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Description of four cases of male genital schistosomiasis (MGS) in children and adolescents, with a scoping review

Published online by Cambridge University Press:  24 February 2025

Joachim Richter Open the ORCID record for Joachim Richter [Opens in a new window] ,
Sekeleghe A. Kayuni ,
J. Russell Stothard Open the ORCID record for J. Russell Stothard [Opens in a new window] ,
Charles Émile Ramarokoto ,
Andreas K. Lindner ,
Daniela Fusco ,
Hermann Feldmeier ,
Amaya L. Bustinduy Open the ORCID record for Amaya L. Bustinduy [Opens in a new window]  and
Jennifer F. Friedman
Joachim Richter*
Affiliation:
Institute of International Health, Global Health Center, Charité Universitätsmedizin, Corporate Member of Free University and Humboldt University and Berlin Institute of Health, Berlin, Germany Centre for Tropical and Travel Medicine, Swiss Tropical and Public Health Institute, Basel, Switzerland
Sekeleghe A. Kayuni
Affiliation:
Department of Tropical Disease Biology, Liverpool School of Tropical Medicine, Liverpool, UK
J. Russell Stothard
Affiliation:
Department of Tropical Disease Biology, Liverpool School of Tropical Medicine, Liverpool, UK
Charles Émile Ramarokoto
Affiliation:
Epidemiology Unit, Institut Pasteur, Antananarivo, Madagascar
Andreas K. Lindner
Affiliation:
Institute of International Health, Global Health Center, Charité Universitätsmedizin, Corporate Member of Free University and Humboldt University and Berlin Institute of Health, Berlin, Germany
Daniela Fusco
Affiliation:
Implementation Research Group, Bernhard Nocht Institute for Tropical Medicine, Hamburg, Germany
Hermann Feldmeier
Affiliation:
Institute of Microbiology, Charité Universitätsmedizin, Corporate Member of Free University and Humboldt University and Berlin Institute of Health, Berlin, Germany
Amaya L. Bustinduy
Affiliation:
Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
Jennifer F. Friedman
Affiliation:
Lifespan Center for International Health Research (CIHR), Department of Pediatrics, Warren Alpert Medical School of Brown University, Providence, RI, USA
*
Corresponding author: Joachim Richter; Email: [email protected]
Rights & Permissions [Opens in a new window]

Abstract

We present four cases of male genital schistosomiasis (MGS) within children and adolescents opportunistically encountered as part of a wider screening programme for imported schistosomiasis in Germany and community outreach screening in Mali. Such genital manifestations in young children and adolescents are often overlooked but can include hydrocele, hypogonadism, varicocele, cutaneous granulomata on the penis and scrotum, echogenic spots in the prostate and the epididymis, alongside testicular masses. Though these cases appear sporadic, from our scoping literature review, they draw fresh attention on MGS in young children and highlight wider confusion with other congenital, neoplastic and infectious disease. These might include an insufficient closure of the tunica vaginalis, malignancies or lymphatic filariasis. Frequently haematuria is not present. One typical sign indicating MGS in adults, i.e. haematospermia is not present before puberty. Another reason of missing MGS cases may be that screening with scrotal or transabdominal ultrasonography are not easily accepted unless the reason for it is not extensively explained beforehand and that transabdominal ultrasonography is less sensitive for revealing prostatic lesions than transrectal ultrasonography.

Keywords

adolescentschildrenhydrocelehypogonadismmale genital schistosomiasisminorsSchistosomaschistosomiasistesticular massesultrasound
Type
Review Article
Information
Parasitology , First View , pp. 1 - 10
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This is an Open Access article, distributed under the terms of the Creative Commons Attribution licence (http://creativecommons.org/licenses/by/4.0), which permits unrestricted re-use, distribution and reproduction, provided the original article is properly cited.
Copyright
© The Author(s), 2025. Published by Cambridge University Press.

