Kinetics and effect of percutaneous administration of dihydrotestosterone in children

Longitudinal clinical course in patients with 5α-reductase type 2 deficiency treated with testosterone and dihydrotestosterone during infancy and puberty

5α-reductase type 2 (5αRD2) deficiency is a 46,XY disorder of sex development caused by impaired conversion of testosterone (T) to dihydrotestosterone (DHT). Penile enlargement therapy is important for male patients with 46,XY 5αRD2 deficiency who have undermasculinized external genitalia, such as severe micropenis. High-dose T and percutaneous DHT replacement are reportedly efficacious for penile enlargement in patients with this disorder. We presented herein the longitudinal course of four patients with 46,XY 5αRD2 deficiency who received T and DHT. T replacement therapy during infancy increased the stretched penile length (SPL) in three of the patients but was ineffective in one patient. DHT was administered to the three patients after T replacement therapy and further increased the SPL. During and after puberty, two patients asked for and received T replacement therapy, which contributed to increasing their SPL. A semen test in one patient with T replacement therapy at age 27 years revealed cryptozoospermia despite normal testicular volume. The clinical course of our patients during infancy indicated that DHT therapy may be preferrable to T replacement therapy for penile enlargement in patients with 5αRD2 deficiency. During and after puberty, T replacement therapy promoted penile enlargement possibly because of increased conversion of T to DHT via increased 5α-reductase type 1 activity even in patients in whom it was ineffective during infancy. In conclusion, DHT is effective for penile enlargement during infancy in patients with 5αRD2 deficiency while T replacement therapy is a viable option during puberty.

Congenital Micropenis: Etiology And Management

In the newborn, penile length is determined by a number of androgen dependent and independent factors. The current literature suggests that there are interracial differences in stretched penile length in the newborn and although congenital micropenis should be defined as a stretched penile length of less than 2.5 SDS of the mean for the corresponding population and gestation, a pragmatic approach would be to evaluate all boys with a stretched penile length below 2 cm, as congenital micropenis can be a marker for a wide range of endocrine conditions. However, it remains unclear as to whether the state of micropenis, itself, is associated with any long-term consequences. There is a lack of systematic studies comparing the impact of different therapeutic options on long-term outcomes, in terms of genital appearance, quality of life, and sexual satisfaction. To date, research has been hampered by a small sample size and inclusion of a wide range of heterogeneous diagnoses; for these reasons, condition-specific outcomes have been difficult to compare between studies. Lastly, there is a need for a greater collaborative effort in collecting standardized data so that all real-world or experimental interventions performed at an early age can be studied systematically into adulthood.

Recent advancement in the treatment of boys and adolescents with hypogonadism

Clinical manifestations and the need for treatment varies according to age in males with hypogonadism. Early foetal-onset hypogonadism results in disorders of sex development (DSD) presenting with undervirilised genitalia whereas hypogonadism established later in foetal life presents with micropenis, cryptorchidism and/or micro-orchidism. After the period of neonatal activation of the gonadal axis has waned, the diagnosis of hypogonadism is challenging because androgen deficiency is not apparent until the age of puberty. Then, the differential diagnosis between constitutional delay of puberty and central hypogonadism may be difficult. During infancy and childhood, treatment is usually sought because of micropenis and/or cryptorchidism, whereas lack of pubertal development and relative short stature are the main complaints in teenagers. Testosterone therapy has been the standard, although off-label, in the vast majority of cases. However, more recently alternative therapies have been tested: aromatase inhibitors to induce the hypothalamic-pituitary-testicular axis in boys with constitutional delay of puberty and replacement with GnRH or gonadotrophins in those with central hypogonadism. Furthermore, follicle-stimulating hormone (FSH) priming prior to hCG or luteinizing hormone (LH) treatment seems effective to induce an enhanced testicular enlargement. Although the rationale for gonadotrophin or GnRH treatment is based on mimicking normal physiology, long-term results are still needed to assess their impact on adult fertility.

Efficacy and Safety of Continuous Subcutaneous Infusion of Recombinant Human Gonadotropins for Congenital Micropenis during Early Infancy

BACKGROUND

Early postnatal administration of gonadotropins to infants with congenital hypogonadotropic hypogonadism (CHH) can mimic minipuberty, thereby increasing penile growth. We assessed the effects of gonadotropin infusion on stretched penile length (SPL) and hormone levels in infants with congenital micropenis.

