Echo color Doppler findings in postpubertal mumps epididymo-orchitis

A rare case of a testicular lesion related to hand, foot, and mouth disease

Introduction

Hand, foot, and mouth disease generally occurs in children. In rare cases, hand, foot, and mouth disease affects the testicles.

Case presentation

A 29-year-old man presented to our emergency department with testicular pain for several days after the onset of hand, foot, and mouth disease. Ultrasonography revealed hypoechoic mass-like areas in the right testis. A mild inflammatory response was noted, tumor markers and urinary data were normal, and tests for infection were all negative. Antibiotics were initiated and ultrasonography was performed in every subsequent examination. Testicular pain disappeared 6 months later.

Conclusion

We encountered a rare case of a testicular lesion related to hand, foot, and mouth disease that was successfully treated. The careful selection of treatment for testicular pain and scrotal enlargement in young adult males, such as surgery and symptomatic treatment, based on their medical history and laboratory findings, is important.

Various Intratesticular Hypoechoic Lesions on Scrotal Sonography

Sonography with a high-frequency transducer is the modality of choice for imaging the scrotum. Most intratesticular lesions are hypoechoic. Differentiation of intratesticular hypoechoic lesions as either malignant or benign is important because the treatment of these lesions vary. In this paper, we review the sonographic features of different types of intratesticular hypoechoic lesions, such as testicular cysts, testicular tumors, testicular inflammatory lesions, segmental testicular infarction, and testicular trauma.

Viral Infections and Male Infertility: A Comprehensive Review of the Role of Oxidative Stress

Viral infections have been a part of human existence to date, though viruses have posed a huge threat with various outbreaks lately. These threats are associated with reproductive health challenges, especially male infertility. The prime focus of this review is to highlight the mechanisms associated with viral infection-induced male infertility/subfertility and identify new treatment strategies with the aim to preserve male fertility. The reviewed data showed that viral infections stimulate inflammatory responses, resulting in the release of proinflammatory cytokines, which induces oxidative stress. This oxido-inflammatory cycle could continue in a vicious cycle and threaten male fertility. Existing data from human and experimental studies show that viral infection-induced oxido-inflammatory response results in testicular damage, atrophy of the seminiferous tubules and Sertoli cells, and reduced Leydig cell mass. This is accompanied by reduced circulatory testosterone, impaired spermatogenesis, reduced sperm motility, lipid peroxidation, DNA fragmentation and apoptosis of the sperm cells. Based on the available pieces of evidence, antioxidant therapy, in vivo and in vitro, may be beneficial and protects against the potential risk of male infertility from viral infection. It is, however recommended that more clinical studies be conducted to demonstrate the possible protective roles of antioxidants used as adjuvant therapy in viral infections, and in the in vitro treatment of semen samples for those utilizing semen washing and artificial reproductive techniques.

[Viral infections in urology]

Einleitung

Die COVID-19-Pandemie („coronavirus disease 2019“) hat eindrucksvoll gezeigt, dass Infektionskrankheiten enorme Auswirkungen auf das Gesundheitswesen und darüber hinaus haben können. In der Urologie spielen Viren bei spezifischen Entitäten eine Rolle, wo sich der Urologe mit Viruserkrankungen beschäftigen muss.

Methodik

Diese Übersichtsarbeit hat zum Ziel in der Urologie relevante Virusinfektionen zu beschreiben und insbesondere die Impfprävention hervorzuheben. Es erfolgte eine selektive Literaturrecherche zu den Themen „COVID und Urologie“, „Urogenitale Virusinfektionen“, „Virale urologische Infektionen in der Transplantationsmedizin“ sowie „Impfprävention von Viruserkrankungen“.