Introduction

Schistosomiasis is a neglected parasitic infection caused by blood fluke trematodes of the genus Schistosoma. Four out of six Schistosoma species pathogenic to humans have been described as being capable of inducing disease sequelae within the genital tract: S. haematobium; causing urogenital schistosomiasis, S. mansoni, S. intercalatum, and S. japonicum; mainly causing intestinal and hepatosplenic schistosomiasis (Lee et al., Reference Lee, Hsueh and Tang2000; Shekhar et al., Reference Shekhar, Soh and Jayalakshmi2000; Yu et al., Reference Yu, Wei, Wang, Ye, Wang, Chen, Ni, Yang, Gui, Guan, Cai and Lai2013; Bustinduy et al., Reference Bustinduy, Richter and King2023). Recently, the zoonotic species S. matthei has also been found to cause human genital schistosomiasis (Kayuni et al.,Reference Kayuni, Cunningham, Kumwenda, Mainga, Lally, Chammudzi, Kapira, Namacha, Ntaba, Chisale, Nchembe, Kinley, Chibwana, Juhasz, Jones, Archer, Makaula, Chiphwanya, LaCourse, Musaya and Stothard2024). Globally, approximately 240 million people are infected (about 90% living in sub-Saharan Africa) (WHO 2020). Health complications arising from genital schistosomiasis have been more and more acknowledged, especially those occurring in women (Abul Kahir et al. Reference Abul-Khair, Sobeih, Taalab and Taalab1980; Richter et al., Reference Richter, Poggensee, Helling-Giese, Kjetland, Chitsulo, Koumenda, Gundersen, Krantz and Feldmeier1995, Reference Richter, Poggensee, Kjetland, Helling-Giese, Chitsulo, Kumwenda, Gundersen, Deelder, Reimert, Haas, Krantz and Feldmeier1996, Reference Richter, Lux, Reinecke and Müller-Mattheis2008; Kjetland et al., Reference Kjetland, Poggensee, Helling-Giese, Richter, Sjaastad, Chitsulo, Kumwenda, Gundersen, Krantz and Feldmeier1996; Helling Giese et al., Reference Helling-Giese, Kjetland, Gundersen, Poggensee, Richter, Krantz and Feldmeier1996a; Helling-Giese et al., Reference Helling-Giese, Sjaastad, Poggensee, Kjetland, Richter, Chitsulo, Kumwenda, Roald, Gundersen, Krantz and Feldmeier1996b; Poggensee et al., Reference Poggensee, Sikelu, Saría, Richter, Krantz and Feldmeier1998; Schanz et al., Reference Schanz, Richter, Beyer, Baldus, Hess and Kruessel2010; Christinet et al., Reference Christinet, Lazdins-Helds, Stothard and Reinhard-Rupp2016; Kayuni et al. Reference Kayuni, Lampião, Makaula, Juziwelo, Lacourse, Reinhard-Rupp, Leutscher and Stothard2020; Kayuni et al., Reference Kayuni, Cunningham, Kumwenda, Mainga, Lally, Chammudzi, Kapira, Namacha, Ntaba, Chisale, Nchembe, Kinley, Chibwana, Juhasz, Jones, Archer, Makaula, Chiphwanya, LaCourse, Musaya and Stothard2024; World Health Organization, 2020; Bustinduy et al., Reference Bustinduy, Randriansolo, Sturt, Kayuni, Leustcher, Webster, Van Lieshout, Stothard, Feldmeier and Gyapong2022; Fusco et al., Reference Fusco, Martínez-Pérez, Remkes, De Pascali, Ortalli, Varani and Scagliarini2022; Kutz et al., Reference Kutz, Rausche, Rasamoelina, Ratefiarisoa, Razafindrakoto, Klein, Jaeger, Rakotomalala, Rakotomalala, Randrianasolo, McKay-Chopin, May, Rakotozandrindrainy, Puradiredja, Sicuri, Hampl, Lorenz, Gheit, Rakotoarivelo and Fusco2023; Shanaube et al., Reference Shanaube, Ndubani, Kelly, Webb, Mayaud, Lamberti, Fitzpatrick, Kasese, Sturt, Van Lieshout, Van Dam, Corstjens, Kosloff, Bond, Hayes, Terris-Prestholt, Webster, Vwalika, Hansingo, Ayles and Bustinduy2024). However, little is known about the frequency of genital manifestations of schistosomiasis in younger children and adolescents, particularly in males. To shed light on the latter, we report on four cases of MGS in male children and adolescents, and place these cases within a wider appraisal of available literature.

