A 58-year-old, obese, Caucasian male presents to the emergency department immediately after a motor vehicle accident in which he was a restrained passenger. His medical history is significant for diabetes mellitus type 2, hypertension, gastroesophageal reflux disease, erectile dysfunction, and gout. His current medications include metformin, rosiglitazone, lisinopril, and omeprazole. He drinks 1-2 beers daily and denies the use of tobacco or recreational drugs. His temperature is 36.9 C (98.4 F), blood pressure is 134/88 mmHg, pulse is 86/min, and respirations are 15/min. Normal S1 and S2 heart sounds are present, with no murmurs or rubs. The lung fields are clear. The abdomen is obese, nontender and nondistended; bowel sounds are present. Brown stool in the rectal vault is guaiac negative. The rectal sphincter tone is normal. There is no evidence of clubbing, cyanosis, or edema in the extremities. Dorsalis pedis and posterior tibial pulses are present and equal bilaterally. On neurologic exam, the patient is awake, alert, and oriented. Cranial nerves II-XII are intact. Motor strength is 5/5 in all extremities. Finger to nose cerebellar exam is well done. Reflexes are 1+ at the ankles and 2+ at the knees, biceps, and triceps. The cremasteric reflex is absent. Sensation is intact throughout, except for a bilateral symmetric reduction in perception of vibration, pain, and temperature in both feet and hands. Plantar flexion and dorsiflexion are normal. Ambulation is normal, and the Romberg sign is negative. What is the most likely etiology of this individual's absent cremasteric reflex?

Question

A 58-year-old, obese, Caucasian male presents to the emergency department immediately after a motor vehicle accident in which he was a restrained passenger.  His medical history is significant for diabetes mellitus type 2, hypertension, gastroesophageal reflux disease, erectile dysfunction, and gout.  His current medications include metformin, rosiglitazone, lisinopril, and omeprazole.  He drinks 1-2 beers daily and denies the use of tobacco or recreational drugs.  His temperature is 36.9 C (98.4 F), blood pressure is 134/88 mmHg, pulse is 86/min, and respirations are 15/min.  Normal S1 and S2 heart sounds are present, with no murmurs or rubs.  The lung fields are clear.  The abdomen is obese, nontender and nondistended; bowel sounds are present.  Brown stool in the rectal vault is guaiac negative.  The rectal sphincter tone is normal.  There is no evidence of clubbing, cyanosis, or edema in the extremities.  Dorsalis pedis and posterior tibial pulses are present and equal bilaterally.  On neurologic exam, the patient is awake, alert, and oriented.  Cranial nerves II-XII are intact.  Motor strength is 5/5 in all extremities.  Finger to nose cerebellar exam is well done.  Reflexes are 1+ at the ankles and 2+ at the knees, biceps, and triceps.  The cremasteric reflex is absent.  Sensation is intact throughout, except for a bilateral symmetric reduction in perception of vibration, pain, and temperature in both feet and hands.  Plantar flexion and dorsiflexion are normal.  Ambulation is normal, and the Romberg sign is negative.  What is the most likely etiology of this individual's absent cremasteric reflex?

Quizplus · Accepted Answer

Explanation: The loss of the cremasteric reflex in this patient is secondary to his diabetes mellitus. The presence of distal symmetric polyneuropathy (in the classic "stocking-glove" pattern) and history of erectile dysfunction are suggestive of significant diabetic neuropathy. Other possible presentations of neurogenically induced erectile dysfunction in the diabetic male include diminished testicular sensation, bladder dysfunction, and inability to masturbate. (Choice A)The symptoms of cauda equina syndrome include severe lower back pain, urinary or bowel incontinence, motor weakness or sensory loss in the legs bilaterally, and saddle anesthesia. (Choice B)The cremasteric reflex corresponds to the L1-L2 level of the spinal cord, a region also responsible for hip flexion and adduction. The patient's normal ambulation and motor strength indicate that an injury to the spinal cord at L1-L2 is unlikely. (Choice C)The normal dorsiflexion and plantar flexion in this patient signify functionality of the L5-S2 region of the spinal cord. (Choice D)The normal anal sphincter tone in this patient signifies functionality of the S2-S4 region of the spinal cord. Educational Objective: The cremasteric reflex is regulated at the L1-L2 level of the spinal cord. This reflex can be diminished or lost secondary to diabetic autonomic neuropathy.

A 58-Year-Old, Obese, Caucasian Male Presents to the Emergency Department