Discussion
Testicular pain is divided two groups according to acute or chronic.
Acute severe testicular pain is usually related with testicular torsion
but chronic testicular pain is a rare condition and be considered as
part of the chronic pelvic pain syndrome.17 Infectious
or non-infectious causes may induce to acute testicular pain. Isolated
acute orchitis is an infrequent phenomenon and usually accompanied by
epididymitis.18 There are nearly 600,000 cases of
epididymo-orchitis per year in the United States and the majority of
epididymo-orchitis cases are aged 20 to 39 years.19
Testicular pain and epididymo-orchitis caused by bacterial pathogens
specifically Chlamydia trachomatis and Neisseria gonorrhoeae, are a
common condition in andrology. Orchitis in especially young patients is
caused by virus infections such as mumps, rubella, coxsackievirus,
varicella, echovirus, and cytomegalovirus.20,21 Since
the using of the mumps-measles-rubella vaccination, the frequency of
mumps orchitis has decreased dramatically.
Mechanism of occured COVID-19 infection by binding to
Angiotensin-converting enzyme 2 is known main pathway of influencing to
host cells.22 ACE2 is expressed in many tissues,
including kidney, bladder and testicular cells in genitourinary system
and therefore virus may affect to testicular tissue and cause to
testicular tissue damage.23,24
As in many medical sections, current literature on the genital
involvement of coronavirus is limited with a few case
reports.15,16 In this case reports, testicular and
abdominal pain or both of them continued for eight days. In another case
report, a patient with Covid-19 whose complaint was acute abdominal pain
diagnosed and revealed ovarian vein thrombosis. Although it develops in
a female patient, but this case was significance in terms of genital
involvement and it might explained to testicular pain how to occurs by
vascular mechanisms.25 However pain control was better
in our patients of which group 2. Nonsteroidal anti-inflammatory drug
therapy was successful in all patients with testicular pain and no
patient required more invasive procedures. It can be concluded that this
period is shorter than testicular pain due to bacterial pathogens. When
the patients’ history was assessed, having a history of
epididymo-orchitis increased the probability of CoV related testicular
pain. Blood-testis barrier defect which is the cause or result of
previous epididymo-orchitis; may be one of the reasons for this
increase.
In the current population, patients with testicular pain or
epididymo-orchitis appeared to be slightly older than expected.
Testicular pain or epididymo-orchitis was observed 10.98% in the study
population. One of the most important reasons for this rate to be high
is to have a systemic infection condition and it can be explained by the
less response to systemic inflammation in the older population, unlike
younger men. But this condition was unrelated to the level of
lymphopenia. As we mentioned before, the history of previous
epididymo-orchitis increases the probability of testicular pain due to
CoV. Sun et al. reported that viral RNA was detected in multiple organs
in patients with COVID-19 was successfully isolated from urine of
patient with COVID-19.26 The possibility of having
COVID-19 in urine can lead to epididymo-orchitis by vas deferens reflux
secondary to increased voiding pressure in aging males.
Another important risk for young adults with testicular pathology is the
affecting of male reproductive system27,28. This may
be a critical reproductive problem for young patients. “Società
Italiana di Andrologia e Medicina della Sessualità” and Aversa et al.
were reported that in patients recovered from COVID-19, especially for
those in reproductive age, andrological consultation and gonadal
function evaluation including semen examination should be
suggested.29,30 Cryopreservation is really important
risk for patients in reproductive age due to COVID-19 stored in liquid
nitrogen retain its pathogenic properties.31Similar
results were reported in the literature for Zika virus which cause to
damage on the testicular tissue and male productive
system.32,33 Therefore, it may be kept in mind in case
of a possible pandemic due to Zika virus in the future.
The study has several limitations. In this study, spermiogram and
scrotal Doppler ultrasonographic evaluation could not be done in our
hospital due to the pandemic; therefore, recommendations were not made
to protect the reproductive system of young male patients.
Number of patients in our study is limited; more patients including
cohorts or multicentic studies should be done in near future.