Ethical considerations

Mandatory routine infectious and parasitic diseases screening of unaccompanied minor refugees (UMR) arriving in Berlin is performed at the Institute of Tropical Medicine and International Health of Charité – Universitätsmedizin Berlin, and previous findings have been described in detail elsewhere (Theuring et al., Reference Theuring, Friedrich-Jänicke, Pörtner, Trebesch, Durst, Dieckmann, Steiner, Harms and Mockenhaupt2016).

Case reports

Case 1

A 4-year-old boy, son of German volunteers living in Tanzania for 2 years, had intermittent non-febrile bloody diarrhoea for 5 months. After returning to Germany he was examined and presented with a painless swelling of the scrotum and livid skin discoloration, with congestion of the dorsal vein of the penis, accompanied by tenderness and swelling of two inguinal lymph nodes. At interview the parents recalled that he used to play near a river in Tanzania; they remembered no trauma. The diagnosis of schistosomiasis was confirmed by faecal microscopy, where viable ova of S. mansoni were found. Urinary sediment was normal; Schistosoma ova were not detected by microscopy of urine collected over 24 h with the whole volume filtered through microfilters (Nucleopore, Corning, Acton, USA). A differential white blood cell count showed eosinophilia (10%, 600 µL−1). Serology for anti-Schistosoma antibodies (anti-adult worm antibodies, an immune-haemagglutination assay) was highly positive. Amoebiasis, filariasis, toxocariasis and urogenital tuberculosis were excluded by clinical, parasitological, serological and ultrasonography means and antigen testing for Wuchereria bancrofti (Amaral et al., Reference Amaral, Dreyer, Figueredo-Silva, Noroes, Cavalcanti, Samico, Santos and Coutinho1994, Chung et al., Reference Chung, Kim, Lee, Voo and Lee1997, Weil et al., Reference Weil, Lammie and Weiss1997). On abdominal ultrasonography, he had nonspecific hepatosplenomegaly, as encountered in the early stages of the disease (Barata et al., Reference Barata, Pinto-Silva and Lambertucci1999) but without typical signs of schistosomal hepatic fibrosis (Richter et al., Reference Richter, Zwingenberger, Mohamed-Ali, Moura Lima, Dacal, Vergetti Siqueira, Doehring-Schwerdtfeger and Feldmeier1992). No abnormalities of the urinary tract were detected (Niamey Working Group, Reference Richter, Hatz, Campagne and Jenkins2000). Scrotal ultrasonography showed an echo-free fluid in the scrotum; the testis, epididymis, prostate and seminal vesicles were normal (Figure 1). A consultant paediatric urologist interpreted these findings as due to a patent processus vaginalis and recommended surgical division of the processus. However, more invasive investigations were declined by the boy’s parents because we suspected a causal relation between schistosomiasis and the boy’s hydrocele. He was treated with one standard dose of praziquantel at 40 mg kg−1 and surgery was postponed. The treatment was repeated at the same dose over 2 days 8 weeks later, owing to the detection of viable ova still being excreted in the stool; 16 weeks after therapy Schistosoma ova were absent in the faeces. The hydrocele had disappeared and remained so during the following 12 months, when the boy was last reviewed.

Figure 1. Two-year-old German boy with Schistosoma mansoni infection, who had grown up in Kenya and Tanzania. Scrotal swelling and ultrasonography showing hydrocele before (1a, 1b) and six weeks after praziquantel (1c, 1d).

