Endocrine tests in phenotypic children with bilateral impalpable testes can reliably predict "congenital" anorchism

Basal Levels and hCG Responses of Serum Testosterone and Estrogen in Male Alpacas

Steroid response to human Chorionic Gonadotropin (hCG) administration has been used in various species to study testicular function and for diagnostic purposes. In this study, two experiments were conducted to determine serum testosterone concentration response to administration of hCG and its correlation with testicular weight. In the second experiment the relationship between age, testosterone and estrogen response to hCG, and testicular histometry was in pre-pubertal and post-pubertal male alpacas. For experiment 1, males in two age groups (2 to 3 years, n = 9) and (4 to 7 years; n = 15) received 3,000 IU hCG IV, 36 to 48 h before castration. Serum testosterone concentration was determined before (T0), 1 h (T1), 2 h (T2), 8 h (T8), and 24 h (T24) after administration of hCG. Basal concentrations of serum testosterone was significantly different (P < 0.01) between age groups. Serum testosterone concentrations increased over time and doubled 2 h after treatment. The highest change (250 to 300% increase from T0) was observed at 8 h (3.5 ± 0.3 ng/ml). A significant correlation (P < 0.01; r = 0.64) was found between serum testosterone concentration and total testicular weight. For experiment 2, 60 males ranging in age from 6 to 60 months were used. Serum testosterone and estrogen was determined in samples taken just prior to and 2 h after administration of 3,000 IU hCG. Basal serum testosterone concentrations were very low (≤0.1 ng/mL) until 9 months of age then increased steadily with age. There was a significant variation amongst males within the same age group. Serum testosterone concentration increased by 2- to 4-fold 2 h after hCG injection (P ≤ 0.05). Males in the 13 to 14 months of age group had the highest rise. Estrogen concentration increased in response to hCG administration and was detected only in males with high testosterone. We conclude that administration of 3,000 IU of hCG IV can be used reliably to detect testicular tissue and study its steroidogenic activity. The response is correlated with testicular weight and Leydig cell number. Testicular growth and sensitivity to LH stimulation increases between the ages of 13 and 14 months. The aromatizing ability of Leydig cells increased significantly in post-pubertal male alpacas.

Congenital absence of the testis in human fetuses and in cryptorchid patients

BACKGROUND

The aim of the present study is to make a comparative study in human fetuses and in patients with cryptorchidism, analyzing the incidence of a number anomalies of the testes for both populations.

METHODS

We studied 326 testes from 163 human fetuses ranging in age from 10 to 35 weeks postconception (WPC) and 133 testes from 101 cryptorchid patients aged from 1 to 15 years old (mean, 6.4 years). The Fisher's exact test was used for comparison.

RESULTS

Among 326 fetal testes, 224 (68.7%) were abdominal, 45 (13.8%) were inguinal and 55 (16.8%) were scrotal. In one fetus at 23 WPC, both testes (0.6%) were absent. Of the 133 cryptorchid testes, 17 (12.78%) were abdominal, 92 (69.1%) were inguinal and 24 (18%) were high scrotal. Of the 17 abdominal testes, three (17.6%) were atrophic and two were vanished (11.7%). Of the 92 inguinal testes, one (1.08%) was vanished. Twenty-eight (21%) of the cryptorchid testes were impalpable and among these, 17 were located in the abdomen (60.7%) and 11 (38.2%) in the inguinal region (internal ring).

CONCLUSIONS

Testicular agenesis is a very rare anomaly, both in fetuses and patients with cryptorchidism.

[What a hidden testicle can hide?..or the clinical traps of cryptorchidism]

Although cryptorchidism is probably the most frequent genital anomaly encountered in boys, this pathology remains largely unexplained and its long-term prognosis is still uncertain. Despite the relative easiness of this diagnosis, attention should be paid to some clinical traps, which can mislead the sexual identity. Indeed, beside the isolated common cryptorchidism, many troubles of the testicular migration can be associated with various malformative syndromes and can be named as "cryptorchidism symptoms". Most of these syndromes are obvious, but some can be suspected only by the way of an abnormal descent of testis. Cryptorchidism, which is systematically screened out during any pediatric consultation, should play the role of clinical marker for various endocrine or genetic disorders. Among them, the intersex states should be underlined to avoid the harmful effects of misdiagnosis. We dealt with this subject through a clinical and practical approach.

