What is the appropriate management for a diabetic patient presenting with scrotal swelling?

Management of Diabetic Patients with Scrotal Swelling

Immediate Action Required

Diabetic patients presenting with scrotal swelling require emergency ultrasound duplex Doppler of the scrotum to rule out testicular torsion and Fournier's gangrene, both of which are surgical emergencies that can result in testicular loss or death if not treated within 6-8 hours. 1, 2, 3

Critical Initial Assessment

Physical Examination Findings to Identify

• Assess for signs of necrotizing infection: Look for crepitus, skin discoloration (purple/black), rapid progression of erythema, or spontaneous rupture of scrotal tissue—these indicate Fournier's gangrene requiring immediate surgical debridement 4, 5, 6
• Evaluate pain characteristics: Sudden, severe pain with negative Prehn sign (no relief with testicular elevation) suggests torsion, while gradual onset suggests epididymitis 1, 3
• Check vital signs: Fever and hemodynamic instability indicate severe infection requiring aggressive intervention 5, 6
• Examine for lymphadenopathy: Bilateral inguinal lymphadenopathy may indicate severe infection 7

Immediate Laboratory Workup

• Complete blood count: Leukocytosis >35,000/μL suggests severe infection like Fournier's gangrene 2, 3, 6
• C-reactive protein: Elevated levels indicate significant inflammation 4
• Urinalysis: Check for infection, though normal urinalysis does not exclude testicular torsion or epididymitis 1, 3
• Blood glucose and HbA1c: Assess diabetes control, as poor glycemic control (HbA1c >9%) significantly increases infection risk 6, 7, 8

Diagnostic Imaging Protocol

Perform immediate ultrasound duplex Doppler of the scrotum including both grayscale and color/power Doppler examination of bilateral scrotal and inguinal areas. 2, 3

Key Ultrasound Findings by Diagnosis

• Testicular torsion: Decreased/absent blood flow, "whirlpool sign" of twisted spermatic cord, enlarged heterogeneous testis 1
• Epididymitis/epididymo-orchitis: Enlarged epididymis with increased blood flow on Doppler 1, 3
• Fournier's gangrene: Elevated air density in subcutaneous tissue, thickened scrotal wall 6

If CT scan is needed: Order if ultrasound is inconclusive or Fournier's gangrene is suspected to assess extent of tissue involvement and gas formation 5, 6, 7

Differential Diagnosis and Management Algorithm

Testicular Torsion (Surgical Emergency)

If torsion is confirmed or highly suspected, proceed immediately to surgical exploration and detorsion within 6-8 hours of symptom onset. 1

• Perform bilateral orchiopexy during surgery to prevent contralateral torsion 1
• Do not delay surgery for additional imaging if clinical suspicion is high 1

Fournier's Gangrene (Life-Threatening Emergency)

If Fournier's gangrene is diagnosed, initiate immediate broad-spectrum IV antibiotics, aggressive fluid resuscitation, and emergency surgical debridement. 4, 5, 6, 7

• Antibiotic regimen: Cover gram-positive, gram-negative, and anaerobic organisms (common pathogens include Streptococcus agalactiae, Enterococcus faecalis, and Candida species) 4, 8
• Surgical approach: Perform extensive debridement of all necrotic tissue, with planned return to operating room for repeat debridement and possible vacuum-assisted closure 7
• Consider IV immunoglobulin in severe cases 4
• Orchidectomy may be necessary if testicular involvement is extensive 5
• Monitor for septic complications: Including septic pulmonary embolism, which can occur 7 days post-operatively 5

Epididymitis/Epididymo-orchitis (Most Common Cause)

If epididymitis is diagnosed, initiate empiric antibiotic therapy based on age and risk factors. 9

• For sexually transmitted pathogens (age <35): Ceftriaxone 250 mg IM single dose PLUS doxycycline 100 mg orally twice daily for 10 days 9
• For enteric organisms or cephalosporin allergy: Ofloxacin 300 mg orally twice daily for 10 days 9
• Adjunctive therapy: Bed rest, scrotal elevation, and analgesics until fever and inflammation subside 9
• Reevaluate within 3 days: If no improvement, consider abscess formation, testicular infarction, or alternative diagnosis 9

Special Considerations in Diabetic Patients

SGLT2 Inhibitor-Associated Risk

If the patient is taking empagliflozin or other SGLT2 inhibitors, immediately discontinue the medication, as these drugs significantly increase risk of severe genital infections including Fournier's gangrene and complicated epididymo-orchitis. 7, 8

• SGLT2 inhibitors cause increased glycosuria, creating an environment conducive to bacterial and fungal growth 7, 8
• Multiple preceding episodes of genital thrush should raise suspicion for SGLT2 inhibitor-related complications 7
• Uncontrolled diabetes (HbA1c >9%) combined with SGLT2 inhibitor use creates particularly high risk 7, 8

Glycemic Optimization

Initiate or intensify insulin therapy immediately to achieve tight glycemic control, as hyperglycemia impairs immune function and worsens infection outcomes. 4, 7, 8

• Transition to basal-bolus insulin regimen if not already on intensive therapy 7
• Target euglycemia during acute infection to optimize wound healing and immune response 4

Atypical Presentations

Diabetic autonomic neuropathy may mask typical pain responses, leading to delayed presentation with more advanced disease. 2, 3

• Maintain high index of suspicion even with minimal pain complaints 2, 3
• Do not assume pain is purely neuropathic without ruling out acute pathology 2, 3

Critical Pitfalls to Avoid

• Never delay imaging or surgical consultation in diabetic patients with acute scrotal swelling, as diabetes increases risk of rapid progression to life-threatening infection 2, 3
• Do not rely on normal urinalysis to exclude testicular torsion or epididymitis 1, 3
• Recognize that ultrasound has 30% false-negative rate for partial testicular torsion; proceed to surgery if clinical suspicion remains high despite normal Doppler 1
• Do not underestimate minor genital infections in diabetic patients on SGLT2 inhibitors, as they can rapidly progress to Fournier's gangrene 7, 8
• Always consider anal fistula or perianal abscess as potential source of Fournier's gangrene in diabetic patients 6

Follow-Up Management

• If epididymitis: Reevaluate at 3 days; persistent swelling after antibiotic completion requires comprehensive evaluation for abscess, tumor, or tuberculous/fungal infection 9
• If Fournier's gangrene: Plan for split-thickness skin grafting after infection control and granulation tissue formation 7
• Address erectile dysfunction if present, as it commonly coexists in diabetic patients with genitourinary complications; PDE5 inhibitors are first-line therapy after cardiovascular risk assessment 9, 2