Unilateral testicular injury from external trauma: evaluation of semen quality and endocrine parameters

Long-term impact of commonly performed operations in pediatric urology on reproductive and sexual health

Introduction

Sexual dysfunction is highly prevalent among men of reproductive age. Clinical practice guidelines have been established to assist providers in identification and education of patients who are at increased risk for infertility and sexual dysfunction with certain congenital and acquired urogenital disorders. The authors sought to review the reproductive and sexual health implications of treating common childhood urological conditions with commonly performed surgical procedures.

Methods

To ensure the inclusion of influential and highly regarded research, we prioritized citations from the most-frequently cited articles on our respective review topics. Our inclusion criteria considered studies with substantial sample sizes and rigorously designed methodologies. Several topics were reviewed, including penile chordee, hypospadias, posterior urethral valves, varicoceles, undescended testicles, and testicular torsion.

Results

For chordee, surgical plication or corporal grafting may be employed. Erectile function remains unaltered post-surgery, while penile length may decrease after repair, which may be avoided using dermal grafts. Hypospadias repair hinges on severity and availability of the urethral plate. Those who underwent hypospadias repair report decreased penile length, but sexual satisfaction, libido, and semen quality are comparable to controls. Posterior urethral valves are usually treated with valve ablation. While valve ablation and bladder neck incision have not been found to affect ejaculatory function, high degree of concurrent renal dysfunction related to nephrogenic and bladder dysfunction may impact semen parameters and erectile function. Regarding varicocele, earlier management has been associated with better long-term fertility outcomes, and surgical intervention is advisable if there is observable testicular atrophy. Earlier repair of undescended testicle with orchiopexy has been found to improve fertility rates as well as decrease malignancy rates. Unilateral orchiectomy for testicular torsion without the ability for salvage has been shown to have decreased semen parameters but unaffected fertility rates.

Conclusion

Infertility and sexual dysfunction are multivariable entities, with etiologies both congenital and acquired. At the same time, many common pediatric urology surgeries are performed to correct anatomic pathology that may lead to reproductive dysfunction in adulthood. This review highlights the need for diagnosis and management of pediatric urologic conditions as these conditions may impact long-term sexual function post-operatively.

Antisperm Antibody Testing: A Comprehensive Review of Its Role in the Management of Immunological Male Infertility and Results of a Global Survey of Clinical Practices

Antisperm antibodies (ASA), as a cause of male infertility, have been detected in infertile males as early as 1954. Multiple causes of ASA production have been identified, and they are due to an abnormal exposure of mature germ cells to the immune system. ASA testing (with mixed anti-globulin reaction, and immunobead binding test) was described in the WHO manual 5th edition and is most recently listed among the extended semen tests in the WHO manual 6th edition. The relationship between ASA and infertility is somewhat complex. The presence of sperm agglutination, while insufficient to diagnose immunological infertility, may indicate the presence of ASA. However, ASA can also be present in the absence of any sperm agglutination. The andrological management of ASA depends on the etiology and individual practices of clinicians. In this article, we provide a comprehensive review of the causes of ASA production, its role in immunological male infertility, clinical indications of ASA testing, and the available therapeutic options. We also provide the details of laboratory procedures for assessment of ASA together with important measures for quality control. Additionally, laboratory and clinical scenarios are presented to guide the reader in the management of ASA and immunological male infertility. Furthermore, we report the results of a recent worldwide survey, conducted to gather information about clinical practices in the management of immunological male infertility.

Hidden trauma: shedding light on the relationship between gun violence and infertility

Objective

To study the existing data on the relationship between penetrating abdominopelvic injuries and fertility guidance on managing fertility concerns of these patients using a case report and scoping review.

Design

Case report and scoping review.

Setting

Not applicable.

Patient(s)

People who have experienced abdominopelvic trauma from gun violence or in the course of combat.

Intervention(s)

None.

Main Outcome Measure(s)

We extracted case report data from electronic health records. We performed a scoping review using PubMed and Scopus. Search terms were related to penetrating abdominopelvic trauma, gunshot wounds (GSW), war, and fertility/infertility. We evaluated the study year, age and race, mechanism of injury, fertility outcomes, and how fertility concerns were addressed with patients who experienced penetrating abdominopelvic trauma.

Result(s)

In the case report, the couple had 10 years of infertility. The male partner experienced an abdominopelvic GSW before attempting to conceive. After evaluation, he was diagnosed with retrograde ejaculation. He recalled being advised that his GSW might affect his future fertility. The couple has discontinued care.

