53 yo active male w/ hx of aortic valve replacement 4/25/23 referred to Urologist who sees pt on 4/25/25 because of acute scrotal swelling. US ordered by PCP & done 3 days before significant for scrotal skin thickening with mild hyperemia and subcutaneous edema, moderate left hydrocele. UA blood +; nitrite +; protein +. No CBC to learn hct, hgb, or rbc. Dx: scrotal swelling. Rx antibx. Told to come back in 2 weeks. Pt dies the next day. Autopsy: hemorrhage and septic emboli complicating aortic graft failure, 1000 ml left hemothorax. Did any departure deprive the decedent of a substantial probability to avoid death?
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Q: This case has no urological negligence issues.
A: —
Do you believe there might have been medical error?
From the standpoint of the scrotal swelling, there is no direct connection of the swelling or hydrocele to the hemorrhage, hemothorax or septic emboli. Scrotal swelling is common in men after surgeries with large fluid shifts, large IV fluid loads. This is benign and resolves over days to weeks. I'd focus on the fact that the patient was discharged home 2 days after aortic valve replacement and what the standards of care are regarding this. The cause of death is directly related to the valve surgery and this is where to focus, and if vitals, labs or other findings were missed prior to discharge including issues intra-operatively.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
As answer as above. There is no urological connection to this man's death
What makes you a good expert for this case?
I have reviewed over 400 cases for all types of attorneys and testified at depo and court over 80 times. I am a urologist and urogynecologist. This case does not reflect urological negligence.
How often do you encounter cases similar to this one in your practice?
this is a common finding in clinical practice I see (-scrotal swelling)
Do you believe there might have been medical error?
Assuming patient not a diabetic, positive UTI by UA (I assume a culture ordered) and maybe some scrotal wall inflammation, he was started on an antibiotic appropriately. No evidence of a fever from above history. No skin crepitus. I do not believe his hemothorax and graft failure 2 years after original surgery is caused by scrotal finding. A CBC might have been helpful but from what is described there is no real evidence of sepsis.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
The 2 events do not seem to be related. I do not see evidence of sepsis from the note. I do see a likely UTI which may or may not be related to scrotal swelling. Possible early epididymoorchitis?
What makes you a good expert for this case?
Urologist for 37 years although mostly retired from practice I still assist my partners in surgery. I have seen a lot.
How often do you encounter cases similar to this one in your practice?
I have seen lots of scrotal swelling and UTIs but not related to heart valve issues
Do you believe there might have been medical error?
There is definitely no Urological negligence in this case. In the unlikely event that this patient was having orchitis he was covered appropriately with antibiotics.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Nothing in the scrotum led to this patient’s death
What makes you a good expert for this case?
I’ve been a general urologist for 30 years I see 20 to 30 cases of acute scrotal swelling monthly
How often do you encounter cases similar to this one in your practice?
I see 20 to 30 cases of Scrotal pain and swelling every month
Do you believe there might have been medical error?
Based on the history provided, this patient had developed a reactionary hydrocele and/or anasarca of the scrotum. The urinalysis is grossly unremarkable but may be indicative of superimposed scrotal cellulitis. The patient may have been offered antibiotic therapy, but conservative management was appropriate for this patient. There was no indication for acute urologic surgical intervention based on non-emergent presentation.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
A reactionary hydrocele and/or anasarca of the scrotum is completely unrelated to the patients cause of death. The patient died from sepsis and/or septic emboli involving his aortic valve. The scrotal issues are incidental and not causative for the patients death. Furthermore, there was no reported signs of fournier's gangrene nor necrosis involving the scrotum nor perineum.
What makes you a good expert for this case?
I am a senior urologic consultant with >17 years of experience. I work in a thriving private practice and community hospital serving more than 500,000 member patients in a large metropolitan area. I have extensive experience with scrotal pathology including abscess, hydrocele, torsion, malignant masses, benign tumors, penoscrotal trauma, as well as genitourinary prosthetic surgery, among other specialties in this field.
How often do you encounter cases similar to this one in your practice?
I am on primary call at least twice per month either during weekday or weekend calls, and I see multiple scrotal pathology cases on a routine basis.
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