Genitourinary Symptoms Caused by Monkeypox Virus: What Urologists Should Know

Monkeypox virus (MPXV), a type of orthopoxvirus that was previously thought to have a high fatality rate, has recently been reported in many countries and regions [1]. Monkeypox is a zoonotic viral disease that was first detected in research monkeys and is epidemic in West and Central Africa. In general, rodents and small mammals are considered to be the natural hosts of MPXV [2]. According to the global epidemiological situation presented by the World Health Organization (WHO) Secretariat, more than 14 000 probable and laboratory-confirmed cases were reported from 72 countries between January 2022 and July 2022. In the past 2 mo, confirmed cases of monkeypox have increased rapidly and spread in many countries. The WHO Director-General has designated the multicountry outbreak of monkeypox a public health emergency of international concern [3].

Unlike the sudden onset of the COVID-19 outbreak, monkeypox cases occurred as early as 1970 [4]. MPXV is comparable to smallpox virus, which has been studied by researchers for many years. There are two distinct MPXV clades, the West African clade and the Congo Basin clade, and the mortality rate for the Congo Basin clade is as high as 10% [5], [6]. In contrast to COVID-19, transmission of MPXV is not easy and the chief modes of human-to-human spread are direct contact and sexual intercourse. Interestingly, a high rate of male homosexual infection is one of the characteristics of this monkeypox epidemic [7]. Therefore, in addition to dermatologists, urologists and andrologists have encountered many monkeypox cases in sexually transmitted infection clinics; these patients present with genital lesions, which greatly increases the risk of monkeypox infection for clinicians [8]. We conducted a big data analysis that revealed severe neglect of monkeypox research [9], with a lack of studies on monkeypox-related genitourinary symptoms and protective measures.

Identification of the early symptoms of monkeypox infection and improvements in awareness of protection measures are essential to reduce the risk of occupational exposure and transmission for health care workers. Monkeypox is characterized by fever, headache, cervical lymphadenopathy, and other flu-like symptoms in the early stage. At 1–3 d after disease onset, a rash appears, progressing from a maculopapular rash to herpes (including blisters and pustules), and then scabs or crusts. Most monkeypox lesions are distributed on the face and limbs, but can also appear in anogenital areas, the mouth, and the conjunctiva. Monkeypox lesions are well circumscribed and the exudate is highly contagious. Monkeypox infection is a self-limiting disease for most patients, with recovery usually taking 2–4 wk [10], [11]. However, individuals with poor immunity, such as children, pregnant women, and the elderly, are prone to serious complications and even death [12], [13].

In addition to the typical symptoms (prominent cervical and axillary lymphadenopathy), diagnosis of monkeypox depends on laboratory assays involving pathogenic detection in body fluids (including rash exudate, whole blood, urine) and throat swabs. Viral DNA is isolated and identified using methods such as electron microscopy, real-time polymerase chain reaction, and serological testing for specific antibodies. It should be noted that since smallpox, chickenpox, measles, shingles, and herpes simplex may have the same symptoms, monkeypox needs to be differentiated from these diseases [14], [15]. We have summarized the differences among six common sexually transmitted diseases in Table 1 .

Table 1.

Differences between the six most common sexually transmitted diseases and monkeypox