For the scoping review, 879 sources were identified and 25 studies were included in the review. Among the studies conducted in the United States, most patients included were African American.

Eighty-eight percent (n = 22) of the sources acknowledged the importance of fertility or used fertility-related outcome measures. One study commented on how to address fertility concerns with victims of abdominopelvic penetrating trauma.

Conclusion(s)

There is a paucity of data on the intersection of penetrating abdominopelvic injuries and fertility or guidance on how to discuss fertility issues with patients.

Testicular rupture after blunt scrotal trauma in children: A case report and literature review

Blunt testicular trauma with rupture of albuginea is one of the rarest emergencies in children. Medical history and Testicular Doppler Ultrasound lead to diagnosis. Appropriate management is necessary to preserve the testis. Follow-up to adulthood is recommended to assess the impact on fertility.

Testicular rupture successfully treated with a tunica vaginalis flap

INTRODUCTION

Testicular injury with a tunica albuginea tear is typically reconstructed by primary closure. We herein describe the successful use of a tunica vaginalis flap for reconstruction of a ruptured testis for which primary closure was not possible.

CASE PRESENTATION

A 21-year-old man visited our hospital with scrotal swelling after a baseball struck his left testis. Magnetic resonance imaging and ultrasonography indicated a left tunica albuginea tear, and emergency surgery was performed. Primary closure of the tunica albuginea was impossible since a tight closure could cause secondary damage. A vascular pedicle flap was prepared by shaping the tunica vaginalis to replace the tunica albuginea. He was discharged 2 days postoperatively. Ultrasonography showed normal size and blood flow in the ruptured testis at the 2-week and 3-month follow-up.

CONCLUSION

A testicular vaginalis flap should be considered when primary closure is difficult in cases of testicular rupture with tunica albuginea damage.

Fertility considerations in men with testicular cancer

The modern approach to cancer management has evolved into a multidisciplinary initiative focused not only on cancer specific and overall survival, but also patient quality of life and survivorship. Future fertility is often a major concern for young patients undergoing cancer therapy. Fertility preservation has emerged as a viable but significantly underutilized option. Patients and families should be aware of the varying effects of antineoplastic therapy on their future fertility to allow for an informed decision regarding their fertility preservation options. In this review we discuss the epidemiology, pathophysiology, and management of fertility in the setting of testicular cancer diagnosis and treatment.

Protective effects of melatonin solid lipid nanoparticles on testis histology after testicular trauma in rats

Testicular traumatic injuries occur frequently, which can result in an alteration in spermatogenesis. These injuries can also cause oxidative stress and male infertility. Antioxidant efficiency of melatonin (MLT), known as a potent antioxidant, will be improved if used in a form of solid lipid nanoparticles (MLT-SLN). The aim of the current study is to evaluate the effect of MLT-loaded SLN on traumatic testis in rats. In this study 32 adult male Wistar rats were divided into 4 groups. Group 1 (sham group), right testicle was drawn out from the scrotum and returned without manipulation. Group 2, right testicle was dropped by 25 g sinker for 4 times. Group 3, animals were received a single dose (25 mg/kg) of MLT intraperitoneally after trauma. Group 4, animals were received a single dose of MLT-SLN intraperitoneally after trauma. Under anaesthesia, rats were sacrificed, and their testicles were removed three days after the surgery. After tissue processing, the sample sections were H&E stained. MLT and MLT-SLN could partially repair spermatogenesis by Johnson’s criteria but the repairs were significant only in MLT-SLN group (P = 0.02). Trauma decreased seminiferous tubule diameter and its epithelium height. MLT could restore epithelium height (P ≤ 0.05) but its NPs improved both epithelium diameter (P ≤ 0.05) and thickness (P ≤ 0.001). The Malondialdehyde increased significantly in trauma group (P = 0.002), but decreased in MLT and NPs groups compared to trauma group (P = 0.098 and P = 0.002 respectively). This decrease was significant only in NPs group. Testicular trauma disturbed spermatogenesis, morphometric, and oxidative parameters. MLT and specially MLT-SLN improved traumatic damages.

Effects of Intratesticular Hematoma on Testis Microstructure, Spermatogenesis, and Testosterone Production: Defining a Cutoff Point for Significant Intratesticular Hematoma

OBJECTIVE

To evaluate the effects of different degrees of intratesticular hematoma (ITH), a major consequence of blunt testis trauma, on testis microstructure and function. We determined a cutoff point for significant vs nonsignificant ITH.

