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Expert working group develops national consensus pathway for suspected testicular torsion

A new pathway aiming to reduce delays and prevent more boys and young men losing a testicle as a result of testicular torsion has been developed by the GIRFT team.

GIRFT has brought together a multi-disciplinary group of more than 50 NHS colleagues – comprising urologists, paediatric surgeons, general surgeons, anaesthetists, emergency care physicians, radiologists and Operational Delivery Network (ODN) leads – to build a national consensus pathway for best practice in the management of acute testicular pain.

Trusts, systems and networks implementing the pathway can not only shorten the time between the onset of testicular pain and surgical treatment for torsion, reducing the number of testicles being lost due to this time-sensitive condition, but can also limit the number of patients having unnecessary surgery when their pain is not caused by testicular torsion.

"GIRFT’s work to review paediatric surgical services across England highlighted to us that many boys are presenting late to a healthcare practitioner; too late for the testis to be saved. We also found that testicular torsion represents a challenge for hospitals in terms of capability and delays in surgery as a result of transfers. This pathway can help to streamline care and supports clinical decision making to get the right child to theatre at the right time, while limiting the number of children and young people who undergo surgery and are then found to not have torsion.”

Join our webinar

 GIRFT is holding a webinar on 27 February (1pm) to highlight the pathway and to discuss the importance of engagement with boys and young adults and their parents/carers to raise awareness of testicular torsion.

Background to the pathway

Testicular torsion is a time-critical surgical emergency, which occurs when a testicle twists, cutting off the blood supply and causing sudden scrotal pain. Torsion can happen at any age but is most common in teenagers and young adults, and it occurs in around 1 in 1,000 boys between the age of 10 and 20. If a testicle is twisted, it can die within six hours unless the patient has emergency surgery.

The Getting It Right First Time (GIRFT) national report on paediatric general surgery and urology, authored by Professor Kenny, found that some boys and young adults with testicular torsion were reaching surgery too late for their testes to be saved. Among the contributing factors were delays in the boy or their family seeking medical help, and delayed transfers between providers for surgery. The new pathway fulfils a recommendation in the GIRFT report, supporting ODNs to ensure that all boys with suspected testicular torsion are assessed promptly and treated close to home to reduce the incidence of testicular loss.

The GIRFT pathway coincides with publication of the National Confidential Enquiry into Patient Outcome and Death (NCEPOD) report Twist and Shout (published 8 February 2024), which reports on a review of the pathway and quality of care provided to 827 children and young people aged 2-24 who presented to hospital with testicular torsion between 2021-22.

While the findings of the review were broadly positive about the NHS care young patients receive, NCEPOD concluded that:

  • There needs to be greater public awareness about testicular torsion: testicular torsion was not recognised by 66% patients or 36% of parents/carers.
  • Pathways should be in place to minimise the need for transfers: where possible, patients should be directed to hospitals where surgery for testicular torsion can be performed, with transfer arrangements in place where services are not available. Patients not on a pathway were more likely to have their testicle removed (40%) compared with those who were (24%).
  • Hospitals should be equipped to deal with testicular torsion as an emergency, with senior clinicians able to review the patient and carry out urgent surgery: 9% of patients waited more than four hours for a senior surgical review, and there was a delay in diagnosis for 18% of patients.

It is hoped that the new GIRFT pathway can help to address many of the NCEPOD findings.

Raising awareness to prevent delays

GIRFT has recognised that the time between the onset of pain and contact with a healthcare practitioner can often be delayed because of the private and sensitive nature of the condition. A consensus statement within the pathway states that education about testicular torsion should be delivered by schools, so that boys experiencing acute testicular pain recognise the signs of torsion and the importance of acting quickly, and feel confident in reporting it to an adult.

While the GIRFT pathway is for clinicians – beginning at the point of presentation whether at a GP practice, the emergency department or to NHS 111 – the working group recognised that awareness is key to ensuring timely presentation. GIRFT is now working with the Office for Health Improvement and Disparities (OHID) and the Department for Education (DfE) to discuss delivery of education in schools and how to effectively raise awareness through online resources.

“We know that many boys present to hospital late because they are too embarrassed or reluctant to discuss the pain they are experiencing with their parents or with school staff. We are working to promote a series of NHS-endorsed online resources developed by UK clinicians, including information for teenagers, parental information and lesson plans for schools, to help integrate education about testicular torsion into the personal, social, health and economic (PSHE) national curriculum.”

Components of the GIRFT pathway

 Among the 28 consensus statements which form the GIRFT pathway are:

  • ICBs and ODNs should develop a clear pathway from primary to secondary care for CYP with testicular pain, to ensure that a child is referred to a centre where they can receive definitive management for testicular torsion.
  • NHS111 algorithms and primary care should have a low threshold for immediate referral for children with acute testicular pain to a hospital where scrotal exploration can be performed on site for that child.
  • Referral pathways should minimise the number of transfers a patient undergoes, aiming for a maximum of one transfer between healthcare providers (including transfer from primary to secondary care).
  • Timely evaluation by a surgical decision maker means review within 60 minutes of a child or young person with testicular pain arriving at the emergency department.
  • Surgeons and anaesthetists caring for children with acute testicular pain should maintain their skills and competency to ensure they can assess and operate on young patients without delay.

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