Case 2

Unaccompanied minor refugees are routinely screened in our outpatient clinic. Here, we attended a 17-year-old male Fulani adolescent from Sierra Leone. He had been treated successfully for disseminated tuberculosis a year earlier. At his presentation in our OPD, his differential blood count revealed an eosinophilia of 1.1 nl−1 (norm < 0.5) and IgE was increased to 4646 ku l−1 (norm < 100). Serology revealed positive antibodies against filariae, Strongyloides stercoralis and schistosomes. Microscopy of microfiltered urine collected during 24 h did not reveal the presence of helminths or their ova. Microscopy of four skin snips and of anticoagulated full blood microfiltered through a nuclepore filter at lunchtime and after provocation with di-ethyl-carbamazine were all negative. Microscopy of enriched fresh stool samples for helminth larvae according to the Baermann method was negative for worm larvae but instead, ova of S. mansoni were found. The patient was initially seen by a female doctor. At the second visit he asked for being seen by a male doctor because he was ashamed to report a recurrent scrotal swelling with disappearance of his penis inside the swollen scrotum. Ultrasonography of the scrotum revealed a hydrocele of the right scrotum and to a lower degree of the left side (Figure 2). Adult filariae (‘filarial dance sign’) were not detected in the scrotal lymphatics (Al-Saeed et al., Reference Al-Saeed, Figueiredo-Silva and Noroes1994). Therapy with ivermectin 200 μg kg−1 was given and repeated after two weeks followed by praziquantel three doses of 40 mg kg−1 body weight. Since during the 12 months following antiparasitic therapy the hydrocele persisted, surgical therapy was performed in order to completely cure his hydrocele.

Figure 2. Scrotal ultrasonography of a 17-year-old Fulani refugee from Guinea Conakry with Schistosoma mansoni infection. Right testis immerged in anechoic scrotal fluid.

We cannot exclude that the aetiology of hydrocele in his case was multifactorial. He had been cured in the past from disseminated tuberculosis and had probably been previously infected by filariae as proven by positive antibodies against filariae. The moment he was attended in our service, he suffered from active schistosomiasis. Anti-helminthic alone was not sufficient for curing his hydrocele, so that we opted for additional surgical therapy which was finally successful. The patient was well until three years later, when he was last reviewed.

Case 3

During a training course on ultrasonography in urinary schistosomiasis in Mali 25 children were selected, 13 of whom (52%) excreted ova of S. haematobium in urine. Among the children one 12-year-old boy was identified by ultrasonography who presented a hyperechogenic spot measuring 7× .4 × 4 mm in the right prostate lobe (Figure 3). Microfiltration of noon urine revealed a quantitative egg excretion of 11 eggs/10 ml urine. Findings of seminal vesicles, urethers and kidneys were unremarkable. The patient was treated by praziquantel with a single standard dose of 40 mg kg−1 body weight. The patient was lost to follow-up.

Figure 3. Hyperechoic spot in the prostate of a 12-year-old boy from Mali with S. haematobium infection.

Case 4

This case was seen among other minor refugees to Germany from Guinée Conakry, presenting with a hydrocele which reversed after three doses of praziquantel at 40 mg kg−1. Details are described in Table 1.

Literature search

Literature search was performed in several data bases including PubMed, Medline, Cochrane, Google scholar and Embase with the search terms ‘Male genital schistosomiasis AND child, children’ and ‘Male genital schistosomiasis AND adolescent/adolescents’. The selection process of eligible publications is shown in.

