What is the management approach for spermatic cord tenderness and testicular pain in a patient with uncontrolled diabetes (DM)?

Management of Spermatic Cord Tenderness and Testicular Pain in Uncontrolled Diabetes

In patients with uncontrolled diabetes presenting with spermatic cord tenderness and testicular pain, immediate ultrasound duplex Doppler of the scrotum is essential to rule out acute pathologies like testicular torsion, as diabetes can complicate clinical presentation and increase risk of certain conditions. 1

Initial Diagnostic Approach

• Perform immediate ultrasound duplex Doppler of the scrotum, including both grayscale and Doppler examination of bilateral scrotal and inguinal areas to rule out acute pathologies 1
• Obtain urinalysis to check for infection, as diabetic patients are at increased risk for epididymitis/epididymo-orchitis, the most common cause of acute scrotal pain 1
• Complete blood count should be performed to assess for leukocytosis, which may indicate infection 1
• Evaluate blood glucose and HbA1c to assess diabetes control, as poor glycemic control may worsen outcomes and increase infection risk 1

Differential Diagnosis

• Testicular torsion - surgical emergency requiring immediate intervention 1
• Epididymitis/epididymo-orchitis - most common cause of acute scrotal pain, with higher risk in diabetic patients 1
• Referred pain from diabetic neuropathy - should be considered after ruling out acute pathologies 1
• Diabetic genitourinary autonomic neuropathy - may complicate clinical presentation 1

Treatment Algorithm

Step 1: Rule out emergent conditions

• If ultrasound shows testicular torsion, immediate surgical intervention is required 1
• If epididymitis/epididymo-orchitis is diagnosed, initiate appropriate antibiotic therapy 1

Step 2: Optimize glycemic control

• Poor glycemic control is associated with testicular dysfunction and may exacerbate symptoms 2
• Improving glycemic control may help reduce symptoms, as glycosylated hemoglobin (GHb) levels correlate with testicular dysfunction 2

Step 3: Pain management

• For chronic testicular pain after ruling out acute causes, consider microsurgical spermatic cord denervation (MSCD) in select patients 3
• MSCD has shown 86.2% of patients experiencing ≥50% reduction in pain at mean follow-up of 42.8 months 4

Special Considerations in Diabetic Patients

• Diabetic patients may have atypical presentations due to neuropathy 1
• Diabetes is associated with reduced testicular volume, semen volume, and sperm quality 2
• Oxidative stress in testicular cells due to diabetes may contribute to pain and dysfunction 5
• Diabetes-related erectile dysfunction often coexists with testicular pain and should be addressed 6

Pitfalls to Avoid

• Delaying imaging in diabetic patients with acute testicular pain can lead to poor outcomes 1
• Assuming pain is purely neuropathic without ruling out acute pathologies can lead to delayed diagnosis 1
• Overlooking the possibility of referred pain from other sources in diabetic patients can lead to misdiagnosis 1
• Failing to address erectile dysfunction that may coexist with testicular pain in diabetic patients 6

Management of Associated Erectile Dysfunction

• If erectile dysfunction is present, PDE5 inhibitors (sildenafil, vardenafil, tadalafil) are the recommended first-line therapy 7
• Before initiating treatment for erectile dysfunction, perform cardiovascular risk assessment 7
• Patients at high cardiovascular risk should be stabilized by cardiological treatment before sexual activity is considered 7
• Review current medications for potential contributors to erectile dysfunction, such as diuretics and beta-blockers 7