Baby Boy is delivered on November 19, 2019. He was small for gestational age (2840 grams/ 48.5cm birth length) On admission to Nursery he is evaluated by APRN for pediatric hospitalist. APRN notes normal external male genitalia and scrotal edema.
Baby is seen again on November 20, 2023 by different rounding APRN for hospitalist group. On exam he is noted to have normal external genitalia and descended bilateral testes.
Baby is discharged on November 21, 2023. APRN notes at that time "normal external genitalia".
Baby begins seeing out patient pediatrician on November 22, 2023. The Peds MD notes "testes down" and genitalia grossly normal.
Follow up visits with Peds MD occur on December 4, 2023, January 24, 24 and April 1, 2024. At each visit, Peds MD notes testes down.
Baby is subsequently seen on May 20, 2024 by Peds MD. During this visit, Peds MD notes that the male left testicle was "not palpable". Her plan was to reevaluate in one month.
On June 19, 2024 at 2242, Mom brings Baby to emergency room with complaints that Baby is having groin pain and swelling. He had reported discomfort with diaper changes for two days and poor appetite. The ED MD notes swelling to the left inguinal area and that he was unable to palpate the left testicle. An ultrasound is completed and interpreted as showing "A heterogenous, ovoid shaped structure within the left goin, favored to represent the undescended left testicle. It is difficult to determine if this represents an enlarged left testicle with intratesticular lesions-herterogeneity versus the left testicle and an adjacent prominent epididymis. There is color flow at the periphery and internal vascular waveforms are noted. Intermittent torsion of the undescended left testicle with areas of infarction are a consideration." Baby is transferred to facility with peds urologist at 0205.
Baby seen at 0314 by peds urologist. He notes Mom only noted left groin swelling and inflammation last night. He further noted that family has never seen testicle within the scrotum. Mom states left groin became hard and left scrotum became more enlarged which prompted visit to ER. Peds Urologist noted that on repeat scrotal sonogram, there appeared to be some congestion of the cord and flow to the cord itself. There was artifact when patient was crying, however, he found no convincing intratesticular flo.w. He recommended surgical exploration.
Surgery begins at 0541. Peds Uro notes left testicle to be located just outside the external ring with a severe inflammatory fibrinous phlegmonic type of reaction. The testicle was fixed within the inguinal position and demonstrated necrosis of with 540 degrees of clockwise torsion. The testicle was untwisted and appeared nonviable, necrotic black testicle, epididymis and distal cord structures.
Exploration and fixation of the right testicle revealed evidence of bell clapper and almost complete inversion anatomy of the testis.
Questions:
1. Given the surgical description and findings on ultrasound, is it likely the left testicle had ever descended as described by the APRN's after birth and the outpatient pediatrician?
2. If the answer is yes to 1, why would it then be in the inguinal canal.
3. Was an emergent or urgent referral to a pediatric urologist warranted in May 2024, when the pediatrician first notes undescended left testicle? This would have been around the 6 month visit after birth.
4. Assuming an urgent referral is made to a peds urologist on May 20, 2024 by the pediatrician, would the standard of care of necessitated the peds urologist to complete an ultrasound of the testicle and take the Baby surgery for the undescended testicle before he begins exhibiting symptoms on June 18, 2024?
5. Simply put, I am determining whether an earlier referral by the pediatrician on May 20, 2024 to peds urologist would likely have changed the outcome.
Files:
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Do you believe there might have been medical error?