Ergebnisse

Coronaviren sind Viren, die bereits 2‑mal lokale Epidemien verursacht haben (SARS- [„severe acute respiratory syndrome“] und MERS-Epidemie [„middle east respiratory syndrome“]). Die Tatsache, dass die SARS-CoV-2-Erkrankung („severe acute respiratory syndrome coronavirus 2“) auch ohne Symptome ansteckend ist, hat im Wesentlichen zu der raschen Ausbreitung und weltweiten Pandemie geführt. Eine Vielzahl von Viren, die auch eine Virämie induzieren können, wurde im Ejakulat nachgewiesen und wird damit mit einer etwaigen urogenitalen Infektion in Verbindung gebracht. Hierzu zählen u. a. das Mumps‑, Coxsackie-Viren oder Enteroviren. Es wurde auch gezeigt, dass auch eine Zika-Virusinfektion sexuell über die Spermien als Carrier übertragen werden kann. Somit spielen Viren auch eine wichtige Rolle in der Reproduktion. Bei der Nierentransplantation sind Urologen häufig mit viralen Infektionen konfrontiert. Die effektivste Waffe gegenüber Viren stellt die Impfprävention dar.

Schlussfolgerung

Äthiopathogenetisch ist der Urogenitaltrakt im Rahmen einer Virämie oder über eine Reaktivierung durch eine Immunsuppression am häufigsten mitbetroffen. Therapeutisch kommt der Immunmodulation sowie der Impfprophylaxe eine führende Rolle zu.

Role of color flow Doppler ultrasound in the evaluation of acute scrotal pain

Color flow Doppler ultrasound is a critical tool in the assessment of the scrotum. Ultrasound is the first-line imaging modality and can rapidly differentiate between surgical and nonsurgical conditions, allowing for appropriate and prompt patient management. We review the role of color flow Doppler in the evaluation of acute scrotal pain, highlighting some of the most commonly seen pathologies such as epididymo-orchitis and testicular torsion.

Mumps Orchitis: Clinical Aspects and Mechanisms

The causative agent of mumps is a single-stranded, non-segmented, negative sense RNA virus belonging to the Paramyxoviridae family. Besides the classic symptom of painfully swollen parotid salivary glands (parotitis) in mumps virus (MuV)-infected men, orchitis is the most common form of extra-salivary gland inflammation. Mumps orchitis frequently occurs in young adult men, and leads to pain and swelling of the testis. The administration of MuV vaccines in children has been proven highly effective in reducing the incidence of mumps. However, a recent global outbreak of mumps and the high rate of orchitis have recently been considered as threats to male fertility. The pathogenesis of mumps orchitis remains largely unclear due to lack of systematic clinical data analysis and animal models studies. The alarming increase in the incidence of mumps orchitis and the high risk of the male fertility have thus become a major health concern. Recent studies have revealed the mechanisms by which MuV-host cells interact and MuV infection induces inflammatory responses in testicular cells. In this mini-review, we highlight advances in our knowledge of the clinical aspects and possible mechanisms of mumps orchitis.

Ultrasound of scrotal and penile emergency: how, why and when

High-resolution ultrasound is the most common imaging technique used to supplement the physical examination of scrotum and penis with great accuracy in assisting the diagnosis of the various pathologies of male genital system, with the highest diagnostic potential in emergency conditions. Technical advancements in real-time high-resolution, color flow Doppler sonography and contrast enhanced ultrasonography (CEUS) have led to an increase in the clinical applications of scrotal and penile sonography. In this pictorial review we focus on common and uncommon male genitalia emergency with special emphasis on the role of ultrasound assessment and its specific findings to improve diagnostic accuracy.

Testicular atrophy after mumps orchitis: ultrasonographic findings

PURPOSE

The purpose of this study was to describe the ultrasonographic findings of testicular atrophy after mumps orchitis.

METHODS

We retrospectively reviewed the case files of eight patients (14 to 24 years old; mean, 17 years) with mumps orchitis and testicular atrophy who were treated between January 2011 and September 2017. On gray-scale and color Doppler, the ultrasonographic features of volume, shape, echogenicity, and degree of blood flow in the testes were analyzed as part of both initial and follow-up ultrasonography. The duration between the initial diagnosis of mumps orchitis and the ultrasonographic diagnosis of testicular atrophy after mumps orchitis ranged from 25 to 230 days (mean, 95.9 days).

