Persistent mullerian duct syndrome and transverse testicular ectopia: embryology, presentation, and management

Diagnostic and therapeutic challenges with germ cell tumours associated with transverse testicular ectopia and persistent Müllerian duct syndrome

Transverse testicular ectopia (TTE) is an infrequent ectopic testis where both testes descend via the same inguinal canal, located in the same hemiscrotum, and augments the risk of developing testicular tumours. Type II TTE is accompanied by persistent Müllerian duct syndrome, where the Müllerian structures persist for various reasons. Here, we present a case of an adult in his early 30s, who presented with a right testicular swelling and was diagnosed as type II TTE and testicular mixed germ cell tumour after surgery. We could find only 13 similar cases of TTE and testicular tumours in the literature. Our case highlights the importance of clinical acumen with detailed history, meticulous clinical examination, radiological investigations and a detailed pathological examination while dealing with such sporadic presentations.

Persistent Müllerian Duct Syndrome: Understanding the Challenges

Persistent Müllerian duct syndrome (PMDS) is a rare autosomal recessive condition defined by the presence of Müllerian duct-derived structures in an otherwise normally masculinized phenotypical and genotypical (46,XY) male. We describe the case of an infant diagnosed with PMDS, managed and followed up for 7 years. The diagnosis of PMDS was made at laparoscopy at 6 months of age for investigation and management of bilateral impalpable testes. A Müllerian structure resembling a uterus with bilateral fallopian tube-like structures was seen in the pelvis, along with bilateral intra-abdominal testes. Gonadal biopsy confirmed normal testicular tissue. The child underwent successful bilateral two-stage Fowler-Stephens orchidopexies. The Müllerian remnant was preserved to maintain testicular vascularity. At the most recent follow-up, the testes are intrascrotal and normal on palpation. There have been no clinical symptoms or concerns with the Müllerian remnant during surveillance with ultrasound and MRI. To date, there are less than 300 cases described in the medical literature, with limited consensus on management. We reflect on challenges the condition poses, including fertility preservation in PMDS, testicular and Müllerian malignancy risk in PMDS, and optimal management and surveillance of PMDS.

Persistent Mullerian Duct Syndrome: A Rare Case of an Adult Infertile Male with Bilateral Cryptorchidism

Background:

Persistent mullerian duct syndrome (PMDS) is a very rare form of internal male pseudohermaphroditism in individuals who are phenotypically males with 46 XY karyotypes harboring internal female reproductive organs which are Mullerian derivatives. It occurs as a defect in the genes coding for the Mullerian inhibiting substance (MIS) or the anti Mullerian hormone (AMH) receptor, ultimately leading to failure of regression of Mullerian ducts.

Case Presentation:

A 29-year-old male with PMDS presented with complaints of primary infertility. Diagnosis was made with the help of high index of suspicion, radiological imaging, and karyotyping. Our patient underwent exploratory laparotomy with hysterectomy and bilateral orchidopexy.

Conclusion:

The purpose of this study was increasing awareness regarding rare entities and surgeons should have high clinical suspicion of PMDS when patient with bilateral undescended testis comes for the evaluation of primary infertility.

Management of Groin Pain Using an Iliohypogastric Nerve Block in a Patient with Inguinal Hernia due to Persistent Müllerian Duct Syndrome

Persistent Müllerian duct syndrome can cause an inguinal hernia, although this is a rare occurrence; recurrent inguinal hernias can, in turn, cause ongoing groin pain. Management of groin pain plays an important role in patients' quality of life. We present our experience with a 43-year-old man who had a 2-week history of left-sided groin pain. The patient underwent laparoscopic surgery for a left inguinal hernia via the transabdominal preperitoneal approach. Right-sided cryptorchidism was noted during surgery, with a solid structure-thought to be a uterus-extending into the left inguinal canal. The diagnosis was persistent Müllerian duct syndrome, and the groin pain was relieved after a laparoscopic right orchiectomy with a bilateral preperitoneal hernia repair using a mesh. Four years later, magnetic resonance imaging performed for new-onset left groin pain showed a left inguinal hernia caused by the uterine structure. We diagnosed the recurrent hernia as the cause of his pain. Prior to performing any invasive surgical procedures, an iliohypogastric nerve block was performed using 1% lidocaine. Short-term analgesia was provided by the block, improving his quality of life. He has been followed since then and has declined surgical neurectomy. An iliohypogastric nerve block can be an effective method of controlling groin pain caused by an inguinal hernia resulting from persistent Müllerian duct syndrome; the effectiveness of the nerve block will help determine whether surgical neurectomy is indicated for permanent pain control.

