S. Dean, T. Molitor, A. Mayell

University Hospitals Coventry and Warwickshire (UHCW) NHS Trust, UK


Paediatric testicular torsion is a urological emergency. NICE guidance states surgical repair should occur within four hours (1). This quality improvement project reviewed the management of paediatric torsion over two years at a large university Trust.


Paediatric anaesthetists, during the pandemic, had concerns that children were increasingly undergoing emergency inhalational inductions. This was due to no, or inadequate topical local anaesthetic (LA) being applied in ED before induction, putting children at additional risk.

Strategy for change

We set the following standards:

  1. 100% patients receive topical LA in ED when presenting with scrotal pain?
  2. How many gas inductions are performed on patients with full stomachs and why? Were there adverse events?
  3. How many emergency scrotal explorations prove to be torsions?
  4. Are there delays between admission, decision to operate, booking and anaesthesia?

Measure of improvement

We performed a retrospective data collection on all emergency scrotal explorations performed at UHCW NHS Trust in 2019-2020, pre-Covid, and 2020-2021, during the pandemic, when cases were consultant led out of hours.

Data on time intervals, anaesthetic management and the use of topical LA were sought.

Lessons learnt

Results are shown in table 1. We follow the NICE guidelines for emergency scrotal surgery in over 80% of children. However, we identified unnecessary delays in the patients journey to theatre, and inadequate topical LA use for emergency paediatric surgery. Time from surgical decision to theatre indicated that even if topical LA was applied at surgical decision, there was time for this to be effective. This led to children having an unnecessarily painful cannula in 30% and 56% of cases respectively. Gas inductions were performed regularly on non-fasted children. No adverse anaesthetic events were recorded.

Message for others

This QI project highlighted several areas for further improvement.

  • Topical LA administration as standard on initial assessment in Paediatric ED for all children with testicular pain.
  • Updating guidelines/pathways in children’s ED urology and training.
  • Re-audit with standards implemented - in progress.


  1. National Institute for Health and Care Excellence. Clinical Knowledge Summaries: Scrotal pain and swelling. 2024. https://cks.nice.org.uk/topics/scrotal-pain-swelling/ [Accessed 1st February 2024]
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