Testicular Cancer Misdiagnosed as Epididymitis in Oregon

Testis cancer is, in the words of the American Urological Association's guideline, "the most common solid malignancy in young males."¹ Its usual presentation is not the one most people picture. The guideline describes "a painless, enlarging mass," and says acute testicular pain "is less common," arising from rapid expansion of the testis due to intra-tumor hemorrhage or infarction.¹

Epididymitis, by contrast, hurts. So when a testicular mass does present with pain and swelling, two very different conditions can look alike in the same place. The guideline records that diagnostic delay "is a common phenomenon, with both patients and physicians contributing to this delay."¹

The difficulty is what happens when the antibiotics do not fix it. A course of treatment that produces no improvement is information, and the question in these cases is whether anyone treated it as information.

What the urology guideline says to do with a mass

The American Urological Association's guideline on early-stage testicular cancer sets out the first steps, and the first one is a posture rather than a test.

Statement 1 provides that "a solid mass in the testis identified by physical exam or imaging should be managed as a malignant neoplasm until proven otherwise." The AUA designates that a Clinical Principle — in its framework, a statement of widely agreed practice rather than one graded on a body of evidence.¹

Statement 4 addresses imaging: "Scrotal ultrasound with Doppler should be obtained in patients with a unilateral or bilateral scrotal mass suspicious for neoplasm." That one is graded a Strong Recommendation on Grade B evidence.¹

Statement 2 addresses blood work: in a man with a solid testicular mass suspicious for malignant neoplasm, serum tumor markers — AFP, hCG and LDH — "should be drawn and measured prior to any treatment, including orchiectomy." That is a Moderate Recommendation on Grade C evidence.¹

Three statements, three different weights. The AUA is explicit about which of its statements rest on graded evidence and which rest on agreed principle, and reading them as interchangeable loses information the guideline deliberately encoded.

What the ultrasound shows, and what it does not

Ultrasound is where the imaging half of that question gets answered, and the guideline describes what the images show. It does not treat imaging as the whole answer: Statement 1 keys off a mass found on "physical exam or imaging," and the guideline addresses the infection question directly, stating that "antibiotics are inappropriate unless signs and symptoms of epididymo-orchitis … are present" — a list that includes swelling, tenderness, fever, diffuse hyperemia on ultrasound, and a urinalysis or culture indicating infection.¹ Seminomas tend toward a hypoechoic, homogeneous appearance. Non-seminomatous germ cell tumors are often more heterogeneous, with irregular margins, cystic areas and echogenic foci such as calcification, hemorrhage and fibrosis. Any hypoechoic mass with vascular flow on Doppler is highly suggestive of malignancy — though the guideline adds a caution that matters in a negligence review: the absence of flow does not exclude a germ cell tumor.¹

That last clause is worth dwelling on. A negative-looking Doppler is not a clearance, and a report that reads as reassuring on flow alone does not answer the question Statement 1 poses.

Situations that raise the question in a records review include these. A palpable mass is documented and treated empirically for infection with no imaging ordered. Antibiotics are prescribed, the symptoms persist, and a second and third course follow without ultrasound. An ultrasound is ordered, a mass is described, and no urology referral is made. A patient returns repeatedly over months and each visit is treated as a new episode of epididymitis rather than as a failure of the previous treatment.

What Oregon law measures

A guideline and a legal duty are separate things, and Oregon sets the duty by statute.

Under ORS 677.095(1), a physician licensed to practice medicine or podiatry by the Oregon Medical Board has "the duty to use that degree of care, skill and diligence that is used by ordinarily careful physicians in the same or similar circumstances in the community of the physician or a similar community."² Subsection (2) states the same kind of duty for a physician associate licensed by the board, measured against ordinarily careful physician associates.²

The statute asks about practice — what ordinarily careful physicians do in the same or similar circumstances, in that community or a similar one. A published guideline is a document. Establishing what it said at the time of the care is a starting point for that inquiry, not a substitute for it.