RESULTS

Of the eight patients with testicular atrophy after mumps orchitis, the testes were affected unilaterally in seven patients (6 right-sided and 1 left-sided) and bilaterally in one patient. The affected testes (n=9) were 23%-55% (mean, 44.7%) smaller in volume (mean, 6.3±2.0 mL) than the contralateral normal testes (n=7) (mean, 10.8±2.3 mL) on follow-up ultrasonography (P=0.001). The shape of the atrophic testes was oblong in seven cases and elliptical in two cases. The atrophic testes were either heterogeneously hypoechoic with multiple hyperechoic islands (n=7) or heterogeneously hyperechoic (n=2). On follow-up color Doppler ultrasonography, the degree of vascularity of the atrophic testis was either similar to (n=3) or lower than (n=6) that of the contralateral testis.

CONCLUSION

On ultrasonography, atrophic testes after mumps orchitis tended to exhibit an oblong shape, heterogeneous low echogenicity with multiple hyperechoic islands, and decreased vascularity.

Tunica Vaginalis Thickening, Hemorrhagic Infiltration and Inflammatory Changes in 8 Children with Primary Hydrocele; Reactive Mesothelial Hyperplasia? A Prospective Clinical Study

The aim of this study is to describe an entity of primary hydrocele accompanied with fibrosis, thickening and hemorrhagic infiltration of parietal layer of tunica vaginalis (PLTV). During a 4-year period (2011-2014), 94 boys (2.5-14 years old) underwent primary hydrocele repair. Hydrocele was right sided in 55 (58.5 %), left sided in 26 (28.7%) and bilateral in 12 patients (13.8%). Eighty three out of 94 patients (88.30%) had communicating hydrocele and the rest eleven patients (11.7%) had non-communicating. Our case group consists of 8 patients (8.51%) based on operative findings consistent with PLTV induration, thickening and hemorrhagic infiltration. Preoperative ultrasonography did not reveal any pathology of the intrascrotal structures besides hydrocele. There weren't hyperechoic reflections or septa within the fluid. Evaluation of thickness of the PLTV was not feasible. Presence of lymph or exudate was excluded after fluid biochemical analysis. Tunica vaginalis histological examination confirmed thickening, hemorrhagic infiltration and inflammation, while there was absence of mesothelial cells. Immunochemistry for desmin was positive, excluding malignant mesothelioma. One patient underwent high ligation of the patent processus vaginalis and PLTV sheath fenestration, but one year later, he faced a recurrence. An elective second surgery was conducted via scrotal incision and Jaboulay operation was performed. The latter methodology was our treatment choice in other 7 out of 8 patients. During a 2-year postoperative follow-up, no other patient had any recurrence. We conclude that in primary hydrocele with macroscopic features indicative of tunica vaginalis inflammation, reversion of the tunica should be a part of operative strategy instead of sheath fenestration, in order to minimize the recurrence.

Distribution of Epididymal Involvement in Mumps Epididymo-orchitis

OBJECTIVES

To evaluate characteristic sonographic findings for mumps orchitis with epididymal involvement.

METHODS

This study included 18 patients (aged 12-18 years) with mumps orchitis. We assessed the volume, echogenicity, and vascularity of the testes and the transverse diameter, echogenicity, and vascularity of the epididymal head, body, and tail. We classified 4 types of epididymal involvement: 1A, focal swelling of the epididymal head with hypervascularity only on the swollen head; 1B, focal swelling of the epididymal head with hypervascularity on the entire epididymis; 1C, diffuse swelling of the entire epididymis with hypervascularity; and 2, no epididymal involvement. The Student t test was used to evaluate the significance of the size of each part of the epididymis and the epididymal head-to-tail diameter ratio.

