolescents and young men, often in those with a congenital anatomic variant called a “bell-clapper” deformity that lets the testicle rotate freely, but it can happen at any age, including in newborns. The onset is typically sudden and the pain severe, frequently with nausea or vomiting, and it can begin during sleep, after activity, or after minor trauma.

The reason speed is non-negotiable is what happens without it. According to a 2013 review in American Family Physician by Sharp, Kieran, and Arlen, testicular salvage rates are 90 to 100 percent when surgery is performed within six hours of symptom onset, drop to roughly 50 percent after 12 hours, and are typically under 10 percent once symptoms have lasted 24 hours or more. The definitive treatment is emergency surgery — untwisting the cord to restore blood flow and fixing both testicles in place to prevent a recurrence. Nothing else substitutes for it: pain control and antibiotics do not relieve the strangled blood supply, and only the operating room does.

The Standard of Care: Examine It, Suspect It, and Operate — Fast

No one expects an emergency physician to send every case of scrotal pain to surgery. What the standard of care asks is that clinicians perform a proper genitourinary examination, know the presentation that should raise suspicion, take that suspicion seriously when it is present, and move quickly to urology and the operating room rather than settling on “infection” and waiting. The governing principle across the emergency-medicine and urology literature is simple: sudden, severe testicular pain is torsion until proven otherwise, and a high index of suspicion should trigger urgent surgical consultation without waiting on imaging.

The physical examination and the warning signs

The examination is where torsion is most often won or lost. Classic findings described in the American Family Physician review include a high-riding testicle, an abnormal horizontal (rather than vertical) orientation of the affected testicle, and an absent cremasteric reflex — the normal reflex in which stroking the inner thigh draws the testicle upward. The review notes that the presence of the cremasteric reflex suggests, but does not confirm, the absence of torsion; its absence is a recognized red flag. A recurring theme in the malpractice literature is that when the genitourinary examination is skipped or rushed, these findings are never elicited — and a 2025 scoping review in Cureus by George and colleagues flagged failure to perform an adequate exam as a driver of misdiagnosis.

The TWIST score

To make that examination systematic, clinicians increasingly use the TWIST score (Testicular Workup for Ischemia and Suspected Torsion), which assigns points for testicular swelling, a hard testicle, an absent cremasteric reflex, nausea or vomiting, and a high-riding testis. A validation study by Sheth and colleagues in the Journal of Urology (2016) found that a high-risk score identified torsion with very high specificity — a top score of 7 reached 100 percent positive predictive value in that cohort — while a low-risk score made torsion very unlikely. The point of the tool is not to replace judgment but to structure the exam so the red flags are actually checked and recorded, and quality-improvement studies have found the score is documented in only a small fraction of cases where it would help.

The ultrasound trap

Color Doppler ultrasound of the scrotum is a useful test, but it is dangerous when used backward — to rule torsion out in a patient the exam already flags. Pooled data summarized in the emergency-medicine literature put its sensitivity at roughly 86 percent and specificity around 95 percent, which means a real share of true torsions are missed by the scan. In incomplete, partial, or intermittent torsion the ultrasound may still detect blood flow and read as normal while the cord is twisting. The American Family Physician review is explicit that in patients with a suggestive history and examination, imaging should not be performed — they should undergo immediate surgical exploration — because the delay from imaging extends the time of ischemia and lowers salvage. This is the same logic that governs our other emergency-room guides, such as stroke missed in the emergency department and sepsis missed in the hospital: each has a documented input and a documented output, so a reviewer can measure exactly what was done against what the pathway required, and exactly when.

