Undescended testis

Baby LM was taken to see his GP, Dr E, for his six-week check. During this examination Dr E noted that his left testis was in the scrotum but his right testis was palpable in the canal. He asked LM’s mother to bring him back for review in a month.

Two weeks later his mother brought him to see Dr E because he had been more colicky and had been screaming a lot in the night. As part of that consultation, Dr E documented that both testes were in the scrotum.

LM was brought for his planned review with Dr E in another two weeks. Both testes were noted to be in the scrotum although this time the left testis was noted to be slightly higher than the right. His mother was reassured.

When LM was 16-months-old he appeared to be in some discomfort in the groin when climbing stairs. His mother was worried so she took him back to Dr E for a check-up. Dr E examined him carefully and documented that both testes felt normal and were palpated in the descended position. He also noted the absence of herniae on both sides. He advised some paracetamol and advised his mother to bring him back if he did not improve.

When LM was 15-years-old he noticed that one of his testicles felt different to the other. At that time he was found to have a left undescended testis which was excised during surgical exploration. LM’s mother felt that Dr E had missed signs of his undescended testis when he was younger. A claim was brought against Dr E, alleging that he had failed to carry out adequate examinations and that she should have referred to the paediatric team earlier. It was claimed that if Dr E had referred to paediatrics earlier then this would have resulted in a left orchidopexy, placing the testis normally in the scrotum before the age of two years and thus avoiding removal of the testis. 

Expert opinion

Medical Protection obtained expert opinions from a GP and a consultant in paediatric surgery. Both were supportive of Dr E’s examination and management. The consultant in paediatric surgery thought that LM had an ascending testis. This is a testis which is either normally situated in the scrotum or is found to be retractile during infancy, and later ascends. He thought that even if LM had been referred in infancy, it would have been likely that examination would have found the testes to be either normal or retractile and he would have been discharged with reassurance. He explained that it is thought that in cases of ascending testis testicular ascent occurs around the age of five years. Therefore, on the balance of probabilities, referral to paediatrics before the age of four would not have led to diagnosis of an undescended testis.

This claim was dropped after Medical Protection issued a letter of response to the claimant’s legal team which carefully explained the expert opinion.

Learning points

• Medical Protection were able to defend Dr E in light of his appropriate clinical management, good note-keeping and the expert advice.
• Good documentation helped Dr E’s defence. Doctors should always document the presence or absence of both testes in the scrotum at the six-week check.
• A testis that is retractile or normally situated in the scrotum in infancy can ascend later. NHS-choices have a useful leaflet for parents outlining that “retractile testicles in young boys aren’t a cause for concern, as the affected testicles often settle permanently in the scrotum as they get older. However, they may need to be monitored during childhood, because they sometimes don’t descend naturally and treatment may be required”1.
• NICE have published a Clinical Knowledge Summary that covers the primary care management of unilateral and bilateral undescended testes, including referral.

References

1. nhs.uk/conditions/undescendedtesticles/Pages/Introduction.aspx