Testicle Pain Now A Sign Of COVID-19 - Turkish Doctors

Doctors in Turkey have discovered a rare sign of COVID-19 in a 49-year-old man who tested positive for the virus but with no confirmed symptoms except that he complained of testicle pain.

This was disclosed recently by doctors at Acıbadem Mehmet Ali Aydinlar University in Istanbul, Turkey in their medical journal called Urology Case Reports.

The anonymous Turkey patient sought medical advice because of swelling and pain in the left side of his groin and testicles.

Results showed he had coronavirus, therefore the doctors suspected the testicular pain was his first symptom. They said he didn’t have any other health problems that could have caused it, such as an STI.

With no symptom of the virus in the patient such as persistent cough or high temperature, the doctors decided to swab him for the disease because he was in contact with someone who had later tested positive. 

Dr. Hakan Özveri and his colleagues said the man’s testicular pain appeared to be the ‘first clinical sign of COVID-19’in him.

The man went to the hospital with a ‘swelling sensation’ and pain on the left side of his groin and testicles that had started earlier that day.

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At first, his discomfort was intermittent, but after a few hours, it had become more severe and spread further up to his stomach.

Doctors who reported the ‘unusual case’ in the journal said it shows how the coronavirus can take hold in people differently. 

It is not clear how many men suffer testicular pain as a symptom of COVID-19 but a study in China suggested it was as common as one in five, although there have been no large-scale studies of both mild and seriously ill COVID-19 patients.  

Scientists have raised concerns the virus could enter the testicles, where sperm is produced, and cause ‘long-term damage’. But so far, there is little evidence of this is happening, and none to suggest the virus can be spread through semen, the fluid which carries sperm.

Ultrasound images used by the doctors to show increased inflammation along the spermatic cord (black arrows)

HOW COULD COVID-19 CAUSE TESTICULAR PAIN? 

Researchers have been trying to uncover whether coronavirus can cause testicular pain or even damage. 

Urologists at Suzhou Affiliated Hospital of Nanjing University said their interest in the topic was roused when it came to light that the coronavirus enters cells by binding to ACE2 receptors.  

The team analysed ‘online datasets’ and found ACE2 expression in different human organs. The results suggested that ACE2 is highly expressed in the man's testes, and can be concentrated in several cells which are directly related to the male reproductive abilities, including the germ cells, supporting cells, and Leydig cells.  

‘Therefore, virus might directly bind to such ACE2 positive cells and damage the kidney and testicular tissue of patients,’ the researchers wrote in their paper.

They warned that doctors should pay close attention to possible damage in the testicles of coronavirus patients, especially if they are of reproductive age.

The warning was echoed by another team of scientists at Tongji Hospital, affiliated to Huazhong University of Science and Technology, Wuhan. 

They said the coronavirus could cause orchitis, an inflammation of the testicles. This in turn could reduce a man’s sperm count and possibly lead to infertility, according to the team.

They added that during the 2003-2004 outbreak of SARS, a virus in the same family as the one which causes Covid-19, medics observed serious immune system damage in the testicles of some male patients. 

The hospital report was widely shared on social media despite being pulled from the provincial government’s website just hours after being uploaded. 

An international team ruled out the possibility of the coronavirus entering cells via the ACE2 pathway in a paper published in Fertility and Sterility,

The team led by Huazhong University of Science and Technology, Wuhan, used a DNA database of three healthy young organ donors from previous research to investigate if testicular cells could be infected with the virus. 

‘If the virus is in the testes but not the sperm it can’t be sexually transmitted,’ said co-author Dr. Jingtao Guo, of the Huntsman Cancer Institute.

‘But if it is in the testes, it can cause long-term damage to semen and sperm production.’ 

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The team was looking for the expression of two genes, ACE2 and TMPRSS2, which must be present in the same cell in order for the coronavirus to enter and begin replicating. 

But they did not find any evidence to show high expression of the genes. Only four of 6,500 testicular cells carried the two genes.

The team concluded that it’s unlikely the virus affects testicles through an ACE2-mediated entry. 

Examination of his genitals revealed tenderness in the left spermatic cord, which runs through the abdominal region down into the testes.  

The man reported that it hurt to touch his nether region, but there was no visible signs of inflammation on the skin. 

Doctors were unable to give an explanation for his symptoms, with tests for STIs that can cause testicular pain, including chlamydia, coming back negative.

There was no indication he had a urinary tract infection or orchitis. Inflammation of the testicles usually triggered by a virus or bacterial infection. 

Dr. Özveri and team wrote: ‘Covid-19 is a viral infection which predominantly attacks [the] respiratory organs. 

‘However, as in our case, patients can exhibit various symptoms in organs other than the lungs, such as in genitals.

‘Patients with isolated genital symptoms such as testicular/spermatic cord pain and discomfort without other systemic symptoms should be closely followed for Covid-19.’ 

The man was hospitalised for treatment of Covid-19 even though he was not critically ill. He was given a five-day course of hydroxychloroquine, an anti-malarial drug which has been under trial for the potential of fighting the virus.

He was also given azithromycin and imipenem/cilastatin, two antibiotics used to treat a number of bacterial infections, despite the fact, doctors insisted he did not have any other infection.

On the second day of his treatment, the man no longer complained about having any pain in his testicles.

But it took more than three weeks for him to clear coronavirus from his system. He returned home after 24 days in the hospital. 

It’s not the first time a link between the coronavirus and pain in the scrotum or groin area has been reported by doctors.

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In July, American doctors reported a 43-year-old-man from Massachusetts had only testicular pain, needing hospital attention before a positive Covid-19 test.

Also in November, it was reported a man in Italy had 'uncontrollable testicular pain' before he died of Covid-19 several days later. He also suffered shortness of breath. 

A group of scientists led by Huazhong University of Science and Technology, Wuhan, found that during COVID-19 illness, up to a fifth of infected men may have pain in the testes.

Six of the 34 men in China they studied complained of the symptom, the researchers reported in April.

The researchers said the significance remains unclear, noting that other viruses, such as mumps, HIV, and herpes, can cause inflammation in the testicles (orchitis).

Because the team did not look at semen during illness, they could not rule out that the coronavirus can spread during sex via semen.

Dcotors from the San Antonio Uniformed Services Health Education Consortium in Texas have previously warned the damage caused by Covid-19 could have ‘a future impact on male fertility’.

They reported the virus had damaged the spermatocytes, which keep sperm healthy, of a 37-year-old man.  

But no study has yet conclusively proven the virus can damage a man’s reproductive organs, reduce fertility or sexual potency.

Scientists say it is theoretically possible because of how the SARS-CoV-2 virus enters cells through a receptor called ACE2. 

ACE2, which acts as a doorway for the virus to enter cells in various parts of the body, is found in abundance in the testicles. 

But there is no proof the coronavirus travels through the body and replicates in the testes. 

Another explanation for testicular pain in Covid-19 males is that the coronavirus travels in the bloodstream to reach the testes.