Endocrine abnormalities in boys with hypospadias

Hypospadias: A Comprehensive Review Including Its Embryology, Etiology and Surgical Techniques

Hypospadias is among the most prevalent urogenital malformations in male newborns. It is characterized by the displacement of the urethral meatus to the ventral side of the penis, an aberrant ventral curve of the penis referred to as "chordee," and an abnormally arranged foreskin with a "hood" found dorsally and lacking foreskin ventrally. Patients may have an extra genitourinary abnormality based on the area of the lesion. In around 70% of cases, the urethral meatus is positioned distally to the shaft, representing a milder form of the disease. The remaining 30% of cases are located proximally, are more complicated, and require further evaluation. Although the origin of hypospadias is mostly obscure, several suggestions exist about genetic susceptibility and hormonal factors. The objective of hypospadias restoration is to restore aesthetic and functional regularity, and surgery is currently advised at a young age, mostly between six and 18 months. At any age, hypospadias can be repaired with an equivalent risk of complications, functional outcomes, and aesthetic outcomes. However, the best age of treatment is still undetermined. Even though the long-term effects on appearance and sexual function are usually good, males may be less likely to make the first move after rectification. Also, people who have hypospadias treated are twice as likely to have problems with their lower urinary tract. These problems can last for years after the initial repair.

One-stage tubularized urethroplasty using the free inner plate of the foreskin in the treatment of proximal hypospadias

Objective

This study summarizes the short-term efficacy of the one-stage tubularized urethroplasty using the free inner in proximal hypospadias.

Methods

A retrospective analysis was conducted on 42 patients with proximal hypospadias. All cases were treated with one-stage tubularized urethroplasty from January 2020 to June 2021. The postoperative complications like urethral fistula, urethral stricture, diverticulum, and split penis head were recorded.

Results

Patients were followed up for 3 to 15 months (an average of 8.5 months). A total of 26 cases (62%) were repaired without any complication. Five patients (11.9%) developed urinary fistulas and underwent secondary repair: three cases with anastomotic fistulas and two cases of coronal fistulas. Nine patients (21.4%) had stenosis of the head segment of the penis, six (14.3%) had stenosis that was relieved by urethral dilatation combined with topical mometasone furoate 1 month after urethral catheter removal. Two patients (4.8%) had severe stenosis with secondary surgical stenosis incision, and one (2.4%) had combined urethral diverticulum in which urethral stenosis incision and diverticulectomy were performed.

Conclusions

Tubularized urethroplasty using the free inner bears the advantages of easy access, reduced short-term complications, low incidence of diverticula.

Impact of gestational and parental factors and maternal intake of progesterone on the development of hypospadias: A retrospective case-control study

OBJECTIVE

Impact of environmental, maternal, paternal, and fetal factors on the development of hypospadias have been questioned in association with disrupted hormonal balance. We aimed to examine the association between maternal progesterone use and the associated risk factors and hypospadias.

MATERIALS AND METHODS

There were 429 male children as the cases with hypospadias (n = 280, Group 1) and the controls without hypospadias (n = 149, Group 2). Those working in agriculture and industry, cleaners, and hairdressers were determined as risky occupational groups concerning the exposure of estrogenic endocrine disrupters. The association of progestin usage and the other risk factors with hypospadias were the study outcomes.

RESULTS

The median gestational age was significantly lower in Group 2 (p = 0.019). Prematurity was more common in Group 1 (p = 0.043). Although the median birth weight in Group 1 was significantly lower (p < 0.001), there was no significant difference between the ratios of low birth weight babies in the groups. The risky occupations were more frequently detected in Group 2 (p = 0.001). The rate and duration of progestin usage in Group 1 were significantly higher than that in Group 2 (p < 0.001).

CONCLUSION

Low birth weight and the use and duration of progestins during pregnancy were significantly associated with increased hypospadias risk.

Frozen-thawed blastocyst transfer in natural cycle: feasibility in everyday clinical practice

PURPOSE

Transfer of frozen-thawed embryos in natural cycle is gaining consensus but evidence on this approach is scanty. The aim of this study is reporting on the feasibility of this type of policy in everyday clinical practice.

