What is the appropriate workup and management for a diabetic patient presenting with testicular pain?

Diagnostic Approach for Diabetic Patients with Testicular Pain

In a diabetic patient with testicular pain, immediate ultrasound duplex Doppler of the scrotum should be performed to rule out testicular torsion and other acute pathologies, as diabetes can complicate the clinical presentation and increase risk of certain conditions. 1

Initial Evaluation

• Obtain a focused history including onset (sudden vs gradual), duration, severity, radiation, and associated symptoms such as nausea/vomiting 1
• Perform physical examination focusing on:
  • Testicular swelling, position (high-riding), and consistency (hard vs soft) 2
  • Presence or absence of cremasteric reflex 2
  • Signs of infection (erythema, warmth) 1
• Consider using the TWIST score (Testicular Workup for Ischemia and Suspected Torsion) which includes:
  • Testis swelling (2 points)
  • Hard testis (2 points)
  • Absent cremasteric reflex (1 point)
  • Nausea/vomiting (1 point)
  • High-riding testis (1 point) 2

Diagnostic Imaging

• Ultrasound duplex Doppler of the scrotum is the first-line imaging modality for all patients with acute testicular pain 1
• Ultrasound should include both grayscale and Doppler examination of bilateral scrotal and inguinal areas 1
• Bedside ultrasound performed by emergency physicians has shown high sensitivity (95%) and specificity (94%) in diagnosing acute scrotal conditions 3

Specific Considerations in Diabetic Patients

• Diabetic patients are at increased risk for:
  • Epididymitis/epididymo-orchitis (most common cause of acute scrotal pain) 1
  • Segmental testicular infarction due to diabetes microangiopathy 4
  • Genitourinary autonomic neuropathy that may complicate the clinical presentation 1

Differential Diagnosis

• Testicular torsion (surgical emergency - requires immediate intervention) 1
• Epididymitis/epididymo-orchitis (most common cause) 1
• Torsion of testicular appendages 1
• Segmental testicular infarction (rare complication of diabetes) 4
• Referred pain from diabetic neuropathy 1

Laboratory Tests

• Urinalysis to check for infection 1
• Complete blood count to assess for leukocytosis 1
• Blood glucose and HbA1c to evaluate diabetes control 1
• Consider additional tests if specific diagnoses are suspected:
  • Urine culture if infection is suspected 1
  • Lipid profile to assess cardiovascular risk factors 1

Management Algorithm

1. High TWIST score (≥6): Immediate urological consultation for surgical exploration without delay for imaging 2
2. Intermediate TWIST score (1-5): Urgent ultrasound duplex Doppler followed by appropriate management based on findings 2
3. Low TWIST score (0): Ultrasound to confirm diagnosis and rule out other pathologies 2

Special Considerations

• Diabetic patients may have atypical presentations due to neuropathy 1
• Diabetes-related microangiopathy can cause segmental testicular infarction that mimics testicular tumors on imaging 4
• Diabetic autonomic neuropathy can affect genitourinary function and complicate the clinical picture 1
• Poor glycemic control may worsen outcomes and increase infection risk 1

Pitfalls to Avoid

• Delaying imaging in diabetic patients with acute testicular pain, as diabetes may mask typical symptoms of serious conditions 1
• Assuming pain is neuropathic without ruling out acute pathologies 1
• Failing to consider diabetes-specific complications such as microangiopathy 4
• Overlooking the possibility of referred pain from other sources in diabetic patients 1