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.