METHODS

We retrospectively selected all women undergoing the procedure between July 2013 and December 2014. During the study period, women were systematically scheduled for natural cycle if they referred regular menstrual cycles. Hormone replacement therapy (HRT) was conversely prescribed if the woman had irregular menstrual cycles or if the monitoring of the natural cycle failed. The analysis exclusively focussed on the first cycle per woman.

RESULTS

Overall, 251 women were selected. HRT was initially chosen in 52 women, leaving 199 women suitable for the natural cycle. This procedure could be performed in 194 of these women (97%, 95% CI 95-99%). Two additional women initially allocated to HRT ultimately performed the blastocyst transfer with natural cycle. Overall, 196 were thus treated with natural cycle (78%, 95% CI 73-83%). The basal characteristics of the women who did and did not undergo natural cycles were similar with the exceptions of serum FSH (p < 0.001) and AMH (p = 0.03). The live birth rate did not also differ (34% versus 31%, p = 0.63). Characteristics of women treated with the natural cycle who did (n = 67) and did not (n = 129) achieve a live birth did not differ.

CONCLUSION

Frozen-thawed blastocyst transfer in natural cycle can be successfully performed in the vast majority of women.

Hypospadias, all there is to know

Hypospadias is one of the most common congenital anomalies in men. The condition is typically characterized by proximal displacement of the urethral opening, penile curvature, and a ventrally deficient hooded foreskin. In about 70%, the urethral meatus is located distally on the penile shaft; this is considered a mild form that is not associated with other urogenital deformities. The remaining 30% are proximal and often more complex. In these cases, endocrinological evaluation is advised to exclude disorders of sexual differentiation, especially in case of concomitant unilateral or bilateral undescended testis. Although the etiology of hypospadias is largely unknown, many hypotheses exist about genetic predisposition and hormonal influences. The goal of hypospadias repair is to achieve cosmetic and functional normality, and currently, surgery is recommended between 6 and 18 months of age. Hypospadias can be corrected at any age with comparable complication risk, functional, and cosmetic outcome; however, the optimal age of repair remains conclusive. Although long-term overall outcome concerning cosmetic appearance and sexual function is fairly good, after correction, men may more often be inhibited in seeking sexual contact. Moreover, lower urinary tract symptoms occur twice as often in patients undergoing hypospadias repair and can still occur many years after the initial repair.

CONCLUSION

This study explores the most recent insights into the management of hypospadias. What is Known: • Guidelines advise referral for treatment between 6 and 18 months of age. • Cosmetic outcome is considered satisfactory in over 70% of all patients. What is New: • Long-term complications include urinary tract symptoms and sexual and cosmetic issues. • New developments allow a more individualized approach, hopefully leading to less complications and more patient satisfaction.

Luteal phase support post IVF: individualized early stop

While the need for progesterone-based luteal phase support is well documented, the required treatment duration is not well established, and a practitioners' survey showed a wide range of empiric stopping points. It is suggested that an early stop can be based on assessing endogenous luteal activity on the day of pregnancy test. To examine this approach, data were retrospectively collected on 99 patients with positive pregnancy test and high serum concentrations of oestradiol and progesterone (≥ 1000 pmol/l and ≥ 110 nmol/l, respectively), whose luteal support was stopped, and compared with those of 85 patients who did not meet the above criteria, and so luteal support was continued until gestational week 9. Both groups were comparable in terms of live birth and miscarriage rates. We conclude that in the face of strong endogenous luteal activity, exogenous support can be stopped on pregnancy test day, without affecting pregnancy outcome. Further research is needed to substantiate this finding.

Duration of luteal support after IVF is important, so why is there no consistency in practice? The results of a dynamic survey of practice in the United Kingdom

Luteal support is considered as an essential component of IVF treatment following ovarian stimulation and embryo transfer. Several studies have consistently demonstrated a benefit of luteal support compared with no treatment and whilst a number of preparations are available, no product has been demonstrated as superior. There is an emerging body of evidence which suggests that extension of luteal support beyond biochemical pregnancy does not confer a benefit in terms of successful pregnancy outcome. We performed two surveys separated by 5 years of practice evolution, with the latter reporting on the use of luteal support in all IVF clinics in the UK. All clinics reported utilising luteal support with the majority favouring the use of Cyclogest 400 mg twice daily. In contrast, there was no consensus on the optimal duration of luteal support. Whilst 24% of clinics withdrew luteal support at biochemical confirmation of pregnancy, 40% continued treatment until 12 weeks gestation. Several clinics even extended luteal support beyond 12 weeks gestation. We observed no difference in practice based on the size of the IVF unit or treatment funding source. Although there was some change in practice between surveys in many clinics, there was no uniformity in the direction of change.