Transverse testicular ectopia associated with persistent Mullerian duct syndrome in infertile male: two case reports and literature review

Transverse testicular ectopia (TTE) associated with persistent Mullerian duct syndrome (PMDS) is a rare form of male pseudohermaphroditism usually unexpectedly found at surgery for cryptorchidism or inguinal hernia in children. Its etiology and prevalence are unclear, although defects in the gene that encodes anti-Mullerian hormone (AMH) or AMH receptor has been generally considered as the major cause. Adult cases of TTE associated with PMDS are even more peculiar, as the adult patients usually present more complex medical history, require more comprehensive medical examination and management. Two adult men with normal karyotype were referred to the urology outpatient clinic for infertility and cryptorchidism. Semen analysis showed both patients were azoospermic. Ultrasound and computed tomography (CT) found both testes were located at the same side of abdominal cavity or pelvic cavity, which was confirmed during the laparoscopic exploration. A tubular structure adhering to the spermatic cord was also found in both cases. Laparoscopic-assisted transabdominal orchiopexy was performed and the tubular mass was removed. Pathological examination confirmed the existence of Mullerian duct, which showed positive immunostaining of the uterus marker genes. The principles of treatment include the restoration of testes, the preservation of fertility, and the prevention of malignancy. Much attention should be payed to avoid damage of fertile testes and vas deferens in the surgery. Long-term postoperative follow-up is necessary for assessment of malignant transformation and infertility.

Genetic and histopathological analysis of transverse testicular ectopia without persistent Müllerian duct syndrome: two case reports

Background

Transverse testicular ectopia (TTE) is a rare anomaly in which both testes descend through a single inguinal canal into the same hemiscrotum. Although almost 20–50% of patients with TTE exhibit persistent Müllerian duct syndrome (PMDS) and many genetic analyses have been performed, no reports have described the genes contributing to TTE without PMDS. Here, we report two cases of TTE without PMDS using immunohistochemical staining and genetic analysis.

Case presentation

Two Asian patients with TTE without PMDS were subjected to orchiopexy. We performed testicular biopsies during operation and obtained blood samples before the operation. Testicular tissues were stained for c-kit, placental alkaline phosphatase (PLAP), and undifferentiated embryonic cell transcription factor 1 (UTF1) to evaluate the presence of intratubular malignant germ cells. Additionally, we performed polymerase chain reaction-based direct sequencing to identify single nucleotide polymorphisms in genes associated with regression of the Müllerian duct and testicular descent (that is, anti-Müllerian hormone [AMH], AMH receptor 2 [AMHR2], insulin-like 3 [INSL3], and relaxin family peptide receptor 2 [RXFP2]). The three-dimensional structures of proteins were predicted using SWISS-MODEL. In immunohistochemical analysis, c-kit and UTF1 were positive, whereas PLAP was negative in three testicular tissue samples from the two patients. These features were also detected on the unaffected side. In variant analysis, common missense variants in the AMH gene (g.365G>T; c.165G>T; p.Ser49Ile [rs10407022]) were observed. All variants in INSL3 and RXFP2 genes were intronic or silent.

Conclusions

Because UTF1, a specific marker of spermatogonial stem cell activity, was expressed in both the affected and unaffected sides in the testicular tissues of two patients, the risk of malignancy may be high in these patients. Although the etiology of TTE without PMDS remains unclear, our variant analysis results were consistent with previous reports, and variants in the AMH gene (rs10407022) may contribute to the specific phenotype of TTE without PMDS.

Persistent Müllerian duct syndrome due to anti-Müllerian hormone receptor 2 microdeletions: a diagnostic challenge

The persistent Müllerian duct syndrome (PMDS) is defined by the persistence of Müllerian derivatives in an otherwise normally virilized 46,XY male. It is usually caused by mutations in either the anti-Müllerian hormone (AMH) or AMH receptor type 2 (AMHR2) genes. We report the first cases of PMDS resulting from a microdeletion of the chromosomal region 12q13.13, the locus of the gene for AMHR2. One case involved a homozygous microdeletion of five exons of the AMHR2 gene. In the second case, the whole AMHR2 gene was deleted from the maternally inherited chromosome. The patient's paternal allele carried a stop mutation, which was initially thought to be homozygous by Sanger sequencing. Diagnostic methods are discussed, with an emphasis on comparative genomic hybridization and targeted massive parallel sequencing.