Congenital bilateral anorchia: clinical, hormonal and imaging study in 12 cases

Twelve anorchid pre-pubertal and post-pubertal patients, aged between 8.5 and 41 years, were studied. The FSH and LH basal levels as well as their responses to Gn-RH (100 micrograms i.v.) were increased and prolonged in the post-pubertal patients. The testosterone levels were in the pre-pubertal range and failed to increase after HCG administration (1500 I.U. t.i.d. for 3 days). Ultrasonography of the pelvis was performed in all the patients. Computed tomography and magnetic resonance of the abdomen were also performed in 6 and 5 patients respectively. These techniques failed to show any testicular tissue. Lastly, in 4 patients, surgical exploration confirmed the absence of testicular structure.

The use of the hCG stimulation test in the endocrine evaluation of cryptorchidism

OBJECTIVE

To review retrospectively the value of the human chorionic gonadotrophin (hCG) test in the evaluation of prepubertal boys with bilateral impalpable testes.

SUBJECTS AND METHODS

The study comprised 31 boys investigated between 1974 and 1990 at the Hospital for Sick Children, London. All boys had an hCG test consisting of three intramuscular injections of hCG on successive days at a daily dose dependent on their age (< 1 year old, 500 units; 1-10 years, 1000 units; > 10 years, 1500 units). Blood samples were taken before the first dose and 24 h after the last dose and the level of plasma testosterone assessed and expressed as a pre/post ratio.

RESULTS

Eight boys had no response to hCG, due to anorchia. One boy had no response to hCG but had bilateral atrophic intra-abdominal testes. Twenty-two boys responded to hCG and had testes whose size was related to the degree of testosterone elevation after this stimulatory test. The hCG test therefore had a positive predictive value of 89% and a negative predictive value of 100%. There was a quantitative difference in testosterone response between 14 boys who had bilateral intra-abdominal testes of 'normal' volume (median pre/post ratio, 11.4) and nine boys who had an otherwise reduced volume of testes (dysplastic or unilateral intra-abdominal) (median pre/post ratio of 4; P = 0.02).

CONCLUSION

The hCG test is a valid indicator of the presence of functioning testicular tissue. It is predictive of anorchia and a good response to hCG suggests the presence of testes sufficiently large for orchidopexy.

Preoperative laparoscopic localization of the nonpalpable testis: a critical analysis of a 10-year experience

Laparoscopy was performed on 107 patients 8 months to 18.5 years old (mean age 46.9 months) with 119 nonpalpable testes. The procedure accurately determined the location of the gonad in 95.3% of the patients, while 16 were spared formal surgical exploration with the laparoscopic visualization of blind-ending spermatic vessels and vasa deferentia. Additionally, patency of the internal inguinal ring, determined laparoscopically, was an accurate predictor of testicular salvageability. We advocate the use of laparoscopy for all boys with a nonpalpable gonad in conjunction with operative intervention if necessary.

PCR analysis and sequencing of the SRY sex determining gene in four patients with bilateral congenital anorchia

OBJECTIVE

We explored the possibility of a genetic anomaly in the sex determining region of the Y chromosome, SRY gene, known to be equated to the testis determining region.

PATIENTS

Four patients with bilateral congenital anorchia, absence of testicular tissue, elevated FSH and a lack of testosterone response to human chorionic gonadotrophin stimulation tests were studied.

MEASUREMENTS

Amplification by polymerase chain reaction of the SRY gene and direct double stranded DNA sequencing were performed with the same primers.

RESULTS

The expected 648 basepairs band of SRY was detected in the four DNA samples from patients with bilateral congenital anorchia. Direct sequencing did not show any difference with the previous published sequence.

CONCLUSIONS

These data suggest that, in the four patients, bilateral congenital anorchia is not related to an anomaly of the opening reading frame sequence of the SRY gene.

Laparoscopy for Nonpalpable Testes in Childhood: Is Inguinal Exploration also Necessary When Vas and Vessels Exit the Inguinal Ring?

Laparoscopy has proved to be a safe method for determining the status for nonpalpable testes. In a combined series 52 boys with 57 nonpalpable testes were evaluated laparoscopically. Of the 57 nonpalpable testes 26 were located above the internal inguinal ring (abdominal), 4 were found more distally, and blind-ending vas and vessels terminated in the abdomen in 3, and beyond the internal ring (vanished testes) in 24. Of 29 abdominal testes primary orchiopexy was performed in 15, 4 were removed, the vessels were transected (Fowler-Stephens) in 5, stage 1 of staged repairs was done in 2, distinct laparoscopic evidence of blind-ending vessels and vas obviated further surgery in 2, and testis was not identified either laparoscopically or by abdominal exploration. Finally, inguinal exploration in 28 children in whom vas and vessels were found to exit the internal ring resulted in localization of 4 testes that were brought into the scrotum. Removal of 23 testicular nubbins and their evaluation histologically resulted in identification of viable tubular structures in 3. We recommend inguinal exploration in all children who on laparoscopy are found to have vas and vessels exit the internal ring, and removal of testicular nubbins.

