Hypospadias mimicking female genitalia on early second trimester sonographic examination

The Predictive Accuracy of Anogenital Distance and Genital Tubercle Angle for First-Trimester Fetal Sex Determination

BACKGROUND

Early identification of fetal gender is crucial for managing gender-linked genetic disorders. This study aimed to evaluate the predictive performance of anogenital distance (AGD) and genital tubercle angle (GTA) for fetal sex determination during the first trimester.

METHODS

A multicenter retrospective cohort study was conducted on 312 fetal cases between 11 and 13 + 6 weeks of gestation from two tertiary hospitals. AGD and GTA measurements were taken from midsagittal plane images using ultrasound, with intra- and inter-reader reproducibility assessed. Binomial logistic regression and ROC curve analysis were employed to determine the diagnostic performance and optimal cutoff points.

RESULTS

AGD had a mean of 7.16 mm in male fetuses and 4.42 mm in female fetuses, with a sensitivity of 88.8%, specificity of 94.4%, and an area under the ROC curve (AUC) of 0.931 (95% CI: 0.899-0.962) using 5.74 mm as a cutoff point. For GTA, the mean was 35.90 degrees in males and 21.57 degrees in females, with a sensitivity of 92%, specificity of 84.7%, and an AUC of 0.932 (95% CI: 0.904-0.961) using 28.32 degrees as a cutoff point. The reproducibility results were excellent for AGD (intra-operator ICC = 0.938, inter-operator ICC = 0.871) and moderate for GTA (intra-operator ICC = 0.895, inter-operator ICC = 0.695).

CONCLUSIONS

The findings suggest that AGD and GTA are reliable markers for early fetal sex determination, with AGD showing higher reproducibility. The findings highlight the feasibility and accuracy of these non-invasive sonographic markers and their potential usefulness in guiding timely interventions and enhancing the management of gender-linked genetic conditions.

Prenatal Diagnosis and Classification of Fetal Hypospadias: The Role and Value of Magnetic Resonance Imaging

BACKGROUND

Prenatal diagnosis and classification of hypospadias are difficult and of value for management during perinatal and neonatal periods. The conventional approach for prenatal diagnosis of hypospadias is ultrasound; however, this technique may be inconclusive in certain cases, which prompts for further exploration with magnetic resonance imaging (MRI).

PURPOSE

To investigate the role of MRI in the prenatal diagnosis and classification of fetuses with hypospadias.

STUDY TYPE

Retrospective.

POPULATION

Thirty-five fetuses (median gestational age = 37, range 24-39 weeks) with possible hypospadias.

FIELD STRENGTH/SEQUENCE

Single-shot fast spin echo T2-weighted imaging, fast imaging employing steady-state acquisition (FIESTA), and three-dimensional FIESTA acquired at 1.5 T.

ASSESSMENT

Diagnosis and classification of hypospadias using MRI were performed by three experienced radiologists based on MRI features, including a short penile shaft, abnormal penile tip, penile curvature, bifid scrotum, "tulip sign," and penoscrotal transposition. The accuracy of MRI in the diagnosis and classification of hypospadias was assessed in comparison to postnatal clinical diagnosis. The interobserver agreement between radiologists was also assessed.

STATISTICAL TESTS

Kendall's W test was applied to assess the interobserver agreement between radiologists. Taking postnatal clinical diagnosis as the reference standard, the sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were calculated.

RESULTS

Of the 35 fetuses, 24 cases were confirmed as hypospadias through postnatal clinical diagnosis. The interobserver agreement between radiologists was substantial (Kendall's W = 0.781, P < 0.001). Of the 24 confirmed cases (13 cases of severe hypospadias and 11 cases of mild hypospadias), 22 cases were correctly diagnosed by MRI. The accuracy of MRI in the diagnosis of hypospadias, severe hypospadias, and mild hypospadias was 85.71%, 82.86%, and 80.00%, respectively.

DATA CONCLUSION

MRI has good performance in the diagnosis of fetal hypospadias. In addition, MRI could help evaluate the severity of fetal hypospadias.

LEVEL OF EVIDENCE

3 TECHNICAL EFFICACY: Stage 2.

Assessment of clitoral anatomy in human fetuses

PURPOSE

To determine fetal clitoral dimensions in antenatal period and to provide a contribution to external genital morphology determination in premature infants.

METHODS

Thirty-one formalin fixed female fetuses aged between 18 and 40 weeks (17 fetuses aged 21.53 ± 1.88 weeks in the second trimester and 14 fetuses aged 31.00 ± 4.90 weeks in the third trimester) were evaluated. 20 (64.5%) fetuses were between 3 and 97% percentile range and within normal limits. Clitoris appearance (completely covered by labium majus/partially showing/prominent), length and width of clitoris, labium minus length, length, and width of labium majus were assessed.