Discussion

The importance of genital manifestations in women and men has been increasingly acknowledged during the last 30 years (Richter et al., Reference Richter, Poggensee, Helling-Giese, Kjetland, Chitsulo, Koumenda, Gundersen, Krantz and Feldmeier1995, Reference Richter, Poggensee, Kjetland, Helling-Giese, Chitsulo, Kumwenda, Gundersen, Deelder, Reimert, Haas, Krantz and Feldmeier1996, Reference Richter, Lux, Reinecke and Müller-Mattheis2008; Kjetland et al., Reference Kjetland, Poggensee, Helling-Giese, Richter, Sjaastad, Chitsulo, Kumwenda, Gundersen, Krantz and Feldmeier1996; Helling Giese et al., Reference Helling-Giese, Kjetland, Gundersen, Poggensee, Richter, Krantz and Feldmeier1996a; Helling-Giese et al., Reference Helling-Giese, Sjaastad, Poggensee, Kjetland, Richter, Chitsulo, Kumwenda, Roald, Gundersen, Krantz and Feldmeier1996b; Leutscher et al. Reference Leutscher, Pedersen, Raharisolo, Jensen, Hoffmann, Lisse, Ostrowski, Reimert, Mauclere and Ullum2005; Schanz et al., Reference Schanz, Richter, Beyer, Baldus, Hess and Kruessel2010; Christinet et al., Reference Christinet, Lazdins-Helds, Stothard and Reinhard-Rupp2016; Kayuni et al., Reference Kayuni, Lampião, Makaula, Juziwelo, Lacourse, Reinhard-Rupp, Leutscher and Stothard2018; World Health Organization, 2020; Bustinduy et al., Reference Bustinduy, Randriansolo, Sturt, Kayuni, Leustcher, Webster, Van Lieshout, Stothard, Feldmeier and Gyapong2022; Fusco et al., Reference Fusco, Martínez-Pérez, Remkes, De Pascali, Ortalli, Varani and Scagliarini2022; Kutz et al., Reference Kutz, Rausche, Rasamoelina, Ratefiarisoa, Razafindrakoto, Klein, Jaeger, Rakotomalala, Rakotomalala, Randrianasolo, McKay-Chopin, May, Rakotozandrindrainy, Puradiredja, Sicuri, Hampl, Lorenz, Gheit, Rakotoarivelo and Fusco2023; Shanaube et al., Reference Shanaube, Ndubani, Kelly, Webb, Mayaud, Lamberti, Fitzpatrick, Kasese, Sturt, Van Lieshout, Van Dam, Corstjens, Kosloff, Bond, Hayes, Terris-Prestholt, Webster, Vwalika, Hansingo, Ayles and Bustinduy2024).

However, knowledge on the importance of genital schistosomiasis in children and adolescents is scarce although genital schistosomiasis in a young boy has been described for the first time by Madden already in 1911. (Madden, Reference Madden1911; Feldmeier et al., Reference Feldmeier, Richter, Helling-Giese and Krantz1995; Bustinduy et al., Reference Bustinduy, Randriansolo, Sturt, Kayuni, Leustcher, Webster, Van Lieshout, Stothard, Feldmeier and Gyapong2022; Aribodor et al., Reference Aribodor, Azugo, Jacob, Ngenegbo, Onwusulu, Obika, Obikwelu and Nebe2024). There has never been a systematic investigation on the importance of genital manifestations at a young age. We came across four cases; two of them observed during health screening of unaccompanied minor refugees to Germany. To our knowledge, our case 1 is the youngest case of genital schistosomiasis age ever reported in the literature (Richter et al., Reference Richter, Stegemann and Häussinger2002). Another case of penile schistosomiasis has been reported to one of our authors (B. Quire personal communication to AL Bustinduy). Surprisingly, besides our cases, we have found only other 23 cases published worldwide since 1911. Other publications on patient series with MGS have been published but it is not possible to understand from the publications whether or not minors included in the cohorts had MGS manifestations (Alves et al., Reference Alves, Woods and Gelfand1955; Gelfand et al. Reference Gelfand and Davis1940; De Souza et al. Reference De Souza Alves, Assis and Rezende2004; Aminu et al. Reference Aminu, Ibrahim, Nasiru and Isaac2023; Mohammed et al., Reference Mohammed, Edino and Samaila2007; Ramarokoto et al., Reference Ramarokoto, Leutscher, van Dam and Christensen2008; Msyamboza et al., Reference Msyamboza, Ngwira, Banda, Mkwanda and Brabin2010; Percheron et al., Reference Percheron, Leblanc, Ulinski, Fila, Malvy, Bacchetta, Guigonis, Debuisson, Launay, Martinez, Morand, Decramer, Schanstra and Berry2024). The relative scarcity of cases published in the literature points at underreporting. One possible reason is that only a minority of patients present with haematuria. In our case series, only 3/27 (11.11%) cases reported haematuria. Another indicative sign of MGS, i.e. haematospermia and changes of the consistence of ejaculate cannot be investigated before puberty (Corachan et al., Reference Corachan, Valls, Gascon, Almeda and Vilana1994; McKenna et al., Reference McKenna, Schousboe and Paltridge1997; van Delft et al., Reference van Delft, Visser, Polderman and van Lieshout2007). A third reason is possibly that MGS may occur without the presence of schistosome ova in urine (Richter et al., Reference Richter, Stegemann and Häussinger2002; van Delft et al., Reference van Delft, Visser, Polderman and van Lieshout2007). A fourth reason may possibly be that the condition is not well known to urologists. 24/27 (88.89%) cases of our series were diagnosed by accident when another cause was suspected such as a malignancy (see Table 1). Even in endemic countries urologists usually do not connect genital problems with schistosomiasis and even less so, when it occurs in children or adolescents. In endemic countries, hydrocele is most frequently ascribed to filariasis. Interestingly, contrary to current notions, in an Egyptian and In a Sudanese case series on histopathological samples collected during scrotal surgery, schistosomiasis was the cause of scrotal swellings more frequently than filariasis (Abdel Wahab et al., Reference Abdel Wahab, Shoeb, Haseeb, Sherif, El-deeb, El-fiky and El-beshlawy1981; Malik et al. Reference Malik and Ibrahim1982). A fifth possible biasing cause is the fact that the patients and their parents are ashamed of their condition which, on the other hand, appears to be painless and not immediately threatening. In fact, in our cases with hydrocele, the patients had never reported spontaneously their ailment to the medical staff at the first visit and mostly asked later to be seen by a male doctor.