RESULTS

Orchitis was unilateral in 13 patients and bilateral in 5. Of 23 affected hemiscrotums, 7 (30.4%) were type 1A, 4 (17.4%) type 1B, 2 (8.7%) type 1C, and 10 (43.5%) type 2. In 11 patients with unilateral epididymal involvement, the mean diameters ± SDs of the epididymal heads on the affected and contralateral sides were 1.11 ± 0.19 (range, 0.7-1.7) and 0.65 ± 0.14 (0.3-0.9) cm (significantly different, P <.001). The diameters of the epididymal tails on the affected and contralateral sides were 0.51 ± 0.41 (0.2-0.8) and 0.46 ± 0.21 (0.3-0.6) cm (not statistically different, P = .106). The mean head-to-tail ratios on the affected and contralateral sides were 2.28 ± 0.49 (1.29-3.00) and 1.41 ± 0.22 (1.00-1.75; significantly different, P < .001). In all types 1A and 1B, the ratio was higher than 2.00; in 22 of 23 unaffected epididymides, the ratio was lower than 2.00.

CONCLUSIONS

Focal swelling of epididymal heads was a characteristic sonographic finding of mumps epididymo-orchitis, and a head-to-tail ratio higher than 2.00 can be a useful diagnostic finding.

Clinical features of mumps orchitis in vaccinated postpubertal males: a single-center series of 62 patients

Purpose

Although the measles-mumps-rubella vaccination covers most children against mumps in Korea, the development of mumps has been reported. However, the clinical manifestations of mumps orchitis in postpubertal vaccinated patients have never been investigated. Herein we report the clinical features of mumps orchitis in postpubertal vaccinated patients.

Materials and Methods

This study included a total of 62 postpubertal males who developed acute mumps orchitis from 2005 to 2010. The clinical manifestations such as the incubation period, febrile duration, and the mean duration of orchitis were retrospectively investigated. The laboratory and sonographic findings were also reviewed and compared with the features of previously reported cases of unvaccinated postpubertal mumps orchitis.

Results

The mean age of the 62 patients was 17.56 years (range, 15 to 29 years). All patients were serologically confirmed with acute mumps infection (positive immunoglobulin [Ig] M and negative or positive IgG). The mean incubation period was 5.39 days (range, 0 to 23 days), with a febrile duration of 1.8 days (range, 0.5 to 3 days), and a mean duration of orchitis of 4.96 days (range, 0 to 17 days). Sonography revealed unilateral orchitis in 58 patients (93.6%) and bilateral orchitis in only 6 (6.4%).

Conclusions

In our study, mumps orchitis in postpubertal vaccinated patients showed a relatively shorter febrile duration. In addition, less scrotal swelling and a lower incidence of bilaterality were found upon physical examination and ultrasonography. In the future, additional long-term follow-up is needed to determine the features of mumps orchitis in postpubertal vaccinated males, and an additional booster vaccination should be considered.

Management of hydrocele in adolescent patients

Hydrocele is defined as an abnormal collection of serous fluid in the potential space between the parietal and visceral layers of the tunica vaginalis. In the majority of affected adolescents, hydrocele is acquired and is idiopathic in origin. The pathogenesis of idiopathic hydrocele is thought to be an imbalance in the normal process of fluid production and reabsorption. The diagnosis is usually clinical. Taking a thorough history is essential to rule out any fluctuation in size, which is an indication of a patent processus vaginalis. Scrotal ultrasonography is mandatory in nonpalpable testicles to rule out a subtending testicular solid mass requiring inguinal exploration. Otherwise, open hydrocelectomy via a scrotal incision is the standard treatment of idiopathic hydroceles. The second most common cause of hydrocele in adolescents is varicocelectomy. The risk of hydrocele formation is higher with non-artery-sparing procedures or those performed without microsurgical aid, and in surgery requiring cord dissection. If hydrocele occurs after varicocelectomy, initial management should include observation with or without hydrocele aspiration. Large persistent hydroceles are best served by open hydrocelectomy.