The optimal duration of progesterone supplementation in pregnant women after IVF/ICSI: a meta-analysis

can improve the rates of clinical pregnancy and live birth, but the optimal duration of treatment remains controversial. The objective of this meta-analysis was to investigate the effects of early progesterone cessation on pregnancy outcomes in women undergoing IVF/ICSI.

METHODS

We searched MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials (CENTRAL), the Chinese biomedicine (CBM) literature database, and the Wanfang database. The final search was performed in July 2012. All available randomised trials that compared the effects of early progesterone cessation with progesterone continuation during early pregnancy after IVF/ICSI were included. The main outcome measures were live birth rate, miscarriage rate and ongoing pregnancy rate. Fixed or random-effects models were chosen to calculate the risk ratio (RR).

RESULTS

Six eligible studies with a total of 1,201 randomised participants were included in the final analysis. No statistically significant differences were detected between patients who underwent early progesterone cessation and those who received progesterone continuation for luteal phase support in terms of live birth rate (RR: 0.95, 95% CI: 0.86-1.05), miscarriage rate (RR: 1.01, 95% CI: 0.74-1.38) or ongoing pregnancy rate (RR: 0.97, 95% CI: 0.90-1.05). These results did not change after a sensitivity analysis.

CONCLUSIONS

The currently available evidence suggests that progesterone supplementation beyond the first positive hCG test after IVF/ICSI might generally be unnecessary, although large-scale randomised controlled trials are needed to strengthen this conclusion.

Molecular mechanisms of external genitalia development

External genitalia development occurs through a combination of hormone independent, hormone dependent, and endocrine pathways. Perturbation of these pathways can lead to abnormal external genitalia development. We review human and animal mechanisms of normal and abnormal external genitalia development, and we evaluate abnormal mechanisms that lead to hypospadias. We also discuss recent laboratory findings that further our understanding of animal models of hypospadias.

Early progesterone cessation after in vitro fertilization/intracytoplasmic sperm injection: a randomized, controlled trial

OBJECTIVE

To investigate the effect of stopping progesterone (P) support at week 5 versus week 8 on ongoing pregnancy rate after in vitro fertilization (IVF)/intracytoplasmic sperm injection (ICSI).

DESIGN

Prospective, randomized, controlled trial.

SETTING

University-affiliated infertility center.

PATIENT(S)

A total of 220 patients with intrauterine pregnancy demonstrated by transvaginal ultrasound after IVF/ICSI.

INTERVENTION(S)

Luteal phase support with micronized vaginal P was suspended at week 5 or at week 8.

MAIN OUTCOME MEASURE(S)

Ongoing pregnancy rate, miscarriage rate, and number of bleeding episodes.

RESULT(S)

Progesterone levels were similar on the day of the first pregnancy ultrasound exam (149 ± 108 vs. 167 ± 115 ng/mL). Significantly more bleeding episodes were observed in the first trimester in the group with early cessation of P supplementation (18.0 ± 2.6 vs. 7.2 ± 1.3 episodes). Miscarriage rates among singleton pregnancies were similar in the two groups (5/80 vs. 6/79).

CONCLUSION(S)

Vaginal P supplementation after IVF/ICSI can be safely withdrawn at 5 weeks' gestation, because cycle outcome was similar to conventional luteal phase support up to 8 weeks of pregnancy.

CLINICAL TRIAL REGISTRATION NUMBER

NCT01177904.