METHODS

Single-center study including 6 males with micropenis in case of isolated CHH (n = 4), panhypopituitarism (n = 1), and partial androgen insensitivity syndrome (PAIS; n = 1). Patients were evaluated at baseline, monthly and at the end of the study through a clinical examination (SPL, testicular position and size), serum hormone assays (testosterone, luteinizing hormone, follicle-stimulating hormone, inhibin B, anti-Müllerian hormone [AMH]), and ultrasound of penis/testes.

RESULTS

In CHH, significant increases occurred in serum testosterone (from undetectable level to 3.5 ± 4.06 ng/mL [12.15 ± 14.09 nmol/L]), SPL (from 13.8 ± 4.5 to 42.6 ± 5 mm; p < 0.0001), inhibin B (from 94.8 ± 74.9 to 469.4 ± 282.5 pg/mL, p = 0.04), and AMH (from 49.6 ± 30.6 to 142 ± 76.5 ng/mL, p = 0.03). Micropenis was corrected in all patients, except one. On treatment, in the patient with PAIS, SPL was increased from 13 to 38 mm.

CONCLUSIONS

Early gonadotropin infusion is a safe, well-tolerated and effective treatment. The effect in PAIS has not been reported previously. Long-term follow-up is needed to assess the impact, if any, on future fertility and reproduction.
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The role of pre-operative androgen stimulation in hypospadias surgery

The hormonal stimulation for the purpose of penile enlargement before the hypospadias repair has been commonly used, but rarely reported. In addition to functional outcome, dihydrotestosterone (DHT) pretreatment has been suggested to improve cosmetic outcome in a preliminary randomized study. Since the randomized and controlled clinical trials on this topic are insufficient, the hormonal agent, the route of administration, dosing schedule, and the timing of treatment has been remained controversial. In order to confirm the efficiency of hormonal treatment, further well designed randomized studies with a larger number of patients and a placebo group are warranted.

Adult care of children from pediatric urology: part 2

PURPOSE

We describe the outcomes of undescended testes and sex development disorders in adolescence and young adulthood. We reviewed the requirements for the long-term care of children born with these and other major congenital anomalies of the genitourinary system.

MATERIALS AND METHODS

The current English language literature was retrieved with a PubMed® search for articles on these subjects. Only articles covering outcomes at ages past puberty were included in analysis. The material was supplemented from the database of the clinic for adults with sex development disorders at University College London Hospitals.

RESULTS

An undescended testis has impaired spermatogenesis. In men in whom a unilateral undescended testis was corrected before puberty the incidence of paternity is normal at around 90% of those who attempt it. The equivalent rate for those with bilateral undescended testes is about 65%. If surgery for bilateral undescended testes is delayed until after puberty, fertility is unlikely. The risk of testicular neoplasms is overestimated and the relative risk is between 2.5 and 8. Children born with a sex development disorder receive multidisciplinary treatment throughout childhood and require the same care as adults. Males who are under virilized likely have a micropenis (greater than 2 SD below the mean stretched length) but they may have normal sexual function. Fertility depends on the underlying condition. Virilized females, who most commonly have congenital adrenal hyperplasia, currently present to adult clinics with an inadequate vagina after infantile surgery. Reconstruction is required to allow intercourse.

CONCLUSIONS

The care of adults born with abnormalities of the genitalia is complex. Early management may define upbringing in childhood but requirements for sexuality and fertility in adult life are different. Multidisciplinary care is essential and a case can be made to establish a subspecialty of urology to coordinate it.

Reduced diffusion in neurocysticercosis: circumstances of appearance and possible natural history implications

BACKGROUND AND PURPOSE

Few studies discuss DWI findings in patients with NCC, and their conclusions are variable and contradictory. The aim of our study was to describe DWI findings of a cohort of patients with NCC, emphasizing the frequency of reduced diffusion.

MATERIALS AND METHODS

This retrospective study included 48 patients with NCC. Two neuroradiologists analyzed MR images regarding location, number, and stage of NCC lesions. On the basis of visual analysis, they defined, by consensus, the presence of high signal within NCC lesions on DWI and measured their ADC values when feasible.