Disease	Pathogen	Genitourinary symptoms	Incubation period	Diagnosis
Genital warts	Human papillomavirus	Warts in the genital or anal area causing itching and redness	1–8 mo	Symptoms and biopsy result
NGU	Mycoplasma, chlamydia, fungus, trichomonad	Pain/burning on urination; discharge from the penis/vagina	7–21 d	DNA tests for the NGU pathogen
Gonorrhea	Neisseria gonorrhoeae	Burning on urination; discharge from the penis/vagina; pelvic or testicular pain	1–10 d	Symptoms and PCR-based tests of urine, urethral swabs, or cervical/vaginal swabs
Syphilis	Treponema pallidum	Primary: Chancre Secondary: nonitchy rash Latent: asymptomatic Tertiary: gummatous syphilis	Primary: 2–6 wk Secondary: 4–10 wk Tertiary: 3–15 yr after initial infection	Symptoms, blood tests, and dark-field microscopy of infected fluid
Genital herpes	Herpes simplex virus	Progressing from small blisters to painful ulcers, and then crusting and healing	5–6 d	Physical examination, blood test for antigen, lesion tests
AIDS	Human immunodeficiency virus	Early: genital sores Latency: asymptomatic Later: large lymph nodes, fever, weight loss	Early: 2–4 wk Latency: 3–20 yr	Symptoms and blood tests (antibody test, p24 antigen test)
Monkeypox	Monkeypox virus	Pustular lesions/vesicles on the dorsal penis Scab/whitish lesions on the (glans) penis Scrotal lesions with a purulent exudate	5–21 d	Symptoms and laboratory testing of body fluids (electron microscopy, real-time PCR, serological testing)

AIDS = acquired immunodeficiency syndrome; NGU = nongonococcal urethritis; PCR = polymerase chain reaction.

The rash associated with monkeypox can also be observed in the genitourinary system. Urologist and andrologists who encounter the following symptoms in the genitourinary system accompanied by fever and cervical/axillary lymphadenopathy should be vigilant and pay attention to identification of monkeypox [8]:

• 1.Penile edema.
• 2.Pustular lesions and vesicles on the dorsum of the penis.
• 3.Scabs and whitish lesions on the (glans) penis.
• 4.Proctalgia and a rectal discharge.
• 5.Perianal vesicles.
• 6.Rectal itching and a rectal discharge.
• 7.Pain in the perineal area.
• 8.Scrotal lesions with a purulent exudate.

In anticipation of a potential monkeypox outbreak, a strategic plan should be prepared in advance for effective management and control of infection. The following summary of the measures that can be taken may be useful for urologists, andrologists, and specialist nurses in protecting against possible occupational exposure.

• 1.During consultations in the outpatient department, inquire carefully to identify patients with a travel history in the monkeypox epidemic area and male patients who have sex with men.
• 2.Classify suspicious patients and isolate them in a negative-pressure isolation room to avoid contact with other patients and confirm the diagnosis as soon as possible.
• 3.Disinfect hands and wear gloves during physical examination of suspicious patients. Personal protective equipment, including a waterproof surgical gown, plastic apron, and visor, is mandatory. A face filter is also recommended to avoid possible respiratory transmission.
• 4.For patients with confirmed monkeypox who need to be hospitalized, an isolation room should be prepared according to infectious disease requirements for isolation treatment.
• 5.
  For patients with a confirmed diagnosis who need surgical treatment, elective surgery should be postponed until the ulcers crusts on the skin fall off to avoid increasing the surgical risk. For patients who must undergo immediate surgery, the following recommendations are based on current international guidelines to ensure the safety of medical workers and other patients [16]:

  • (i)
    Before surgery: Conduct a multidisciplinary consultation to fully evaluate the impact of surgery on patients with MPXV. Aggressive antiviral therapy and nutritional support are necessary.
  • (ii)
    During surgery: Personal protective equipment is essential for operating room personnel. The surgery should be completed by a senior doctor to reduce the operation time and the risk of infection, especially for transurethral procedures, which have the highest exposure risk. Surgical waste should be safely disposed of and the operating room should be disinfected after the surgery is finished.
  • (iii)
    After surgery: Transfer the patient to an isolation room for specialized treatment as soon as possible and reduce the hospitalization time according to the concept of enhanced recovery after surgery.

In summary, monkeypox spreads rapidly and is another important global public health concern besides COVID-19 that needs special attention. At present, direct contact with a patient’s body fluids is the main transmission route, with respiratory transmission another potential mode. Antiviral therapy and supportive and symptomatic treatment are the main approaches for monkeypox at present, and vaccines are under development. Urologists and andrologists are likely to be exposed to patients with monkeypox in the clinic and need to be vigilant and take appropriate precautions to avoid occupational exposure.



Conflicts of interest: The authors have nothing to disclose.