Suspected testicular torsion - urological or general surgical emergency?

Suspected testicular torsion (TT) is a surgical emergency, usually requiring urgent scrotal exploration. Provision of urology on-call cover varies widely between hospitals and often falls under the remit of the general surgical team. The purpose of this study was to investigate whether the management of suspected TT differed between urology (UT) and surgical (ST) trainees in the Severn and South West Peninsula Deaneries.

An on-line questionnaire (SurveyMonkey. com) was sent to all UT and ST within the Deaneries. Questions covered training, on-call cover, intra-operative management and knowledge of complications following testicular fixation. Responses were analysed using an Excel spreadsheet and GraphPad statistical package.

Responses were received from 26/31 UT and 43/52 ST throughout 17 hospitals. Only three hospitals had separate middle-grade specialist urology cover. Scrotal exploration was taught by urologists to 72% of UT compared with 40% of ST (P = 0.012, Fisher's exact test). Variability in the number of operations performed, supervision and management of true TT was insignificant. However, ST were more likely to fix a normal testicle either in the absence of other pathology (53% vs 28%) or with a twisted appendix testis (42% vs 15%) than UT (P = 0.045 and P = 0.032, respectively). UT were more aware of evidence regarding chronic pain (47% vs 14%) and infertility (53% vs 18%) following testicular fixation than ST (P = 0.005 and P = 0.003, respectively). Medicolegally, 76% of UT would inform the on-call consultant prior to operation compared with 45% of ST (P = 0.012).

ST are significantly more likely to fix a normal testicle than UT (and then usually only on the affected side), contrary to best-practice. This variation may be due to the different sources of training received by the two groups. Knowledge of possible chronic pain and infertility following testicular fixation may also affect management.

Due to the variation, we suggest urology departments should draw up guidelines for management; trainees should be encouraged to discuss the case pre-operatively with the consultant; core surgical training should include a urology placement.