Distribution of Epididymal Involvement in Mumps Epididymo-orchitis

Point-of-care ultrasonography for the diagnosis and manual detorsion of testicular torsion

Testicular torsion is a urological emergency caused by the loss of testicular tissue due to ischemic damage. Rapid diagnosis and urgent treatment play a crucial role in the management of testicular torsion. Manual detorsion can be performed at the bedside, thereby reducing the duration of ischemia. Recent studies have reported the use of point-of-care ultrasonography for diagnosing testicular torsion; however, no review article has focused on the ultrasonographic findings pertaining to manual detorsion. This review describes the diagnosis of testicular torsion and the ultrasonographic indications for manual detorsion. Spermatic cord twisting or the whirlpool sign, absence of or decreased blood flow within the affected testis, abnormal testicular axis, abnormal echogenicity, and enlargement of the affected testis and epididymis due to ischemia are the sonographic findings associated with testicular torsion. The following findings are considered indications for manual detorsion: direction of testicular torsion, i.e., inner or outer direction (ultrasonographic accuracy of 70%), and the degree of spermatic cord twist. The following sonographic findings are used to determine whether the treatment was successful: presence of the whirlpool sign and the degree and extent of perfusion of the affected testis. Misdiagnosis of the direction of manual detorsion, a high degree of spermatic cord twisting and insufficient detorsion, testicular compartment syndrome, and testicular necrosis were found to result in treatment failure. The success of manual detorsion is determined based on the symptoms and sonographic findings. Subsequent surgical exploration is recommended in all cases, regardless of the success of manual detorsion.

Prokineticin 2/PROK2 and Male Infertility

Male infertility represents about 50% of the causes of infertility in couples. The diagnosis process represents an important procedure for defining, when possible, the causes and approaching treatments (pharmacological, surgical) aimed at overcoming the problem. Several scientific studies have set out to discover early and indicative markers capable of providing information on the biological origin of infertility and increase current knowledge in the context of new potential therapeutic approaches. The prokineticin system (PROK) consists of the prokineticin 1 (PROK1) and prokineticin 2 (PROK2) proteins. Through the activation of two G-protein receptors (PROKR1 and PROKR2) regulate a wide range of biological functions, including gastrointestinal motility, circadian rhythm regulation, neurogenesis, angiogenesis, pain perception, and mood regulation. Several studies have highlighted the crucial role of the PROK system in the development and maturation of both male and female human reproductive organs. Particularly in men, the PROK system represents a new system useful to clarify some aspects of testicular pathophysiology and provide new potential hypotheses for therapeutic intervention. This narrative review aims to illustrate the state of the art regarding, in particular, the role of PROK2 in male infertility.

[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.

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.

Differential Immune Response to Infection and Acute Inflammation Along the Epididymis

The epididymis is a tubular structure connecting the vas deferens to the testis. This organ consists of three main regions—caput, corpus, and cauda—that face opposing immunological tasks. A means of combating invading pathogens is required in the distally located cauda, where there is a risk of ascending bacterial infections originating from the urethra. Meanwhile, immune tolerance is necessary at the caput, where spermatozoa with immunogenic neo-antigens originate from the testis. Consistently, when challenged with live bacteria or inflammatory stimuli, the cauda elicits a much stronger immune response and inflammatory-inflicted damage than the caput. At the cellular level, a role for diverse and strategically positioned mononuclear phagocytes is emerging. At the mechanistic level, differential expression of immunoprotective and immunomodulatory mediators has been detected between the three main regions of the epididymis. In this review, we summarize the current state of knowledge about region-specific immunological characteristics and unveil possible underlying mechanisms on cellular and molecular levels. Improved understanding of the different immunological microenvironments is the basis for an improved therapy and counseling of patients with epididymal infections.

Small testes: clinical characteristics and ultrasonographic findings

The purpose of this pictorial essay is to describe the ultrasonographic and clinical findings of patients with small testes due to a wide range of causes. We retrospectively reviewed the ultrasonographic and clinical findings of various causes of small testes. We present various causes of small testes on ultrasonography including Klinefelter syndrome, testicular torsion, mumps orchitis, inguinal hernia, cryptorchidism, varicocele, and trauma. On ultrasonography, small testes in patients with testicular torsion, mumps orchitis, and trauma usually showed heterogeneous echogenicity. Atrophic testes were homogeneously hypoechoic in patients with cryptorchidism and inguinal hernia and were isoechoic to the normal testis in patients with varicocele. Klinefelter syndrome patients had small hyperechoic or hypoechoic nodules, but the echogenicity of the remnant portion of the testes was homogeneous. Ultrasonography is helpful for detecting small testes and for the differential diagnosis of the various possible causes of small testes.

The Immune Characteristics of the Epididymis and the Immune Pathway of the Epididymitis Caused by Different Pathogens

The epididymis is an important male accessory sex organ where sperm motility and fertilization ability develop. When spermatozoa carrying foreign antigens enter the epididymis, the epididymis shows "immune privilege" to tolerate them. It is well-known that a tolerogenic environment exists in the caput epididymis, while pro-inflammatory circumstances prefer the cauda epididymis. This meticulously regulated immune environment not only protects spermatozoa from autoimmunity but also defends spermatozoa against pathogenic damage. Epididymitis is one of the common causes of male infertility. Up to 40% of patients suffer from permanent oligospermia or azoospermia. This is related to the immune characteristics of the epididymis itself. Moreover, epididymitis induced by different pathogenic microbial infections has different characteristics. This article elaborates on the distribution and immune response characteristics of epididymis immune cells, the role of epididymis epithelial cells (EECs), and the epididymis defense against different pathogenic infections (such as uropathogenic Escherichia coli, Chlamydia trachomatis, and viruses to provide therapeutic approaches for epididymitis and its subsequent fertility problems.

Does severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) cause orchitis in patients with coronavirus disease 2019 (COVID-19)?

OBJECTIVES

To assess the prevalence of clinical orchitis in patients with coronavirus disease 2019 (COVID-19).

PATIENTS AND METHODS

This was a retrospective clinical observational study using data of male patients who were admitted to hospital with COVID-19 confirmed by reverse transcriptase polymerase chain reaction testing between 1 March and 4 May 2020. Patients were categorised according to age groups and disease severity. Sociodemographic information and general clinical symptoms of COVID-19 and orchitis were collected.

RESULTS

We identified a total of 253 male patients, with a mean (range) age 43 (1-78) years. Patients were followed-up until their recovery or for 21 days. We did not observe any symptoms or signs of orchitis in any patient during follow-up across all age groups and different disease status.

CONCLUSION

Although we did not identify any patients with COVID-19 with symptoms or signs of orchitis, such an association cannot be excluded, and further studies are needed to validate our hypothesis and exclude any association at a molecular level.

ABBREVIATIONS

ACE2: Angiotensin-converting enzyme 2; COVID-19: coronavirus disease 2019; CRP: C-reactive protein; ESR: erythrocyte sedimentation rate; HIV: human immunodeficiency virus; IRB, Institutional Review Board; ISH, in situ hybridisation; RT-PCR: reverse transcriptase-PCR; SARS-CoV-2, severe acute respiratory syndrome coronavirus-2; TMPRSS2: transmembrane protease, serine 2; WBC: white blood cell.

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.