Management of Transverse Testicular Ectopia with Persistent Mullerian Duct Syndrome

According to additional anomalies, transverse testicular ectopia (TTE) is classified into three groups. Type-2 TTE, accompanied by persistent mullerian duct syndrome, constitutes approximately 20% of the patients. Surgical treatment should be planned after careful physical examination, ultrasonography, and genetic/endocrinologic evaluation. Herniorrhaphy, orchiopexy with testicular biopsy, and excision of the mullerian structures are the most appropriate surgical approaches in cases of TTE with persistent mullerian duct syndrome. We aimed to share our approach to the diagnosis and treatment of a patient with type-2 TTE. Possibility of TTE should be kept in mind in children with nonpalpable testis on one side and inguinal hernia on the other side.

Testicular Cancer: Genes, Environment, Hormones

Testicular cancer (TC) represents one of the most peculiar clinical challenges at present. In fact, currently treatments are so effective ensuring a 5 years disease-free survival rate in nearly 95% of patients. On the other hand however, TC represents the most frequent newly diagnosed form of cancer in men between the ages of 14 and 44 years, with an incidence ranging from <1 to 9.9 affected individuals per 100,000 males across countries, while the overall incidence is also increasing worldwide. Furthermore, cancer survivors show a 2% risk of developing cancer in the contralateral testis within 15 years of initial diagnosis. This complex and multifaceted scenario requires a great deal of effort to understand the clinical base of available evidence. It is now clear that genetic, environmental and hormonal risk factors concur and mutually influence both the development of the disease and its prognosis, in terms of response to treatment and the risk of recurrence. In this paper, the most recent issues describing the relative contribution of the aforementioned risk factors in TC development are discussed. In addition, particular attention is paid to the exposure to environmental chemical substances and thermal stress, whose role in cancer development and progression has recently been investigated at the molecular level.

Laparoscopic management of Müllerian duct remnants in the paediatric age: Evidence and outcome analysis

Background:

This study performed a literature analysis to determine outcomes of laparoscopic management in Müllerian duct remnants (MDRs).

Patients and Methods:

Literature was searched for terms ‘Müllerian’ ‘duct’ ‘remnants’ and ‘laparoscopy'. Primary end points were age at surgery, laparoscopic technique, intraoperative complications and postoperative morbidity.

Results:

The search revealed 10 articles (2003–2014) and included 23 patients with mean age of 1.5 years (0.5–18) at surgery. All patients were 46XY, n = 1 normal male karyotype with two cell lines. Explorative laparoscopy was performed in n = 2 and surgical management in n = 21. The 5-port technique was used in n = 10, 3-port in n = 9 and robot-assisted laparoscopic approach in n = 1 (n = 1 technique not described). Complete MDRs removal in n = 9, complete dissection and MDRs neck ligation with endoscopic loops in n = 11 and n = 1 uterus and cervix were split in the midline. After MDRs removal, there were n = 2 bilateral orchidopexy, n = 3 unilateral orchidopexy, n = 1 Fowler–Stephens stage-I and n = 1 orchiectomy. Mean operative time was 193 min (120–334), and there were no intraoperative complications. Mean follow-up was 20.5 months (3–54) and morbidity included 1 prostatic diverticula. There were 13 associations with hypospadias, of which 3 had mixed gonads and 3 bilateral cryptorchidism. Other associations were unilateral cryptorchidism and incarcerated inguinal hernia n = 1, right renal agenesis and left hydronephrosis n = 1 and n = 2 with transverse testicular ectopy.

Conclusion:

This MDRs analysis suggests that the laparoscopic approach is an effective and safe method of treatment as no intraoperative complication has reported, and there is low morbidity in the long-term follow-up.

Prostatic adenocarcinoma in the setting of persistent müllerian duct syndrome: a case report

Persistent müllerian duct syndrome (PMDS) is a form of disordered sex development in which rudimentary müllerian structures are identified in phenotypically and genotypically normal males. It is caused by defects in the anti-müllerian hormone (AMH) system. Since patients with PMDS present with undescended testes, testosterone production by Leydig cells later in life is often decreased. The role of androgens in prostate cancerogenesis is well known. Cryptorchid testes and diminished testosterone levels in post-pubertal life in patients with PMDS play a protective role against prostate cancer, and hence, prostate cancer is a rare event in patients with PMDS. Herein, we present a patient who underwent prostatectomy for high-grade prostatic adenocarcinoma with persistent müllerian structures (such as rudimentary uterus, fallopian tubes, and cervix) identified during surgery. To our knowledge, this is the second case reported in the English language literature where PMDS was associated with prostate cancer.