RESULTS

Clitoris length during the second trimester was 4.84 ± 1.09 mm, whereas it was 5.43 ± 1.07 in the third trimester. Clitoris width was as 3.35 ± 0.88 mm in the second trimester and as 4.55 ± 0.96 mm in the third trimester. A statistically significant increase was seen in width of clitoris, length, and width of labium majus and length of labium minus with gestational age in the second and third trimesters (p < 0.05). No significant difference was found between the second and third trimesters in terms of clitoris length (p = 0.146). A homogenous spread in clitoris appearance was obtained between the second and third trimesters without any significant difference (p = 0.912). In addition, fetus percentiles showed a homogenous spread without any significant differences between completely covered, partially covered and prominent groups (p = 0.452).

CONCLUSION

The anatomical data can be beneficial to the development of fetal radiological screening procedures in females and also in morphological assessment criteria in premature infants, effectively assisting in diagnosing anomalies during the early term.

Prenatal diagnosis of hypospadias with 2-dimensional and 3-dimensional ultrasonography

To compare the prenatal diagnostic performance as well as appearance of ultrasonic details between 2-dimensional ultrasonography (2DUS) combined with 3-dimensional ultrasonography (3DUS) and 2DUS alone for hypospadias. A total of 47 fetuses were enrolled and examined by 2DUS and then 3DUS. Postnatal follow-up data were obtained and 28 cases were confirmed of hypospadias. Although not statistically significant, there was a trend toward higher AUC (0.85 vs. 0.76; p = 0.08), ACC (85.1 vs. 76.6%; p = 0.22), SEN (85.7 vs. 78.6%; p = 0.63), and SPE (84.2 vs. 73.7%; p = 0.50) for 2DUS combined with 3DUS compared with 2DUS alone. The agreement between both methods was moderate [kappa = 0.592]. Both modalities showed accurately the short penis and blunt tip of the penis. 2DUS in combination with 3DUS showed more cases in other detailed features, such as “chordee”, a “hooded” incomplete prepuce, and so on. Overall 2DUS combined with 3DUS showed a trend toward higher performance compared with 2DUS alone for the diagnosis of hypospadias, although the difference was not statistically significant. 3DUS is a useful complement for 2DUS in the diagnosis of fetal hypospadias and may provide more detailed information related to its diagnosis and prognosis.

The ultrasound identification of fetal gender at the gestational age of 11-12 weeks

Introduction

The early prenatal identification of fetal gender is of great importance. Accurate prenatal identification is currently only possible through invasive procedures. The present study was conducted to determine the accuracy and sensitivity of ultrasound fetal gender identification.

Materials and Methods

The present cross-sectional study was conducted on 150 women in their 11^th and 12^th weeks of pregnancy in Hamadan in 2014. Ultrasound imaging performed in the 11^th and 12^th weeks of pregnancy for fetal gender identification identified the fetus either as a girl, a boy, or as a "gender not assigned." Frequency, sensitivity, specificity, positive and negative predictive values, and accuracy of the gender identification was assessed using SPSS version 20. The significant level was 0.05 in all analyses.

Results

Of the total of 150 women, the gender was identified as female in 32 (21.3%), as male in 65 (43.3%), and not assigned in 53 (35.3%); overall, gender identification was made in 64.6% of the cases. A total of 57 male fetuses were correctly identified as boys, and 8 female fetuses were wrongly identified as boys. As for the female fetuses, 31 were correctly identified as girls, and 1 was wrongly identified as a boy. The positive predictive value for the ultrasound imaging gender identification was 87.6% for the male fetuses and 96.8% for the female fetuses.

Conclusion

The present study had a much higher gender identification accuracy compared to other studies. The final success of fetal gender identification was about 91% in the 11^th and 12^th weeks of pregnancy.

Prenatal diagnosis of penoscrotal hypospadias and review of the literature

Urinary tract abnormalities are frequently detected during obstetrical ultrasonography (US). However, hypospadia is often missed on prenatal US, despite it being the most common congenital defect of the male external genitalia. The prenatal recognition of hypospadias is important because it will alert the physician to order karyotyping and to look for any possible associated dysmorphic syndromes. Here, we present a case of a penoscrotal hypospadia mimicking female genitalia and describe our experience of applying two-dimensional and three-dimensional US in the prenatal diagnosis of hypospadia. Prenatal ultrasound scans should include a study of the genitals and should not only be used for sex determination.

The accuracy of 2D ultrasound prenatal sex determination

Background:

Pregnant women have been curious about the sex of their unborn child. The advent of ultrasound, its application into medicine, and the revolutionary changes in its resolution and function has led to the ability to assign a sex to these unborn children, thereby allaying the anxiety of these women but with consequent emergent ethical, moral, psycho-social, and medico-legal issues. The objectives were to determine the accuracy of sonographic prenatal sex determination, perform binary classification test, and the impact it has, including mis-diagnosis.

