Congenital anomalies associated 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.

Prevalence and characteristics of cryptorchidism in a Nigerian district

OBJECTIVE

To determine the prevalence and characteristics of cryptorchidism among primary schoolboys in a Nigerian district.

SUBJECTS AND METHODS

The district selected had 35 primary schools with 23,342 pupils, consisting of 11,275 girls and 11,967 boys. Using a cluster-sampling technique, five primary schools were visited; 1096 boys (aged 5-13 years) participated in the study, giving a sampling ratio of 1:11. The boys underwent a clinical examination of the groin, scrotum and abdomen.

RESULTS

Cryptorchidism was found in nine subjects, giving a prevalence rate of 0.82%. All the undescended testes were unilateral, of which five were right-sided. Eight of the testes were intracanalicular and one was at the external ring. There were no cases of orchidopexy.

CONCLUSION

The prevalence of cryptorchidism among primary schoolboys in this district of Nigeria was high, at eight per 1000. Delayed diagnosis and treatment remains a problem because of the prevailing socio-economic factors. However, the incidence of cryptorchidism was similar to that reported in other parts of the world.

Cryptorchidism in boys with imperforate anus

In a retrospective study of the case reports of 136 boys who were operated on for an imperforate anus and who survived at least 18 months, cryptorchidism was the most common associated anomaly, involving 26 cases (19%). The higher the level of the anorectal malformations, the higher was the incidence of cryptorchidism. The incidence of renal and ureteric malformations and dysplasias showed a parallel tendency. The incidence of vertebral malformations and dysplasias in the T10-S5 area was low among patients with a covered anus or a perineal fistula. Cryptorchidism was found associated with urological and with T10-S5 vertebral malformations and dysplasias. Recognition of this association is probably new. The histopathological findings of testicular biopsy specimens and the location of the undescended testes in patients with an imperforate anus showed the same pattern as seen in undescended testes from patients with cryptorchidism only. These findings, together with the existing literature on the subject, indicate that further studies on the association of cryptorchidism, urological, and T10-S5 vertebral malformations and dysplasias may be very helpful toward a better understanding of cryptorchidism in general.

Abnormal findings associated with undescended testis in Nigerian children

Children between the ages of 6 years and 12 years numbering 2200, were examined for general physical development and external abnormality to correlate these anomalies with frequency of undescended testis. Whereas the overall frequency of undescended testis in this population was 0.5%, this condition was present in 1% of boys with peri-umbilical hernia. Undescended testis should be looked for in children with external congenital anomalies, particularly of the anterior abdominal wall.

The undescended testis. Hormonal and surgical management

Cryptorchidism is the most common disorder of sexual differentiation in males, with an incidence of 3.4 per cent in the term newborn, decreasing to 0.8 per cent at 1 year of age. The mechanisms of normal testicular descent are multifactorial and include an intact hypothalamic-pituitary-testicular axis, as well as a normal gubernaculum and epididymis. In boys with cryptorchidism, the testes demonstrate degenerative changes histologically as early as 1 to 2 years of age. Both testes may be affected, even with a unilateral undescended testis. The most important long-term complications of cryptorchidism include infertility and testicular cancer. The risk of malignancy is 10 to 40 times higher in men with cryptorchidism than in normal men and is highest in men who have had an intra-abdominal testis and in certain intersex conditions. Orchiopexy does not appear to lessen this risk. In clinical trials in the United States, hormonal therapy with hCG or GnRH has not been effective in causing testicular descent; therefore, orchiopexy remains standard treatment. However, hCG is recommended if the clinician suspects that a testis is retractile. Orchiopexy should be performed between 12 and 18 months of age to prevent the degenerative changes that are demonstrable by 2 years.