RESULTS

The total number of lesions was 342: parenchymal (263), subarachnoid (65), and intraventricular (14); 83 were DWI hyperintense. The first pattern was a small eccentric hyperintense dot/curvilinear structure on DWI (representing the scolex) noted in intraparenchymal lesions in vesicular (41 lesions, 29%) and colloidal vesicular (18 lesions, 19%) stages, in 14 (22%) subarachnoid lesions, and 2 (14%) intraventricular lesions; rADC calculations were hampered by the intrinsic small dimensions of this finding. The second pattern was the presence of total/subtotal DWI hyperintensity in intraparenchymal lesions, 5 in the colloidal vesicular stage (5%) and 1 in the granular nodular phase (3%). Two subarachnoid lesions also showed the same presentation; in this second pattern, reduced diffusion was present in different degrees, measured by rADC calculations.

CONCLUSIONS

DWI may identify the scolex, increasing diagnostic confidence for NCC. Total/subtotal DWI hyperintensity, related to the stage of the lesion, though uncommon, allows including NCC as a consideration in the differential diagnosis of lesions with reduced diffusion and ring enhancement.

Disorders of sex development

Infants born with ambiguous genitalia represent a complex clinical challenge. A systematic clinical investigation aims at determining the hormone production and which anatomical structures are present in order to understand at what level the sex differentiation has been affected; chromosomal, gonadal or hormonal synthesis and action levels. The increased genetic knowledge in the field has opened up new diagnostic possibilities. Sex development requires the balanced and sequential activation of transcription factors, signaling molecules and hormones. It has recently been shown that not only testis but also normal ovarian development is an active process. Genes involved in gonadal disorders of sex development often act in a gene dosage-dependent manner, with different effects in XY or XX embryos. The management of patients with disorders of sex development, including decisions about sex of rearing, must be carried out by a specialized multidisciplinary team and include an extended genetic investigation as well as psychological considerations.

Treating hypogonadism in younger males

IMPORTANCE OF THE FIELD

Hypogonadism in the young and middle-aged male is a well-established clinical entity. The majority of the patients have primary gonadal insufficiency with Klinefelter syndrome a common cause. Secondary hypogonadism in these age groups can be congenital, secondary to medications, or associated with a hypothalamic-pituitary mass or inflammatory lesions. Signs and symptoms in males with hypogonadism can include impaired sexuality, decreased muscle strength, increased body fat, decreased bone mass, impaired mood and mild anemia; in young patients puberty can be delayed. Several new treatment modalities have become available in recent years and a number of future compounds are in development.

AREAS COVERED IN THIS REVIEW/WHAT THE READER WILL GAIN

This review explores the treatment options for children, young adult and middle-aged males with hypogonadism related to various etiologies, including currently available and future testosterone formulations and other non-testosterone compounds. The long-term treatment effects, particularly on prostate health, remain unclear and may be particularly relevant for the younger patient initiated on chronic therapy; treatment monitoring and recommended clinical follow-up based on current guidelines are also reviewed.

TAKE HOME MESSAGE

Hypogonadism in younger males can be the result of a diversity of etiologies. Treatment options for hypogonadism and induction of puberty have expanded and can be individualized based on patient preference, side effect profile, and a number of other parameters.

When size matters: a clinical review of pathological micropenis

Micropenis is a significantly small penis with normal internal male genitalia. Micropenis is usually diagnosed shortly after birth, and the cause should be established; in addition, it should be differentiated from other associated syndromes. The role of the pediatric nurse practitioner is to diagnose the micropenis, guide the parents through the options of management, and support all involved through the selected treatment, whether hormonal or surgical. Patients affected with micropenis will need long-term management from their pediatric nurse practitioners, as well as follow-up by endocrinologists, urologists, pediatric surgeons (if surgery is chosen as the treatment), psychologists, and social workers. The need of more long-term research on patients with micropenis also is discussed.

Coinfection of Japanese encephalitis with neurocysticercosis: an imaging study

BACKGROUND AND PURPOSE

Coinfection of neurocysticercosis (NCC) and Japanese encephalitis (JE) has been advocated as more than a chance occurrence resulting in poor outcome. We undertook this study to determine whether the association of the 2 infections is more than a chance occurrence, to define the imaging characteristics of coinfections, and to explore the synergistic effect of NCC in JE.