I assume that the baby was delivered on November 19, 2023, not 2019 as noted in the narrative. At birth and on days 1 and 2 both testicles were noted to be descended. At 4 subsequent visits by an MD up to April 1, 2024, both testicles were noted to be descended. On May 20, 2024, the left testicle was nonpalpable. The pediatrician appropriately recommended a follow-up evaluation in 1 month. Before the follow-up visit occurred, the baby developed torsion of an inguinal undescended testicle. According to the ED note, the pain/swelling had been occurring for 48 hours. An emergency inguinal US was performed and showed absent flow to the testis. The baby was transferred to a facility with a pediatric urologist, who performed emergency inguinal exploration. The torsed testicle was necrotic and was removed. Torsion of an undescended testicle is an uncommon but well documented phenomenon. Below are several recent articles regarding this problem: https://pubmed.ncbi.nlm.nih.gov/29264215/ https://pubmed.ncbi.nlm.nih.gov/38313930/ https://pubmed.ncbi.nlm.nih.gov/34631427/ https://pubmed.ncbi.nlm.nih.gov/31272681/ https://pubmed.ncbi.nlm.nih.gov/29429568/ https://pubmed.ncbi.nlm.nih.gov/37455785/ Torsion of an undescended testicle is unpredictable. When a baby has an undescended testicle, referral is appropriate and orchiopexy is recommended to maximize the fertility potential of the testis. Even if the baby was recognized as having an undescended testicle at an earlier age and he had been referred to a pediatric urologist or pediatric surgeon, it is unlikely that the baby would have undergone an orchiopexy by 6 or 7 months. In fact the Guidelines by the American Urological Association on undescended testicle recommend orchiopexy by 1 year if the condition was recognized at birth and by 18 months if the condition was recognized after the neonatal period. 1. Yes, but I think that the testicle had retracted to an undescended position. 2. This is to position to which retractile testicles typically ascend. 3. Referral would have been appropriate but is not the standard of care at that point, based on the previous documentation that the testis was descended. 4. No. In fact, the AUA Guidelines specifically recommend not performing an US in this setting. In reality, often in this setting I am able to palpate the inguinal testis even if the pediatrician was unable to palpate it. 5.In my opinion, earlier referral would not have changed the outcome..
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
At birth and on days 1 and 2 both testicles were noted to be descended. At 4 subsequent visits by an MD up to April 1, 2024, both testicles were noted to be descended. On May 20, 2024, the left testicle was nonpalpable. The pediatrician appropriately recommended a follow-up evaluation in 1 month. Before the follow-up visit occurred, the baby developed torsion of an inguinal undescended testicle. According to the ED note, the pain/swelling had been occurring for 48 hours. An emergency inguinal US was performed and showed absent flow to the testis. The baby was transferred to a facility with a pediatric urologist, who performed emergency inguinal exploration. The torsed testicle was necrotic and was removed. Torsion of an undescended testicle is an uncommon but well documented phenomenon. Below are several recent articles regarding this problem: https://pubmed.ncbi.nlm.nih.gov/29264215/ https://pubmed.ncbi.nlm.nih.gov/38313930/ https://pubmed.ncbi.nlm.nih.gov/34631427/ https://pubmed.ncbi.nlm.nih.gov/31272681/ https://pubmed.ncbi.nlm.nih.gov/29429568/ https://pubmed.ncbi.nlm.nih.gov/37455785/ Torsion of an undescended testicle is unpredictable. When a baby has an undescended testicle, referral is appropriate and orchiopexy is recommended to maximize the fertility potential of the testis. Even if the baby was recognized as having an undescended testicle at an earlier age and he had been referred to a pediatric urologist or pediatric surgeon, it is unlikely that the baby would have undergone an orchiopexy by 6 or 7 months. In fact the Guidelines by the American Urological Association on undescended testicle recommend orchiopexy by 1 year if the condition was recognized at birth and by 18 months if the condition was recognized after the neonatal period.
What makes you a good expert for this case?
I am a board certified pediatric urologist. I perform > 100 orchiopexies per year and have seen several boys with torsion involving an undescended testis.
How often do you encounter cases similar to this one in your practice?
Approximately once every 4 or 5 years.
Do you believe there might have been medical error?
There were multiple different documentation events suggesting normal testis then one documentation of undescended testis. This is not uncommon - it is called an ascended testis or can be a normal finding with growth (originally undescended but due to a long gubernaculum, looks descended until pelvic growth outpaces gubernaculum stretching). Either way, presentation after 2 days of symptoms is ominous - likely too long to save the testis with surgical intervention.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Unsure what’s being asked here. Causation - no. Associated findings yes - torsion is more common in an undescended testis. Unfortunately patient presentation too late after symptoms started.
What makes you a good expert for this case?
Significant experience with undescended testes, ascended testes and testis torsion including multiple papers.
How often do you encounter cases similar to this one in your practice?
I encounter each of these diagnoses multiple times every week (unfortunately).
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