Orchiopexy of the high undescended testis by division of the spermatic vessels: a critical review of 38 selected transections

The technique used to perform 38 orchiopexies of high undescended testes by spermatic vessel transection in 26 patients is reviewed. Careful attention to detail and selection using the Fowler-Stephens test allowed for an 89 per cent success rate, confirming the efficacy of this procedure in cases selected in this manner.

Ontogeny of gonadotropin secretion in congenital anorchism: sexual dimorphism versus syndrome of gonadal dysgenesis and diagnostic considerations

The hormonal characteristics of anorchism are elevated basal levels of gonadotropins, especially follicle-stimulating hormone and a low concentration of plasma testosterone that fails to increase after the administration of human chorionic gonadotropin. However, little is known about the dynamics of plasma gonadotropin secretion in infants and children with anorchism. We analyzed plasma gonadotropin concentrations and their responses to luteinizing hormone releasing factor, along with plasma testosterone responses to human chorionic gonadotropin, in 9 children with surgically proved bilateral anorchism. Basal concentrations of gonadotropins, especially plasma follicle-stimulating hormone, are elevated above normal during the first 3 to 4 years of life, decrease gradually to normal prepubertal levels and then increase again after age 9 years. This age-dependent diphasic pattern of gonadotropin secretion is comparable to that described previously in patients with the syndrome of gonadal dysgenesis and it is consistent with steroid-independent central nervous system inhibition of pulsatile luteinizing hormone releasing factor secretion during mid childhood. Moreover, a sex difference in follicle-stimulating hormone and luteinizing hormone values was observed; the mean follicle-stimulating hormone and luteinizing hormone concentrations in anorchid boys less than 3 years old were lower than in patients with Turner's syndrome. We suggest that this sex dichotomy is a consequence, at least in part, of the actions of testosterone derived from the fetal testis on the fetal hypothalamus. Luteinizing hormone releasing factor administration to anorchid male subjects resulted in an age-dependent augmented release of gonadotropin, particularly follicle-stimulating hormone. This study emphasizes that the age of the patient must be considered when interpreting basal gonadotropin levels. We also propose that in mid childhood the luteinizing hormone releasing factor test in conjunction with the human chorionic gonadotropin stimulation test is a more accurate hormonal indicator of patients with congenital anorchism than either the human chorionic gonadotropin test or basal gonadotropin concentrations.

Laparoscopy in the management of the nonpalpable testis

Laparoscopy was performed at operation in 32 patients between 7 and 63 months old (average age 31 months), who had 33 nonpalpable testes. Of the testes 7 (21.2 per cent) were in the inguinal region or just proximal to the internal ring, 5 (15.2 per cent) were in a high intra-abdominal position and 21 (63.6 per cent) were absent. In every instance of a nonpalpable gonad in which a testis was found to be absent at operation the vas and gonadal vessels were observed laparoscopically to exit the inguinal ring or to end blindly just proximal to the internal inguinal ring. A hernia or patent processus vaginalis was not observed in these 21 cases. In every case of an absent testis the contralateral testis was located normally in the scrotum. Furthermore, when a hernia was observed laparoscopically a testis was found on the ipsilateral side at the level of the internal ring or more distally.

The assessment of diminished testicular function in boys of pubertal age

Nine boys with anorchia and 9 individuals with diminished testicular function were followed between ages 10 and 18 with serial determinations of urine gonadotrophins and serum testosterone. Ten hCG stimulation tests were performed in eight of these patients. Adult levels of LH (greater than 500 mIU/h) and low measurements of serum testosterone (less than 54 ng/dl) confirmed the anorchic state. Boys with diminished testicular reserve exhibited urinary gonadotrophin changes similar to peripubertal anorchic patients but testosterone levels increased progressively with age (90-715 ng/dl). FSH attained adult castrate levels (greater than 1700 mIU/h) by age 13 in these boys and served to distinguish them from normal controls. The longitudinal assessment of basal hormone levels can separate anorchia from diminished testicular reserve in boys of pubertal age and testing with hCG is not required for evaluation.