METHODS

Seventy male rats were divided into 7 equal groups. The control group remained intact. Sham groups consisted of rats given an intratesticular injection of normal saline in both testicles with volumes equivalent to 40% (group II), 30% (group III), and 10% (group IV) of testis volume. Bilateral ITH was created by the intratesticular injection of autologous blood equivalent to 40% (group V), 30% (group VI), and 10% (group VII) of testicular volume. After 60 days of recovery, testes volume, microstructure, semen parameters, and serum testosterone were recorded.

RESULTS

The most severe destructive effects were observed in groups V and VI. Testes, tubule, and epithelium volumes were reduced between 16.6% and 58.8%. The number of the spermatogenic, Sertoli, and Leydig cells was reduced between 47.5% and 73.1% in group V. Significant volume-dependent decreases in spermatozoa counts were seen in all groups except group IV after injection of different amounts of normal saline or blood. This reduction was most prominent after injections equivalent to 40% of testis volume (groups II and V). There was a nonsignificant trend toward lower testosterone level in groups V and VI.

CONCLUSION

ITH has significant volume-dependent detrimental effects on testis microstructure, semen parameters, and testosterone level. ITH equivalent to 10% of testis volume may be relatively well-tolerated, but the effects can be significant when ITH is ≥30% of testis volume.

Perspectives in Pediatric Pathology, Chapter 23. Testicular Pathology Secondary to Physical and Chemical Injury

Testicles can be damaged by a variety of physical and chemical agents, ranging from trauma suffered in accidents or athletic activities, to diverse drugs or radiation used in cancer treatment. The immediate and long-term effects of these damaging agents at the testicular morphologic and functional levels are quite varied and may have significant impact on the fertility of the pediatric patient once reproductive age is reached.

Causes of male infertility: a 9-year prospective monocentre study on 1737 patients with reduced total sperm counts

STUDY QUESTION

What are the primary causes of severe male factor infertility?

SUMMARY ANSWER

Although 40% of all patients showed primary causes of infertility, which could be subdivided into three groups based on the severity of their effect, ~75% of oligozoospermia cases remained idiopathic.

WHAT IS KNOWN ALREADY

There are few large-scale epidemiological studies analyzing the causes of male factor infertility.

STUDY DESIGN, SIZE, DURATION

A prospective clinical-epidemiological study was conducted at the Andrology Centre, Tartu University Hospital between 2005 and 2013, recruiting male partners of couples failing to conceive a child for over ≥12 months. Among 8518 patients, 1737 (20.4%) were diagnosed with severe male factor infertility. A reference group of fertile controls was comprised of 325 partners of pregnant women.

PARTICIPANTS/MATERIALS, SETTING, METHODS

The mean age of infertility patients and fertile controls was 33.2 ± 7.3 and 31.7 ± 6.3 years, respectively. All participants were examined using a standardized andrology workup, accompanied by a structured medical interview. Hormonal analysis included serum FSH, LH and testosterone. Semen quality was determined in accordance to the World Health Organization recommendations. Cases with spermatozoa concentrations of ≤5 million/ml were screened for chromosomal aberrations and Y-chromosomal microdeletions.

MAIN RESULTS AND THE ROLE OF CHANCE

The primary cause of infertility was defined for 695 of 1737 patients (~40%). The analyzed causal factors could be divided into absolute (secondary hypogonadism, genetic causes, seminal tract obstruction), severe (oncological diseases, severe sexual dysfunction) and plausible causal factors (congenital anomalies in uro-genital tract, acquired or secondary testicular damage). The latter were also detected for 11 (3.4%) men with proven fertility (diagnoses: unilateral cryptorchidism, testis cancer, orchitis, mumps orchitis). The causal factors behind the most severe forms of impaired spermatogenesis were relatively well understood; causes were assigned: for aspermia in 46/46 cases (100%), for azoospermia in 321/388 cases (82.7%), and for cryptozoospermia in 54/130 cases (41.5%). In contrast, 75% of oligozoospermia cases remained unexplained. The main cause of aspermia was severe sexual dysfunction (71.7% of aspermia patients). Azoospermia patients accounted for 86.4% of all cases diagnosed with secondary hypogonadism and 97.1% of patients with seminal tract obstruction. Of patients with a known genetic factor, 87.4% had extreme infertility (azoo-, crypto- or aspermia). The prevalence of congenital anomalies in the uro-genital tract was not clearly correlated with the severity of impaired sperm production. Previously defined 'potential contributing factors' varicocele and leukocytospermia were excluded as the primary causes of male infertility. However, their incidence was >2-fold higher (31.0 vs 13.5% and 16.1 vs 7.4%; P < 0.001) in the idiopathic infertility group compared to controls. In addition, the proportions of overweight (or obese) patients and patients suffering from a chronic disease were significantly increased in almost all of the patient subgroups.