In adults, genital involvement is particularly frequent condition in infections by S. haematobium and to a lesser extent S. intercalatum (Corachan et al., Reference Corachan, Escosa, Mas, Ruiz and Campo1987; Picaud et al., Reference Picaud, Walter, Bennani, Minko Mi Etoua and Nlome Nze1990; Jusot et al., Reference Jusot, Simarro and De Muynck1997; Leutscher et al., Reference Leutscher, Ramarokoto, Reimert, Feldmeier, Esterre and Vennervald2000; van Delft et al., Reference van Delft, Visser, Polderman and van Lieshout2007; Ramarokoto et al., Reference Ramarokoto, Leutscher, van Dam and Christensen2008; Kayuni et al., Reference Kayuni, Lampião, Makaula, Juziwelo, Lacourse, Reinhard-Rupp, Leutscher and Stothard2018) but genital schistosomiasis has been reported to occur also in S. mansoni, S. japonicum and S. matthei infections (Kayuni et al.Reference Kayuni, Cunningham, Kumwenda, Mainga, Lally, Chammudzi, Kapira, Namacha, Ntaba, Chisale, Nchembe, Kinley, Chibwana, Juhasz, Jones, Archer, Makaula, Chiphwanya, LaCourse, Musaya and Stothard2024; Steinberger et al., Reference Steinberger, Lindsay, Alassandri and Wise1975; Armbrust, Reference Armbrust1951; Steinberger et al., Reference Steinberger, Lindsay, Alassandri and Wise1975; Bambirra et al., Reference Bambirra, de Souza Andrade, Bamberg, Costa, Andrade and de Souza1986; Lee et al., Reference Lee, Hsueh and Tang2000; Shekhar et al., Reference Shekhar, Soh and Jayalakshmi2000; de Souza Alves et al. Reference Cassio Saito, de Barros, Chammas, Oliveira and Cerri2004; Cassio Saito et al., Reference Cassio Saito, de Barros, Chammas, Oliveira and Cerri2004; Neto et al., Reference Neto, Grande and Moreira2004; Lopes et al., Reference Lopes, de Almeida and Jacobino2007a, Reference Lopes, Leite, Prando and Lopes2007b; Ricosse et al., Reference Ricosse, Emeric and Courbil1980; Schwartz et al., Reference Schwartz, Pick, Shazberg and Potasman2002).