The deadline, and the word that carries it

ORS 12.110(4) provides that an action for injuries "arising from any medical, surgical or dental treatment, omission or operation shall be commenced within two years from the date when the injury is first discovered or in the exercise of reasonable care should have been discovered."³

The load-bearing word is "injury," and it does not mean what a reader would assume. Under Gaston v. Parsons, 318 Or 247, 864 P2d 1319 (1994), "injury" as used in ORS 12.110(4) consists of harm, causation and tortious conduct.⁴ The two-year period does not begin until the patient knows, or in the exercise of reasonable care should know, facts that would make a reasonable person aware of a substantial possibility that all three exist. The court set that standard between two positions it rejected: actual knowledge of each element is not required, and a mere suspicion is not enough.⁵

Apply that to a young man treated for epididymitis three times. When a reasonable person in his position would become aware of a substantial possibility of the third element — tortious conduct — is not something a general rule answers. Gaston makes it a question of fact "that depends upon the nature of the harm suffered, the nature of the medical procedure, and other relevant circumstances."⁵

The court was careful in both directions, and a reader is owed both. Its illustration is drawn from surgery and is hedged: "Although, in many instances, suffering an untoward result after surgery may put a reasonable person on notice of tortious conduct, certain untoward effects can 'mask' tortious conduct." A plaintiff's failure to make further inquiry where a reasonable person would have done so is relevant too: the discovery rule, the court said, "does not protect those who sleep on their rights, but only those who, in exercising the diligence expected of a reasonable person, are unaware that they have suffered legally cognizable harm."⁵ Nothing about the discovery rule makes it safe to wait.

The same subsection sets an outer limit. It provides that "notwithstanding the provisions of ORS 12.160, every such action shall be commenced within five years from the date of the treatment, omission or operation upon which the action is based …". Where no action has been commenced within five years because of fraud, deceit or misleading representation, the statute allows suit "within two years from the date such fraud, deceit or misleading representation is discovered or in the exercise of reasonable care should have been discovered."³

That five-year limit runs from the treatment or omission rather than from discovery. Where a claim rests on a series of visits, identifying which visit the claim is built on is part of the deadline question rather than separate from it.

Getting a case reviewed

Whether a delayed testicular cancer diagnosis supports a claim depends on what the records show: what was felt and documented on examination, whether imaging was ordered and what it reported, whether tumor markers were drawn, whether a referral was made, and whether the delay changed the stage at which treatment began and what that treatment had to be. Those are questions for a review of the actual records by qualified experts.

If you are concerned that a testicular mass was treated as an infection for months, an Oregon attorney can review the records and the timeline with you.

This article is educational

This article describes Oregon law in general terms. It is not legal advice and does not create an attorney-client relationship.

Time limits matter. Most Oregon personal-injury and auto-accident claims must be filed within two years of the injury or accident. Medical malpractice claims must be filed within two years of when you knew or reasonably should have known of the negligence, with an outer limit of five years from the act itself (with a fraud exception). Wrongful death claims must be filed within three years of the date of death. Claims against public bodies (cities, counties, state agencies, public hospitals) require a notice of claim within 180 days. Missing these deadlines typically ends a case.

If you think you may have a claim, call Huegli Law at 971-317-6436 for a free case review. Todd Huegli is licensed in Oregon and consults on cases in Oregon only.

Footnotes

1. Stephenson A, Bass EB, Bixler BR, et al. Diagnosis and Treatment of Early-Stage Testicular Cancer: AUA Guideline Amendment 2023. J Urol. 2024;211(1):20–25. https://doi.org/10.1097/JU.0000000000003694 ↩ ↩² ↩³ ↩⁴ ↩⁵ ↩⁶ ↩⁷ ↩⁸

2. ORS 677.095 (Duty of care). Oregon State Legislature. https://www.oregonlegislature.gov/bills_laws/ors/ors677.html ↩ ↩²

3. ORS 12.110 and ORS 12.160 (ORS chapter 12 — limitations of actions). Oregon State Legislature. https://www.oregonlegislature.gov/bills_laws/ors/ors012.html ↩ ↩²

4. Oregon Revised Statutes Annotations — ORS 12.110 (Gaston v. Parsons). Oregon State Legislature. https://www.oregonlegislature.gov/bills_laws/ors/ano012.html ↩

5. Gaston v. Parsons, 318 Or 247 (1994) — opinion text, Oregon Reports, digitised by the Caselaw Access Project. https://static.case.law/or/318/cases/0247-01.json ↩ ↩² ↩³