Materials and Methods:

A prospective prenatal sonographic sex determination study on 205 consecutive consenting pregnant women aged 20-40 years in a private hospital in Benin between August 2010 and October 2011. Questionnaires were administered to these women before and after the scan and the women were told the sex of the fetuses and their feelings on the determined sex recorded. The sex at birth was confirmed and compared to the scan determined gender by their case note and telephone. Relevant discussions during the scan and later on were recorded on the questionnaires. The statistical package used was SPSS version 17 and binary classification tests were performed.

Results:

The sensitivity (98.2%) and binary classification components values of prenatal sex determination were high with the sensitivity of detecting a female higher than that of males. Two males were misdiagnosed as females. Most of the women were happy even when the sex differed from that which they desired.

Conclusion:

Prenatal sonographic sex determination has a high sensitivity index. Consequently we advocate its use prior to more invasive sex tests.

Acrania-anencephaly associated with hypospadias. Prenatal ultrasound and MRI diagnosis and molecular folate metabolism pathway analysis

Acrania may occur as a single isolated malformation or associated with extracranial defects. Hypospadias is one of the most common congenital abnormalities of the genitalia frequently missed on prenatal sonograms. Second trimester two- and three-dimensional ultrasound and MRI diagnosis with necropsy and folate metabolism pathway analysis. The mechanisms leading to closure of both neural and urethral tubes, are far from being demonstrated, and molecular studies of this very rare association are lacking although it might be based on a common genetic mechanism, leading to a disturbed development pathway at the molecular level.

Fetal transient clitoromegaly and transient hypertrophy of the labia minora in early and mid pregnancy

OBJECTIVE

The purpose of this study was to describe a series of cases of transient changes in the female fetal external genitalia.

METHODS

In our practice area, most pregnant women usually undergo a detailed sonographic survey of all fetal organs, including the external genitalia in early and mid pregnancy.

RESULTS

During the study period (1987-2010), 62,145 consecutive pregnant women were scanned. We detected 4 fetuses with an isolated finding of clitoromegaly at 15 to 16 weeks' gestation, which disappeared at 22 to 26 weeks. Maternal hormonal study results were normal. There was 1 case of clitoromegaly and a cloacal anomaly at 15 weeks' gestation, in which the clitoris retuned to a normal size at 22 weeks. In addition, there were 3 cases of hypertrophy of the labia minora in early pregnancy, which disappeared at 26 to 32 weeks. All fetuses in these series had a normal XX karyotype and normal external genitalia at birth.

CONCLUSIONS

Transient changes in the appearance of the fetal external genitalia may occur in chromosomally normal female fetuses.

Female external genitalia on fetal magnetic resonance imaging

OBJECTIVES

To characterize the normal development of the female external genitalia on fetal magnetic resonance imaging (MRI).

METHODS

This retrospective study included MRI examinations of 191 female fetuses (20-36 gestational weeks) with normal anatomy or minor abnormalities, following suspicion of anomalies on prenatal ultrasound examination. Using a 1.5-Tesla unit, the bilabial diameter was measured on T2-weighted sequences. Statistical description, as well as correlation and regression analyses, was used to evaluate bilabial diameter in relation to gestational age. MRI measurements were compared with published ultrasound data. The morphological appearance and signal intensities of the external genitalia were also assessed.

RESULTS

Mean bilabial diameters, with 95% CIs and percentiles, were defined. The bilabial diameter as a function of gestational age was expressed by the regression equation: bilabial diameter = - 11.336 + 0.836 × (gestational age in weeks). The correlation coefficient, r = 0.782, was statistically significant (P < 0.001). Bilabial diameter on MRI was not significantly different from that on ultrasound (P < 0.001). In addition, on MRI we observed changes in morphology of the external genitalia and in signal intensities with increasing gestational age.

CONCLUSIONS

We have provided a reference range of fetal bilabial diameter on MRI, which, in addition to ultrasound findings, may be helpful in the identification of genital anomalies.

Abnormalities of the penis in utero--hypospadias on fetal MRI

OBJECTIVE

To demonstrate the visualization of penile abnormalities on fetal magnetic resonance imaging (MRI).

METHODS

This retrospective study included five fetuses (25+0 to 31+6 gestational weeks) with penile abnormalities, positively depicted on fetal MRI, using prenatal ultrasonography (US) as a standard of reference. On MRI, the penis, as well as the scrotum and testicles, were evaluated. All fetal organs were reviewed to define penile abnormalities as isolated or in association with other anomalies. Furthermore, US and MRI findings were compared.

RESULTS

Posterior hypospadias were demonstrated in all five fetuses, and abnormal testicular descent in two. Associated anomalies were present in all five fetuses on MRI, including abdominal/urogenital pathologies in four; brain pathologies in three; and craniofacial, cardiac, musculoskeletal, pathologies each in one fetus, and intrauterine growth retardation in one fetus. Compared to US, additional MRI findings were shown in four of five fetuses.

CONCLUSIONS

Our MRI results demonstrate the visualization of fetal penile abnormalities and associated pathologies, which may provide information for perinatal management. MRI may show additional findings compared to prenatal US in certain cases.