Another particular genital manifestation of schistosomiasis had been addressed by Brandt et al. (Reference Brandt, Albuquerque, Brandt, Lorenzato, Leal, Barbosa and Nóbrega2003): severe hepatosplenic schistosomiasis may be associated with hypogonadism and, after porto-systemic collaterals have evolved or been surgically created, with varicocele. Specifically, hypogonadism and retarded sexual development as a manifestation of schistosomiasis which is not systematically explored (Brandt et al., Reference Brandt, Albuquerque, Brandt, Lorenzato, Leal, Barbosa and Nóbrega2003; Jatsa et el. Reference Jatsa, Femoe, Dongmo, Kamwa, Fesuh, Tchuem Tchuente and Kamtchouing2022).

The frequency of the diagnosis of genital schistosomiasis depends also on the diagnostic method. In autopsy digest methods are far more sensitive than histology for detecting schistosome ova (Edington et al., Reference Edington, Nwabuebo and Junaid1975). For detecting scrotal abnormalities scrotal ultrasonography has to be done. In screening programmes, a subject who does not think to have involvement of the scrotal organs is not likely to easily accept scrotal ultrasonography. Examination by transrectal ultrasonography is more sensitive for detecting prostatic lesions than transabdominal ultrasonography (Vilana et al., Reference Vilana, Corachan, Gascon, Valls and Bru1997; Al Saeed et al. Reference Al-Saeed, Sheikh, Kehinde and Makar2003). On the other hand, transrectal ultrasound is usually not applied in children, more time consuming than transabdominal ultrasound alone and is probably not that easily accepted in a field context where privacy is not that easily felt to be warranted.

Conclusions

  1. 1. Male genital schistosomiasis is a manifestation of schistosomiasis, which is neglected specially when occurring in children or adolescents.

  2. 2. Paediatricians and urologists should be aware of this condition to avoid stigmatization or unnecessary surgery.

  3. 3. Shame and fear of stigmatization may play a role of the particular neglect of this condition, also, because on the other hand, MGS in this age appears not to be particularly painful or threatening to the young patients.

  4. 4. Scrotal ultrasonography may require extensive and careful explanation to the patients and their parents if these methods are planned to be integrated into a screening programme.

  5. 5. Praziquantel treatment, when given before surgery appears to be efficient in most cases although, in some cases, surgery may be required.

  6. 6. The occurrence of MGS already in early childhood underscores the concept to treat schistosomiasis at an early age to prevent unnecessary complications which untreated may require surgery or may become no more reversible (Bustinduy et al., Reference Bustinduy, Stothard and Friedman2017).

Ethical approval

All procedures performed were approved by the data Protection Office and Ethics Committee of Charité-Universitätsmedizin Berlin and were in accordance with the ethical standards of the Helsinki Declaration and its later amendments. Approval for surveillance participation was provided by the UMRs’ legal representative, i.e. the Berlin Senate Department for Education, Youth and Science. Initial health inspection, tuberculosis screening and school entrance examination are performed at other facilities in Berlin. In the other cases informed consent for publication was obtained from the parents. Experimentation with vertebrates: Not applicable.

Author contributions

JR, CER and AKL cared for the patients. JR, SAK, JRS and HF conceived and designed the study. JR, SAK, CER and AKL conducted data gathering. JR, DF, RSS, HF, ALB, and JF drafted the article. RSS produced the graphical abstract. All authors contributed to writing the manuscript and approved the final version to be published.

Funding

This research received no specific grant from any funding agency, commercial or not-for-profit sectors.

Competing interests

The authors declare no conflicts of interest exist.

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Figure 0

Figure 1. Two-year-old German boy with Schistosoma mansoni infection, who had grown up in Kenya and Tanzania. Scrotal swelling and ultrasonography showing hydrocele before (1a, 1b) and six weeks after praziquantel (1c, 1d).

Figure 1

Figure 2. Scrotal ultrasonography of a 17-year-old Fulani refugee from Guinea Conakry with Schistosoma mansoni infection. Right testis immerged in anechoic scrotal fluid.

Figure 2

Figure 3. Hyperechoic spot in the prostate of a 12-year-old boy from Mali with S. haematobium infection.

Figure 3

Table 1. Reports on genital schistosomiasis in male children and adolescents