Persistent Mullerian Duct Syndrome: a rare entity with a rare presentation in need of multidisciplinary management

Main findings:

A typical male looking adolescent with a legal female gender assignment presented with haematuria. Investigations led to the diagnosis of Persistent Mullerian Duct Syndrome. The condition is indeed a rare entity that needs a multidisciplinary team management.

Case hypothesis:

A case of Persistent Mullerian Duct Syndrome undiagnosed at birth because karyotyping was defaulted, thus resulting in a significant impact on the legal gender assignment and psychosocial aspects.

Promising future implications:

The reporting of this case is important to create awareness due to its rarity coupled with the rare presentation with hematuria as a possible masquerade to menstruation. There were not only medical implications, but also psychosocial and legal connotations requiring a holistic multidisciplinary management.

A Case of Chromosomal Disorders of Sex Development with Transverse Testicular Ectopia Mimicking Mixed Gonadal Dysgenesis

Transverse testicular ectopia (TTE) is a rare form of ectopic testis observed in boys with a normal 46, XY karyotype. TTE can be associated with persistent Müllerian duct syndrome or other genital anomalies such as hypospadias. However, TTE concomitant with both persistent Müllerian duct remnants and hypospadias has never been reported in the literature. A case of chromosomal disorders of sex development with TTE and persistent Müllerian duct remnants, which was initially presumed to represent mixed gonadal dysgenesis, is presented.

Persistent mullerian duct syndrome: A 24-year experience

BACKGROUND

Persistence of mullerian duct derivatives in otherwise normal male child is a very rare disorder. This may lead to diagnostic as well as management dilemma.

MATERIALS AND METHODS

The medical record of 27 cases of persistent mullerian duct syndrome (PMDS) operated in three teaching hospitals more than a period of 24years is retrieved and analyzed for demography, clinical presentation, investigations, and treatment.

RESULTS

There were a total of twenty seven male children with PMDS. The age was ranged between 3months and 19years. Ten patients presented with isolated bilateral UDT, six patients with bilateral UDT and unilateral inguinal hernia (4 left and 2 right sided inguinal hernia), and eight patients presented with right inguinal hernia and left sided UDT. Eight of 27 patients showed familial trends i.e. four pairs of brothers had PMDS in our series. In 21 patients, the diagnosis was made incidentally while operating for UDT and inguinal hernia. At operation 5 patients had female type of PMDS and 22 patients had male type PMDS. In 6 patients (male type), the PMDS was associated with transverse testicular ectopia. In 18 patients the initial operation was performed through inguinal incision with excision of mullerian remnants in the same settings in 12 patients. In 4 patients, straightforward laparotomy performed (familial cases) to excise mullerian remnants. In 5 patients, the PMDS was diagnosed on laparoscopy; initially biopsy of these remnants and gonads was done followed by excision of remnants by laparotomy approach. Biopsies taken from gonads in each patient revealed testicular tissue with variable degree of immaturity and dysplasia. The biopsy of mullerian remnants did not reveal any malignancy. All patients were genotypically male.

CONCLUSION

Isolated undescended testes, left UDT and right inguinal hernia, bilateral UDT and unilateral inguinal hernia are the main presenting features of PMDS. About 30% of the patients showed familial tendency. Inguinal exploration for UDT or inguinal hernia, and laparoscopy for UDT reveal incidental findings of mullerian remnants. PMDS can be managed as single stage procedure however two stage procedure including gonadal biopsies in first stage followed by mullerian remnants excision and orchidopexy in the second stage can be opted if there is doubt about gonads and genotype.

A case of testicular seminoma in persistent Mullerian duct syndrome with transverse testicular ectopia

We present a rare case of testicular seminoma in persistent Mullerian duct syndrome (PMDS) with transverse testicular ectopia (TTE). A 42-year-old man noticed scrotal swelling a few weeks earlier and underwent magnetic resonance imaging (MRI) on suspicion of testicular tumor. MRI revealed a normal left testis on the left side of the left scrotum and a heterogeneous mass on the right side within the left scrotum. No right testis was found in the right scrotum. A blind-ending tubular structure with thickened wall showed a three-layer appearance on T2-weighted imaging and extended from the prostate through the left inguinal canal to the left scrotum. Findings during surgery suggested right testicular tumor associated with right TTE. The histopathological and immunohistochemical diagnoses of the testicular tumor and blind-ending tubular structure were seminoma and persistent Mullerian duct, respectively. Testicular tumor in PMDS with TTE is rare but may possess a characteristic appearance on imaging. Proper knowledge of these diseases will allow correct preoperative diagnosis.