The Surgical Clock

Torsion is a stopwatch diagnosis, and the timing evidence is stark. A systematic review of testicle survival time after a torsion event by Mellick and colleagues (Pediatric Emergency Care, 2019) reported salvage in roughly 97 percent of cases operated within 0 to 6 hours, about 79 percent at 7 to 12 hours, about 61 percent at 13 to 18 hours, about 43 percent at 19 to 24 hours, and about 24 percent beyond 24 hours. The 2025 Cureus scoping review put it plainly: delay is “the most important determinant of outcome in testicular torsion.” Time to the operating room is, by a wide margin, the factor clinicians can most influence — and the one a malpractice review can measure most precisely.

That measurability is the point. Because the arrival time, the vital signs, the pain score, the examination note, the ultrasound order and result, the urology consult, and the incision time are all time-stamped, a reviewer can reconstruct exactly where the delay happened: whether the exam was done, whether suspicion was raised and simply not acted on, whether the patient was sent for imaging that pushed the surgery past the salvage window, or whether a urology consult was requested and slow to arrive. One especially dangerous variant is intermittent torsion — pain that comes and goes as the cord twists and partly untwists — because the pain-free interval and a reassuring ultrasound are wrongly taken as an all-clear and the patient is discharged shortly before a complete torsion.

The Patterns of Failure

Labeled epididymitis and sent home

The most common pattern: a young man with sudden severe scrotal pain is diagnosed with epididymitis or another infection, given antibiotics, and discharged — without the red flags that separate torsion from infection being examined for or recognized.

The genitourinary exam skipped or rushed

The chart records “scrotal pain” but no documented assessment of testicular lie, the cremasteric reflex, or a TWIST score, so the findings that would have pointed to torsion were never elicited in the first place.

A “normal” ultrasound used as reassurance

A Doppler study that shows blood flow — or is read as normal in a partial or intermittent torsion — is treated as ruling torsion out in a patient whose sudden severe pain and exam should have kept the suspicion alive, exactly the pitfall the literature warns against.

Imaging allowed to delay surgery

A high-suspicion patient is sent to wait hours for an ultrasound or a formal radiology read before urology is even called — pushing the operation past the six-hour window while the testicle is strangled.

Return visits and worsening pain dismissed

A patient sent home with “infection” comes back hours later in worse pain, or calls reporting rapid worsening, and is reassured or told to keep taking the antibiotics rather than re-examined and taken to surgery.

The atypical or younger patient underestimated

A child, an adolescent who is embarrassed to be examined, or a patient whose pain is felt more in the abdomen than the scrotum is presumed to have a routine problem, and the possibility of torsion is never seriously entertained.

What the Records Show

Testicular torsion cases are built on a specific, largely objective set of records, most of it time-stamped:

• The triage note and nursing assessment — when the patient arrived, the vital signs, the pain score, and when the pain reportedly began.
• The physician’s history and physical — whether a genitourinary examination was performed and what it recorded about testicular lie, swelling, and the cremasteric reflex, and what diagnosis was assigned.
• The ultrasound order, images, and radiology report — when the scan was ordered, when it was done and read, and whether a “normal” or equivocal result was used to downgrade concern.
• The urology (or surgical) consult — when it was requested, when the consultant responded, and what was recommended.
• The operative report — the time of incision, the degree of torsion found, and whether the testicle was saved or removed, which establish how much time passed and how far the ischemia had progressed.
• The discharge instructions and any return-visit records — what a discharged patient was told, and what happened when they came back.

Because so much of this is generated automatically and stamped with a time, these cases often turn less on competing expert stories and more on a timeline: when the pain started, when the patient arrived, what the exam showed, what was documented, and how long it took — if it happened at all — for the patient to reach a urologist and an operating room.