Development of the penile urethra in the tammar wallaby

Hypospadias is increasingly common, and requires surgery to repair, but its aetiology is poorly understood. The marsupial tammar wallaby provides a unique opportunity to study hypospadias because penile differentiation occurs postnatally. Androgens are responsible for penile development in the tammar, but the majority of differentiation, in particular formation and closure of the urethral groove forming the penile urethra in males, occurs when there is no measurable sex difference in the concentrations of testosterone or dihydrotestosterone in either the gonads or the circulation [corrected]. Phalluses were examined morphologically from the sexually indifferent period (when androgens are high) to well after the time that the phallus becomes sexually dimorphic. We show that penile development and critical changes in the positioning of the urethra occur in the male phallus begin during an early window of time when androgens are high. Remodelling of the urethra in the male occurs between days 20-60. The critical period of time for the establishment urethral closure occurs during the earliest phases of penile development. This study suggests that there is an early window of time before day 60 when androgen imprinting must occur for normal penile development and closure of the urethral groove.

Hypospadias in Istanbul: incidence and risk factors

BACKGROUND

The aim of the present prospective study was to determine the incidence of hypospadias in newborns in one of the busiest teaching hospitals of Istanbul, and to investigate the risk factors.

METHODS

All live-born boys delivered between September 2007 and December 2008 were screened for hypospadias. A questionnaire was given to the parents of the hypospadias and control subjects for investigation.

RESULTS

Out of 1750 boys examined, 34 had hypospadias, that is, the frequency was 19.4 per 1000 male live-births and 93.7 per 10,000 total live-born deliveries. The incidence of additional coexistent anomalies was 29.4%, predominantly urogenital (17.6%), the majority of which were cryptorchidism (14.7%). Twelve (35.3%) of the 34 hypospadiac boys had a second family member with a genital anomaly, nine (26.5%) of whom had hypospadias, three (8.8%) being the fathers. Mean birthweight, length and head circumference were significantly lower in the hypospadiac infants than the control group (P= 0.003, P= 0.025, P= 0.002). Although parity, parental consanguinity, hypospadias in family members, and low birthweight also varied significantly among the groups, logistic regression analysis indicated that maternal age, prematurity, coexistence of cryptorchidism and presence of genital anomaly among family members were independent risk factors for hypospadias (P= 0.016, P= 0.0001, P= 0.041, P= 0.0001, respectively).

CONCLUSIONS

Genetic predisposition and placental insufficiency in early gestation might play a role in the etiology of hypospadias.

Relationship between maternal dietary patterns and hypospadias

Little is known about the role of maternal nutrition in the development of hypospadias, which is the most common urogenital congenital anomaly. This study investigated the relationship between maternal nutrition and the risk of hypospadias, particularly focusing on maternal food patterns. We compared 471 hypospadias cases with 490 controls in the United Kingdom. A questionnaire including information on life style, occupation, usual maternal diet and dietary supplements was administered using telephone interviews. Cases and controls were compared for individual food item intake and food patterns derived by cluster analysis. Multivariable logistic regression analysis adjusted for income, maternal age, low birthweight, smoking and folic acid supplement use was used to assess the relationship between maternal nutrition and hypospadias. Three food patterns were created with the labels 'health conscious', 'mixed' and 'non-health conscious'. 'Non-health conscious' subjects (low frequency of consumption of yoghurt, cheese, eggs, fruit and vegetables, fish, beans and pulses, olive oil and organic food) had a higher risk of hypospadias (odds ratio 1.54; 95% confidence interval 1.06, 2.26) compared with 'health conscious' subjects (high frequency of consumption of fresh fruit and vegetables, dried fruit, fresh or frozen fish, beans, pulses, soya products, olive oil and organic food), after adjustment for potential confounders. Intakes of individual foods were not strongly associated with hypospadias. We could not exclude the possibility of residual confounding, and this needs to be further investigated. We found an association between food pattern and hypospadias, with those with less health conscious food patterns having a higher risk. Further study is needed to confirm this association.

Genetic pathway of external genitalia formation and molecular etiology of hypospadias

Hypospadias is one of the most common congenital disorders in males. Impaired fetal androgen action interferes with masculinization, including external genitalia formation, and can result in this anomaly; however, the molecular etiology remains unknown. Recent molecular approaches, including gene-targeting approaches in mice and single nucleotide polymorphisms analyses in humans, might provide an opportunity to identify the causative and risk factors of this anomaly. Several genes, such as sonic hedgehog, fibroblast growth factors, bone morphogenetic proteins, homeobox genes, and the Wnt family regulate external genitalia formation. Mastermind-like domain containing 1/chromosome X open reading frame 6 mutation and activating transcription factor 3 variants have been shown to be associated with the incidence of isolated hypospadias. In addition, this anomaly may be associated with a specific haplotype of the gene for estrogen receptor alpha, which mediates the estrogenic effects of environmental endocrine disruptors, and the effects of these disruptors on external genitalia formation might depend on individual genetic susceptibility. These molecular studies will refine our knowledge of the genetic mechanism involved in external genitalia formation, and lead to new strategies for the clinical management of hypospadias.