[Persistent Müllerian ducts syndrome: one case of late hypofertility]

We report the case of a 35-year-old patient with a syndrome of persistent Müllerian ducts (PMDS) of the female type (group A). The diagnosis was made in adulthood during an infertility workup. Clinical examination revealed an empty scrotum, a normal penis and bilateral inguinal cystic masses. The spermogram found azoospermia. Imaging using MRI and tomotensidometry found the presence of an uterus, two fallopian tubes and two inguinal positions of polycystic testes. A surgical management was performed for surgical testicular biopsy. Histological examination then found a cystic formation of multi-celled mesothelial origin, with atrophic testis Sertoli cell involution and without sperm. PMDS is a rare form of pseudo-internal hermaphroditism characterized by the presence in a man of the uterus, fallopian tubes and upper vagina with external male genitalia and virilized characters. About 200 cases are reported in the literature. The diagnosis is often made in children intraoperatively during a cure of testicular ectopia. The karyotype is 46 XY type. The pathogenesis is related to a deficiency of anti-Müllerian hormone (AMH) or tissue resistance to its action by receptor abnormalities. The regression of the Müllerian duct derivatives can give three types of PMDS : masculine type, feminine type and a transverse type. Surgical treatment is difficult but necessary because of the risk of infertility and ectopic testicular degeneration.

Persistent Mullerian duct syndrome: a rare cause of unilateral cryptorchidism

Persistent Mullerian duct syndrome (PMDS) is a rare syndrome and sometimes the cause of a common problem in paediatric and surgical practice, namely undescended testes. PMDS is a recessive disease in which there is a defect in anti-Mullerian hormone secretion or receptor activity resulting in persistence of Mullerian structures such as a uterus or fallopian tubes with otherwise normal virilisation. Here the authors present a case of a 1&frac12;-year-old boy who was referred to their hospital because of unilateral cryptorchidism. During laparoscopic surgery, two gonads were present joined together by a uterus-like structure. Additional investigations showed a normal male karyotype and biopsies of the gonads revealed infantile testis parenchyma making the diagnosis PMDS likely.

Familial transverse testicular ectopia unrelated to persistent Müllerian duct syndrome

Transverse testicular ectopia (TTE) is rare. Although several familial cases of TTE have been reported, most of them were associated with persistent Mullerian duct syndrome (PMDS), which may be inherited as an autosomal-recessive or X-linked recessive trait. We experienced two brothers with TTE unrelated to PMDS. A genetic etiology may be involved even in TTE unrelated to PMDS.

Disorders of Sexual Differentiation

The term, disorders of sexual differentiation, broadly represents a disjunction between genotype and phenotype. Phenotype in turn can refer to external or internal genital development. Disorders of sexual differentiation are determined at conception insofar as (1) the abnormal genotype is the aberrant genetic product of fertilization at the chromosomal level or (2) the abnormal phenotype results from postfertilization errors in function at the gene level, somewhere along the pathway of transcription and translation. In either event, the error is genetic, whether or not sporadic or inherited, even if the pathways have yet to be fully elucidated for a given disorder.

Testicular fusion in a patient with transverse testicular ectopia and persistent mullerian duct syndrome

We report a case of fused testes in a patient with transverse testicular ectopia and persistent Mullerian duct syndrome. A laparoscopy performed to confirm the diagnosis showed a single vas deferens on the left side. Treatment included excision of the Mullerian remnant through a left inguinal incision and orchidopexy of the fused testes via the left inguinal canal after sectioning of the right internal spermatic vessels. Follow-up ultrasound has so far confirmed viability of both testes.

Impact of laparoscopy on the management of transverse testicular ectopia

Transverse testicular ectopia (TTE) is an uncommon condition with different clinical presentations. A significant proportion of cases are diagnosed only during surgery and it is important to define the precise anatomy and associated anomalies in every case of TTE. Laparoscopy is being increasingly adopted in the treatment of undescended testis, especially in cases where the testis is impalpable. We hereby report a child with a variant of TTE wherein laparoscopy proved enormously beneficial in diagnosis and treatment and where a routine groin exploration was likely to have yielded an incorrect diagnosis. We also review the available literature on the use of laparoscopy in the management of TTE and its impact on the ability of surgeons to diagnose and treat TTE and its associated conditions.

Duplicated Müllerian remnant in a 6-year-old boy

We report a 6-year-old boy with large duplicated müllerian duct remnant who presented with recurrent urinary tract infections and dysuria. His prior urological problems included proximal hypospadias (repaired), urachal cyst, and a unilateral undescended testis. Imaging evaluation included US, MRI, and cystoscopy. Laparoscopic resection was performed via a retrovesical approach. The patient was free of symptoms after surgery.