The Medical-Legal Read

Proving a missed torsion case takes both clinical and legal training, because the answer usually lives in the details of the workup — whether the genitourinary examination was done, whether the red flags were recognized, whether a “normal” ultrasound was misused as reassurance, and above all the interval from presentation to surgery — not in a single dramatic moment. At The Alvarez Law Firm, Herb Borroto, M.D., J.D. (Medical-Legal Expert) reads the emergency chart the way a physician reads it — checking whether the exam findings were elicited and recorded, whether urology was called when suspicion should have been raised, and measuring the exact interval from arrival to detorsion against what the standard required. Alex Alvarez (Managing Partner, Board Certified Civil Trial Lawyer) then frames that record for a jury: not as an impossible diagnosis, but as a well-defined, time-critical emergency with red flags that were documentable and a surgical escalation that was available and delayed. A doctor reading the medicine and a board-certified trial lawyer proving the case is how these claims are tested before they are ever filed.

Proving Causation and Damages

Every malpractice claim must prove the same four elements — duty, breach of the standard of care, causation, and damages. In a missed torsion case the defense typically concentrates on causation, arguing that the testicle was already beyond saving by the time the patient arrived. Establishing causation means showing what a timely diagnosis would have changed — that operating within the salvage window, while blood flow could still be restored, would more likely than not have preserved the testicle that the delay allowed to be lost. The damages picture commonly includes:

• The cost of the surgery to remove the lost testicle (orchiectomy) and any follow-up care, including a prosthesis.
• Effects on fertility and hormone function, and the cost of evaluating and managing them.
• Physical pain and the ongoing psychological impact, including on body image and, for adolescents, on development.
• Lost wages for time in treatment and recovery.
• Pain, suffering, and loss of enjoyment of life. See our guide to medical malpractice filing deadlines for how the statute of limitations works, including the discovery rule and the special rules that apply when the patient is a minor.

Who Is Responsible

Liability for a missed torsion can reach more than one party, and sorting it out is its own analysis — covered in our guide to hospital negligence versus doctor malpractice. The emergency physician may be responsible for failing to examine for or escalate the warning signs; a triage nurse or the hospital’s systems may be responsible for a delay in obtaining a urology consult or an ultrasound; an on-call urologist may be responsible for a slow response; and a receiving hospital may be responsible for a delay in transferring a patient to a facility that could operate. Because emergency physicians are frequently independent contractors rather than hospital employees, whether the hospital is directly on the hook can turn on the doctrine of apparent agency, which that guide explains.

What Patients Should Preserve

When you believe a missed testicular torsion harmed you or a family member, the emergency-department, imaging, and operative records are the heart of the case — and they are best requested early:

• Request the complete emergency-department record from the first visit under the federal HIPAA right of access — the triage note, vital signs, the physician’s history and physical (including any genitourinary exam), all orders, and the discharge instructions. Do not settle for the discharge summary alone.
• Ask specifically for the ultrasound images and the radiology report with timestamps, and for the urology consultation note and the operative report, including the time of incision and whether the testicle was saved.
• Preserve the records of any return visit and of the surgery and hospitalization that followed, which establish how the torsion progressed and what was ultimately found.
• Write down what you remember about the symptoms and their timing — especially when the pain began and how fast it worsened — and what you were told at the first visit, while it is fresh.
• Keep the discharge paperwork from the first visit, which usually states the diagnosis the patient was given.
• Note the names of every physician and nurse involved at each visit.

Our guide to the medical records your lawyer needs walks through the broader request process.

Frequently Asked Questions

What is testicular torsion and why is it an emergency?

Testicular torsion happens when the spermatic cord twists on itself and cuts off the blood supply to the testicle. Because the testicle is being strangled, the tissue begins to die within hours, which is why torsion is a true surgical emergency. According to a 2013 American Family Physician review by Sharp, Kieran, and Arlen, testicular salvage rates are 90 to 100 percent when surgical exploration happens within six hours of symptom onset, fall to roughly 50 percent after 12 hours, and are typically under 10 percent once symptoms have lasted 24 hours or more. The definitive treatment is emergency surgery to untwist the cord and restore blood flow, and every hour of delay lowers the chance the testicle can be saved. That is why the standard of care treats sudden severe testicle pain as torsion until proven otherwise, rather than assuming a less dangerous cause.

Why is testicular torsion missed in the emergency room?