“Natural” progesterone: information on fetal effects

BACKGROUND

A variety of progestational agents have been used therapeutically and evaluated for adverse effects over the last 50 years. However, progesterone itself has come into use as a therapeutic agent only recently with the development of an orally bioavailable "micronized" preparation.

METHODS

The current review examines progesterone adverse effects as identified in the larger literature on the toxicity of progestational agents and pharmacokinetics.

RESULTS

Progesterone has cytoplasmic and membrane receptors in a variety of reproductive and nonreproductive tissues including the brain and is a potent inhibitor of GnRH. Limited information is available on progesterone receptors and actions in the fetus. Concern about exogenous progestagen effects on fetal reproductive tract development have led to considerable human research over the years, but this literature review demonstrates that contemporary developmental toxicology research on progesterone is lacking.

CONCLUSIONS

Progesterone is a potent, multi-faceted endocrine agent with an expanding therapeutic profile and a minimal scientific database for evaluating safe use during pregnancy.

Developmental expression of aryl, estrogen, and hydroxysteroid sulfotransferases in pre- and postnatal human liver

Aryl- (SULT1A1), estrogen- (SULT1E1), and hydroxysteroid- (SULT2A1) sulfotransferases (SULTs) are active determinants of xenobiotic detoxication and hormone metabolism in the adult human liver. To investigate the role of these conjugating enzymes in the developing human liver, the ontogeny of immunoreactive SULT1A1, SULT1E1, and SULT2A1 expression was characterized in a series of 235 pre- and postnatal human liver cytosols ranging in age from early gestation to a postnatal age of 18 years. Interindividual variability in expression levels was apparent for all three SULTs in pre- and postnatal liver samples. Expression of the three SULTs displayed distinctly different developmental profiles. Semiquantitative Western blot analyses indicated that SULT1A1 and SULT2A1 immunoreactive protein levels were readily detectable in the majority of developmental human liver cytosols throughout the prenatal period. Whereas SULT1A1 expression did not differ significantly among the various developmental stages, SULT2A1 expression increased during the third trimester of gestation and continued to increase during postnatal life. By contrast, SULT1E1, a cardinal estrogen-inactivating enzyme, achieved the highest levels of expression during the earliest periods of gestation in prenatal male livers, indicating a requisite role for estrogen inactivation in the developing male. The present analysis suggests that divergent regulatory mechanisms are responsible for the differential patterns of hepatic SULT1A1, SULT1E1, and SULT2A1 immunoreactive protein levels that occur during pre- and postnatal human development, and implicates a major role for sulfotransferase expression in the developing fetus.

Hypospadias in the neonate

Hypospadias is a common developmental disorder of the urogenital tract, occurring in approximately 1 in 125 live male births. Defined as an atypical urethral opening anywhere along the shaft of the penis, scrotum, or perineum, hypospadias is often associated with a deficient prepuce and chordee. Hypospadias usually occurs as an isolated defect, but can be part of a recognized syndrome or associated with other genital anomalies. The etiology of nonsyndromic hypospadias is unknown, and is believed to be multifactorial. Recent studies have implicated factors such as familial inheritance, low birth weight, assisted reproductive technology, advanced maternal age, paternal subfertility, and endocrine-disrupting chemicals in the pathogenesis of hypospadias. Infants with hypospadias should not undergo circumcision. Currently, most infants with hypospadias undergo surgical reconstruction between 4 and 8 months of age. Parents of a newborn with hypospadias may be anxious and have many questions about their infant's condition. They should be given the opportunity to speak to a pediatric urologist as early as possible. This article provides a guide to the embryologic origins of hypospadias and a photographic atlas to aid bedside clinicians in identifying the spectrum of hypospadias in the newborn.