Mumps orchitis in the post-vaccine era (1967-2009): a single-center series of 67 patients and review of clinical outcome and trends

Since the introduction of the mumps vaccine, the age of appearance of mumps infection has shifted from children to adolescents and young adults, groups with a higher incidence of disease complications and sequelae. During the years 2000-2001, the Gran Canaria Island was part of an epidemic of mumps. In that period, our institution attended 67 cases of serologically confirmed acute mumps orchitis, the most serious complication of mumps infection in young postpubertal males. We conducted a descriptive and prospective study of this cohort and extensively reviewed the literature from 1967 (the year the first mumps vaccine was introduced) to 2009. Fifty-six patients were admitted because of general impairment and were treated with alpha-interferon. Sixty-six patients presented parotitis previous to orchitis (interval from parotitis to orchitis, 4.9 d). Orchitis was unilateral in 89.5% and bilateral in 10.4% of cases. More than 98% of patients had orchitis-associated fever. Nine patients had clinical and biochemical data showing acute mumps meningitis, and 11 had subclinical pancreatitis. The mean duration of symptoms was 4.6 days (range, 1-9). During the acute phase, more than 41% of the evaluated testes had a volume >25 mL. Acute hormonal disturbances were highly prevalent. These included decreased levels of testosterone and inhibin B with low or normal levels of gonadotropins in 35% of subjects, and, to our knowledge not previously reported, an atypical hormonal pattern consisting of low levels of free testosterone and inhibin B, along with increased measures of luteinizing hormone but low or normal follicle-stimulating hormone levels (11% of cases). During the follow-up period (mean, 331 d) a high incidence of sperm disturbance was found.

The increasing incidence of mumps orchitis: a comprehensive review

There has been a recent increase in mumps orchitis among pubertal and postpubertal males. These outbreaks can be attributed to a reduction in the uptake of measles-mumps-rubella (MMR) vaccine during the early to mid-1990 s in children who have now matured. The mumps virus is commonly associated with extra-salivary complications. Unvaccinated postpubertal males diagnosed with mumps virus frequently develop complications such as mumps orchitis. Therefore, it is important that urologists are familiar with the diagnosis, treatment and complications of this condition. Here we review the epidemiology, clinical presentation, diagnostic methods, treatment options and complications of mumps orchitis, as a complication of mumps virus, with particular emphasis on testicular atrophy, subfertility and infertility.

Three-Dimensional Ultrasound in Small Parts

For longer than 40 years, ultrasound (US) has been a widely used imaging tool in medical practice, which has proved helpful for the diagnosis and staging of diseases. Although three-dimensional ultrasound (3D) US has been available for more than 10 years, it was only through the development of the most recent computer technologies and its adaptation to ultrasound systems, that 3D US has become able to achieve the high level of sensitivity and performance necessary to be considered seriously in clinical practice. 3D US is rapidly turning into a technology with an ever-increasing range of applications in numerous fields because, among other reasons, it helps overcome some of the key limitations related to two-dimensional imaging. 3D US can be used in ultrasonography for small parts, among other medical areas. The assessment of the testicle, parotid, thyroid and parathyroid glands is properly achieved. The multiplanar presentation and niche mode are quite useful to determine the extension--inside or outside the organs-, of nodules, cysts or tumors. The volume measurement is better assessed with 3D US and given this, we can perform studies that follow growth in order to decide medical or surgical treatment. The VOCAL makes it possible to obtain a proper after-treatment follow-up of focal disorders in these small organs. Neovascularization is clearly viewed with 3D US and probably can suggest malignant origin of a neoplasm. 3D US offers a more comprehensive image of anatomical structures and pathological conditions and also permits to observe the exact spatial relationships. We are aware more studies are needed to demonstrate specificity and sensibility of 3D US in particular clinical conditions, not only in small parts but also is some other non-Ob/Gyn applications.