Because its symptoms overlap with far more common and far less dangerous conditions. Sudden scrotal pain, swelling, and nausea can look like epididymitis, orchitis, a urinary infection, or even a muscle strain, and torsion is often dismissed as one of those. A 2025 scoping review in Cureus by George and colleagues cited data showing that about 31.7 percent of torsion patients in one study were initially misdiagnosed, and identified diagnostic delay as the single most important determinant of whether the testicle survives. Two specific traps drive these misses: skipping or rushing the genitourinary examination so the classic findings — a high-riding, horizontally lying testicle and an absent cremasteric reflex — are never elicited, and treating a color Doppler ultrasound that shows blood flow as proof that torsion is not present. Younger patients and those with intermittent or partial torsion are especially likely to be missed.

Does a normal ultrasound rule out testicular torsion?

No. Color Doppler ultrasound is useful, but it does not rule torsion out. Pooled data summarized in the emergency-medicine literature put its sensitivity around 86 percent and specificity around 95 percent — meaning a meaningful share of true torsions are missed by the scan. In incomplete, partial, or intermittent (comes-and-goes) torsion, the ultrasound may still show blood flow and read as reassuring while the cord is twisting. The accepted teaching is that when the history and physical examination strongly suggest torsion, the patient should go to surgical exploration and imaging should not delay it. The 2013 American Family Physician review states that in patients with a suggestive history and exam, imaging should not be performed; they should undergo immediate surgical exploration, because the delay from imaging extends ischemia time and lowers salvage rates.

Is a missed or delayed testicular torsion diagnosis always malpractice?

No. Torsion can be genuinely difficult to diagnose, especially when the presentation is atypical or intermittent, and not every lost testicle is the result of negligence — just as not every bad outcome is malpractice. The question is whether the care fell below the standard a reasonable physician would have met with the information available. A reviewer asks whether a proper genitourinary examination was performed and documented, whether the classic red flags were recognized, whether a urology consultation was obtained promptly when suspicion should have been raised, whether a “normal” ultrasound was wrongly used to dismiss a high-suspicion patient, and how much time passed between arrival and the operating room. A malpractice case turns on a preventable deviation from that standard and on proof that earlier surgery would, more likely than not, have saved the testicle.

If You or a Family Member Had Testicular Torsion Missed

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• See how another time-critical emergency-room miss is built: Stroke Missed in the Emergency Department.
• See how a delayed-infection case is built: Sepsis Missed in the Hospital.
• Understand the line between an error and a hard case: Bad Outcome vs. Medical Malpractice.
• Learn what every case must prove: The Four Elements of Malpractice.

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Sources

• Sharp VJ, Kieran K, Arlen AM. — “Testicular Torsion: Diagnosis, Evaluation, and Management.” American Family Physician, 2013;88(12):835-840. aafp.org
• George AO, Olalekan A, Omiko R, et al. — “Trends in the Management of Testicular Torsion: A Scoping Review of Delays and Outcomes.” Cureus, 2025. pmc.ncbi.nlm.nih.gov
• Sheth KR, Keays M, Grimsby GM, et al. — “Diagnosing Testicular Torsion before Urological Consultation and Imaging: Validation of the TWIST Score.” Journal of Urology, 2016. sciencedirect.com
• Mellick LB, Sinex JE, Gibson RW, Mears K. — “A Systematic Review of Testicle Survival Time After a Torsion Event.” Pediatric Emergency Care, 2019. pubmed.ncbi.nlm.nih.gov
• Laher A, Ragavan S, Mehta P, Adam A. — “Testicular Torsion in the Emergency Room: A Review of Detection and Management Strategies.” Open Access Emergency Medicine, 2020. dovepress.com
• Ta A, D’Arcy FT, Hoag N, et al. / StatPearls — “Testicular Torsion.” NCBI Bookshelf, National Institutes of Health. ncbi.nlm.nih.gov