MATERIALS AND METHODS

Sixty-two patients with JE were studied by MR imaging and CT. CT was done in 53 and MR imaging in 53 patients. The diagnosis of JE was established by CSF JE virus immunoglobulin M capture (MAC) enzyme-linked immunosorbent assay (ELISA). NCC was diagnosed from imaging. A control group of 385 patients was evaluated by imaging for prevalence of NCC in the general population.

RESULTS

A significantly high association of NCC with JE (19.3%) was observed in comparison with prevalence of NCC in control subjects (1.04%; P = .0003). JE lesions in coinfection were significantly asymmetric with lateralization to the side of the brain having the maximum NCC or a cyst with edema. The JE lesions in coinfections were more florid, with a significantly higher proportion of abnormal CT scans and more abnormal MR imaging. Coinfections were significantly more common in children. Significantly lower CSF MAC-ELISA units in patients with coinfection reflected low CSF IgM levels, suggesting altered immune status.

CONCLUSION

In our series, there was a strong association between JE and NCC, and, thus, this coinfection was more than a chance occurrence.

The role of conventional MR imaging sequences in the evaluation of neurocysticercosis: impact on characterization of the scolex and lesion burden

BACKGROUND AND PURPOSE

There are few studies comparing the capacity of lesion detection of conventional MR imaging in neurocysticercosis (NCC). This study was designed to clarify its role in the evaluation of this disease, focusing on the total number of lesions identified and the characterization of the scolex.

MATERIALS AND METHODS

MR images from 115 patients were prospectively collected during a 3-year interval, including axial spin-echo (SE) T1-weighted; axial fast SE T2-weighted; axial fluid-attenuated inversion recovery (FLAIR); and gadolinium-enhanced axial, coronal, and sagittal SE T1-weighted sequences. They were compared regarding the potential for detection of NCC lesions and specifically of the scolex.

RESULTS

Comparing all sequences, we found that FLAIR images were more sensitive to the detection of the scolex (P < .003), whereas the last gadolinium-enhanced T1-weighted series (coronal or sagittal) identified the highest number of lesions (P < .001).

CONCLUSION

When dealing with NCC, optimal MR imaging protocols should include FLAIR images to obtain maximal rates of scolex detection. Special attention should be paid to the last gadolinium-enhanced sequence, which maximizes the quantification of lesion load.

Management of Potential Neurocysticercosis in Patients with HIV Infection

In patients with human immunodeficiency virus, the diagnosis of neurocysticercosis can be complex, and the current diagnostic criteria may not apply. We report 3 cases and suggest including the CD4+ T lymphocyte count as an important factor in the proper diagnosis and treatment of patients with human immunodeficiency virus and potential neurocysticercosis.

ORIGINAL RESEARCH—ENDOCRINOLOGY: The Physiological Role of Androgens in Penile Erection: Regulation of Corpus Cavernosum Structure and Function

It is generally accepted that androgens are critical for development, growth, and maintenance of penile erectile tissue. However, their role in erectile function, especially in humans, remains controversial. Clinical and preclinical studies have suggested that venoocclusion is modulated by the tone of the vascular smooth muscle of the resistance arteries and the cavernosal tissue and a balance between trabecular smooth muscle content and connective tissue matrix. In men with erectile dysfunction, venous leakage is thought to be a common condition among nonresponders to medical management and is attributed to penile smooth muscle atrophy. In the animal model, androgen deprivation produces penile tissue atrophy concomitant with alterations in dorsal nerve structure, endothelial morphology, reduction in trabecular smooth muscle content, and increased deposition of extracellular matrix. Further, androgen deprivation results in accumulation of fat-containing cells (adipocytes) in the subtunical region of the corpus cavernosum. Androgen deficiency diminishes protein expression and enzymatic activity of nitric oxide synthases (eNOS and nNOS) and phosphodiesterase type 5 (PDE5). The androgen-dependent loss of erectile response is restored by androgen administration but not by administration of PDE5 inhibitors alone. These data suggest that androgens regulate trabecular smooth muscle growth and connective tissue protein synthesis in the corpus cavernosum. Further, androgens may stimulate differentiation of progenitor cells into smooth muscle cells and inhibit their differentiation into adipocytes. Thus, we conclude that androgens exert a direct effect on penile tissue to maintain erectile function and that androgen-deficiency produces a metabolic and structural imbalance in the corpus cavernosum, resulting in venous leakage and erectile dysfunction. .