Elevation of serum gonadotropins establishes the diagnosis of anorchism in prepubertal boys with bilateral cryptorchidism

Of more than 500 boys with bilateral cryptorchidism who presented during a 10-year period 28 prepubertal patients less than 11 years old who had no palpable testes after human chorionic gonadotropin therapy were studied to assess the ability of serum gonadotropin levels to identify patients with anorchism. Of the boys 21 had a normal testosterone response to human chorionic gonadotropin therapy and all of them had testes at exploration. The serum luteinizing hormone levels ranged from 2 to 6 mIU per ml., with a mean of 3.7 mIU per ml., and the serum follicle-stimulating hormone levels ranged from 1.6 to 6.2 mIU per ml., with a mean of 3.7 mIU per ml. Seven patients showed no testosterone response to human chorionic gonadotropin and all but 1 underwent exploration, at which time no testes were found. Of these 7 patients 6 had elevated gonadotropin levels that averaged 3 standard deviations above the mean. For comparison, 2 pubertal patients with nonpalpable gonads and 3 castrated prepubertal boys also were studied. From the study we concluded that in boys with nonpalpable gonads 1) abnormally elevated serum gonadotropin levels before puberty are indicative of anorchism, 2) neither exploration nor human chorionic gonadotropin stimulation tests are essential for diagnosis in these select patients, 3) serum gonadotropin levels alone are not sufficient for a definitive diagnosis after puberty and 4) all boys with normal serum gonadotropin levels must undergo exploration regardless of the outcome of a human chorionic gonadotropin stimulation test.

Testicular failure in an adolescent with mesoappendicular testis

A fifteen-year-old male presented with delayed puberty and cryptorchidism. Previous exploratory surgery for bilateral cryptorchidism resulted in left orchiectomy. The right testis was very high and intimately adherent to the mesentery of the appendix, and was left in situ. Subsequently progressive testicular failure was demonstrated by falling plasma testosterone and rising plasma gonadotropin levels. On elective surgical exploration, an atrophic testis with an independent blood supply was found adherent to the mesentery of the appendix. No spermatic duct was present, and orchiectomy was performed. The reasons for orchiectomy and the role of serial hormonal evaluations in the management of this unusual mesoappendicular testis case are reviewed.

Human monorchism: a clinicopathological study of unilateral absent testes in 65 boys

We reviewed the medical records of 65 boys with surgically and pathologically proved monorchism. A striking laterality to the left side was identified. In 83 per cent of the patients wolffian structures were present and in 20 per cent microscopic evidence of a terminal nubbin of hyalinized, calcified or hemosiderin-containing tissue was noted. These findings strongly suggest that in most instances of monorchism a testis had been present and had undergone subsequent in utero degeneration. Characterization of the hormonal changes associated with unilateral absent testes was done by determining fasting morning levels of luteinizing hormone and follicle-stimulating hormone. In a subgroup of monorchid boys and age-matched prepubertal unilateral cryptorchid boys luteinizing hormone release factor stimulation also was performed to determine if endocrine analysis could predict the absence of 1 testis.

The use of computerized tomography scanning to localize the impalpable testis

To determine the usefulness of computerized tomography scanning in the preoperative localization of the impalpable undescended testis 5 patients with 8 impalpable testes were studied. In 2 patients the scan correctly outlined 3 impalpable testes inside the internal inguinal ring, in 2 patients the scan correctly localized 4 impalpable testes at or just inside the external inguinal ring and in 1 patient the scan failed to demonstrate a testis, a finding corroborated at an operation. These results suggest that computerized tomography scanning appears to be an effective, simple and less hazardous method to localize impalpable undescended testes than other currently available techniques.

Clinical implications of gonadal venography in the management of the non-palpable undescended testis

Selective gonadal venography was used on 28 patients with a total of 34 non-palpable undescended testes. The data obtained in this study suggest that 1) an internal spermatic vein with a pampiniform-like plexus indicates the presence of a testis, 2) a blind-ending vein on venography suggests the absence of a testis, 3) an internal spermatic vein or vas deferens may be present without a testis, 4) a testis probably cannot be present without a gonadal vein, 5) a testis may be present without a vas, 6) a blind-ending vas deferens does not necessarily indicate the absence of a testis and 7) a blind-ending vas deferens in a patient in whom a blind-ending gonadal vein is localized to the same region probably indicates the absence of a testis. Gonadal venography may localize a non-palpable undescended testis or suggest testicular agenesis. In addition, gonadal venography has aided in the selection of the operative approach and, in the future, may provide criteria under specific circumstances for determining whether an operation is necessary and, if so, the extent of surgical exploration.