Unsuspected urological anomalies in asymptomatic cryptorchid boys

In a period of 6 years 144 asymptomatic boys with cryptorchidism, of mean age 7 +/- SD 3.5 years, underwent orchiopexy. None of these boys referred to a history of a known urological anomaly, urinary tract infection, haematuria, palpable mass in the renal region, bladder extrophy, epispadias, hypospadias or anorectal malformation. On the third day after orchiopexy and intravenous pyelography was done in every boy following testicular protection against irradiation. Ultrasonic investigation was not available at that time. There were minor urological abnormalities in 36 (25%) boys and major ones in 8 (5.5%) boys. A major anomaly is defined as one resulting in significant loss of renal substance (one case of single kidney and three cases of unilateral renal hypoplasia), or requiring surgical correction for conservation of the renal substance (one case of ureterocele, two cases of pelviureteric stenosis and one case of vesicoureteric stenosis with ipsilateral hydronephrosis). The unsuspected major urological abnormalities are usually ipsilateral to the more undescended testis. They may be associated with a hernia and are more frequent in bilateral cryptorchidism. In conclusion we encourage the routine use of IVP, or ultrasonic investigation or dynamic renal scanning (99mTc-DTPA), if it is possible, in all patients undergoing orchiopexy for the detection of an unsuspected major renal anomaly.

Cryptorchidism: isolated and associated with other genitourinary defects

Cryptorchidism is the most common disorder of sexual differentiation in male children, with an incidence of 3.4 per cent in the term newborn, decreasing to 0.8 per cent at 1 year of age. The mechanisms of normal testicular descent are multifactorial and include an intact hypothalamic-pituitary-testicular axis, as well as a normal gubernaculum and epididymis. In boys with cryptorchidism, the testes demonstrate degenerative changes histologically as early as 1 to 2 years of age. Both testes may be affected, even with a unilateral undescended testis. The most important long-term complications of cryptorchidism include infertility and testicular cancer. The risk of malignancy is approximately 40 times higher in male subjects with cryptorchidism than in normal men, and is highest in male subjects who have had an intra-abdominal testis and in certain intersex conditions. Orchiopexy does not appear to lessen this risk. Hormonal therapy with HCG or LH-RH has remained unproven in clinical trials in the United States; therefore, orchiopexy remains standard treatment. HCG is recommended if the clinician suspects that a testis is retractile, however. Orchiopexy should be performed between 12 and 18 months of age to prevent the degenerative changes that are demonstrable by 2 years.

Cryptorchidism: a pediatrician's view

Cryptorchidism is one of the most common congenital anomalies afflicting male children. This article reviews some of the existing literature regarding this condition for the purpose of presenting the pediatrician with a synopsis of possible diagnosis and treatment options.

Undescended testis and testicular torsion

This article reviews the concepts basic to the management of the undescended testis and testicular torsion and provides specific guidelines for the management of the many variations of these entities.

Cryptorchidism in mental retardation

We surveyed 148 institutionalized male subjects to study the prevalence of cryptorchidism among mentally retarded individuals. Of the patients 121 (81.7 per cent) were profoundly (intelligence quotient 19 or less), 21 severely (20 to 35), 5 moderately (36 to 51) and 1 mildly (65) retarded. Patient age ranged from 1 to 36 years (mean 13.6 means). According to the etiology of the mental retardation the cases were classified into 6 categories: chromosomal aberrations, single gene disorders, polygenic conditions, teratogen-induced anomalies, perinatal/postnatal injuries and idiopathic mental retardation. Cryptorchidism was found in 44 individuals (39.7 per cent), and was bilateral 3.4 times more often than unilateral. Cerebral palsy occurred in 88 patients. There were 36 patients with cryptorchidism and cerebral palsy, representing 41 per cent of the patients with cerebral palsy and 81.8 per cent of the cryptorchid group (p equals 0.0006). Among the noncryptorchid male subjects 52 (50 per cent) had cerebral palsy. Epilepsy also was more frequent in the cryptorchid group (p equals 0.0333). The cryptorchid and noncryptorchid groups did not show a significant difference in the etiology of mental retardation except in the perinatal/postnatal category in which cryptorchidism was more frequent (p equals 0.025), and in the polygenic category in which all 9 patients were noncryptorchid. This study shows a high prevalence of cryptorchidism in individuals with profound and severe mental retardation, and particularly in those having cerebral palsy.

Trends in pediatric uroradiology

Excretory urography, conventional and radionuclide voiding cysto(urethro)graphy, ultrasonography, radionuclide renal imaging and computed tomography are all currently readily available in most locales for the evaluation of the child's urinary tract. It is the responsibility of the radiologist to determine which studies are best for which children and the order in which they should be performed to minimize "cost" while maximizing the information obtained. A description of such an approach and its consequences are presented.