What is the recommended management for a patient with methamphetamine use disorder (MUD) presenting with testicular pain and swelling?

From the Guidelines

The recommended management for a patient with methamphetamine use disorder presenting with testicular pain and swelling requires immediate urological evaluation to rule out testicular torsion, which is a surgical emergency. The patient should undergo a thorough physical examination, including the cremasteric reflex, and diagnostic imaging with a testicular ultrasound with Doppler flow studies, as suggested by the most recent guidelines 1. While addressing the acute testicular condition, it's essential to simultaneously manage the methamphetamine use disorder. This includes initiating a comprehensive substance use assessment, considering medications like bupropion (150-300 mg daily) or naltrexone (50 mg daily) to reduce cravings, and referring to behavioral therapy such as cognitive-behavioral therapy or contingency management. Acute methamphetamine intoxication may require benzodiazepines like lorazepam (1-2 mg IV/PO) for agitation or psychosis. The connection between methamphetamine use and testicular issues stems from the drug's vasoconstrictive properties, which can compromise blood flow to the testicles, potentially exacerbating conditions like epididymitis or contributing to testicular ischemia, as noted in the context of acute scrotal pain management 1.

Some key points to consider in the management of this patient include:

• The importance of prompt recognition and surgical exploration within 6 to 8 hours after symptom onset to prevent testicular loss in cases of testicular torsion 1
• The use of a validated clinical risk scoring system, such as the Testicular Workup for Ischemia and Suspected Torsion Score, to aid in diagnosis, although its adoption may be limited 1
• The consideration of other causes of acute scrotal pain, including epididymoorchitis, torsion of the testicular appendage, and idiopathic scrotal edema, and the appropriate diagnostic and therapeutic approaches for these conditions 1
• The need for a comprehensive approach that addresses both the acute testicular condition and the underlying methamphetamine use disorder, to optimize patient outcomes and reduce the risk of complications.

Given the potential for severe consequences if testicular torsion is not promptly addressed, immediate urological evaluation and intervention are crucial. The patient's methamphetamine use disorder should be managed concurrently, with attention to both the physical and psychological aspects of the condition, to promote overall health and well-being 1.

From the Research

Management of Methamphetamine Use Disorder with Testicular Pain and Swelling

• The management of a patient with methamphetamine use disorder (MUD) presenting with testicular pain and swelling requires a comprehensive approach, considering the potential for testicular ischemia or other complications 2.
• A thorough history and physical examination are essential to determine the underlying cause of testicular pain and swelling, which may be related to methamphetamine use or other factors 3.
• Ultrasound imaging can help diagnose testicular ischemia or other conditions, such as epididymitis, and guide management decisions 2.
• Non-surgical management may be appropriate for patients with methamphetamine-induced testicular ischemia, with close monitoring and follow-up to ensure resolution of symptoms and prevention of complications 2.
• In cases of severe testicular damage or necrosis, orchiectomy may be considered as a treatment option, depending on the individual patient's circumstances and the presence of other complications 4.

Considerations for Methamphetamine Use Disorder

• Methamphetamine use disorder is a significant public health concern, with increasing trends in overdose mortality, methamphetamine use, and frequent use 5.
• Patients with MUD may be at higher risk for testicular complications, such as ischemia or self-mutilation, due to the potential for impaired judgment and increased risk-taking behavior 4, 6.
• A multidisciplinary approach to management, including addiction treatment and urological care, is essential to address the complex needs of patients with MUD and testicular complications 5.

Diagnostic Considerations

• Testicular torsion is a time-sensitive diagnosis that requires prompt recognition and treatment to prevent complications, such as testicular infarction and subfertility 3.
• Other conditions, such as acute orchiepididymitis, may mimic the presentation of testicular torsion, and a thorough diagnostic evaluation is necessary to determine the underlying cause of symptoms 6, 3.
• Ultrasound imaging and other diagnostic tests can help guide management decisions and ensure timely intervention for patients with testicular complications 2, 3.