LIMITATIONS REASONS FOR CAUTION

The study included only subjects with reduced total spermatozoa counts. Thus, these findings cannot be automatically applied to all male factor infertility cases.

WIDER IMPLICATIONS OF THE FINDINGS

The novel insights and improved clarity achieved in the comprehensive analysis regarding the absolute, causative and plausible factors behind male infertility, as well as the 'potential contributing factors', will be valuable tools in updating the current clinical guidelines. The study highlights knowledge gaps and reiterates an urgent need to uncover the causes and mechanisms behind, and potential treatments of, oligozoospermic cases, representing the majority of idiopathic infertility patients (86.3%).

STUDY FUNDING/COMPETING INTERESTS

The project was financed by the EU through the ERDF, project HAPPY PREGNANCY, no. 3.2.0701.12-004 (M.P., M.L.) and the Estonian Research Council: grants PUT181 (M.P.) and IUT34-12 (M.L.). The funders had no role in study design, data collection and analysis, decision to publish or preparation of the manuscript. We have no competing interests to declare. TRAIL  REGISTRATION NUMBER: Not applicable.

The Effect of a Unilateral Orchiectomy before Gonadotoxic Treatment on the Contralateral Testis in Adult and Prepubertal Rats

PURPOSE

Previous studies have shown that the removal of one testis leads to a compensatory mechanism in the contralateral one, but this was species and age dependent. The aim of this study was to check whether this compensation would still occur after the combination of a unilateral orchiectomy and gonadotoxic treatment, since this resembles the clinical situation of patients who have to undergo highly toxic cancer treatment and therefore choose to cryopreserve a testicular biopsy for fertility restoration purposes.

MATERIALS & METHODS

Sprague Dawley rats underwent either unilateral orchiectomy, gonadotoxic busulfan treatment, the combination of both or served as fertile control. A comparison of the compensatory effects was made between adult and prepubertal treated rats. Mating experiments were performed, testosterone levels were followed-up, testicular weight was recorded and histology was analysed.

RESULTS

Adult treated rats were able to restore fertility spontaneously in all treatment groups. On the other hand, 30% of the rats that underwent a unilateral orchiectomy and gonadotoxic treatment at prepubertal age showed hampered spermatogenesis, low testosterone levels, decreased testicular weights and were not able to reproduce.

CONCLUSION

This study emphasizes the need of fertility preservation strategies in prepubertal patients before gonadotoxic interventions.

Sonographic findings of typical and atypical scrotal trauma

This review article illustrates sonographic findings in the setting of accidental and nonaccidental scrotal trauma. Although sonographic findings may be irrespective of the type of trauma, the goals of sonographic evaluation are similar in both atypical and typical mechanisms of scrotal injury. Familiarity with findings such as disruption of testicular integrity or vascularity facilitates prompt diagnosis and plays a critical role in clinical management.

Influence of open testicular biopsy in prepubertal rats on rats' adulthood fertility with correlation to serum levels of inhibin B and follicle stimulating hormone

OBJECTIVE

Open testicular biopsy (OTB) is one of the options to accurately assess fertility potential of the undescended testis. The aim of the study was to investigate consequences of OTB in prepubertal rats on their adulthood fertility.

METHODS

Thirty-eight prepubertal male rats were divided into three groups depending on day 20 procedure. The first group was the control group, the second sham operated and the third has left OTB. Bilateral orchiectomy was performed on day 70 to all groups, with determination of serum inhibin B and follicle stimulating hormone (FSH). Removed testes were compared according to the weight, volume, spermatogenesis, histological and apoptotic changes in both testes with differences in serum levels of inhibin B and FSH.

RESULTS

Ipsilateral testicular weight, volume, and spermatogenesis reduction with a reduction of tubular number, diameter and germinative epithelium was found in OTB group. Significant increase in apoptotic index was found in biopsied testis without compensatory hypertrophy of contralateral testis. Differences of inhibin B and FSH were not statistically significant among three groups.

CONCLUSION

OTB in prepubertal rats has detrimental effects on fertility in adulthood. It does not cause compensatory hypertrophy of the contralateral testis nor does it disturb serum levels of inhibin B and FSH.

Hydroxyurea therapy contributes to infertility in adult men with sickle cell disease: a review

Hydroxyurea therapy, a chemotherapeutic agent, is the only US FDA approved therapy for the prevention of vaso-occlusive pain in sickle cell disease (SCD). The National Institutes of Health has sponsored two Phase III randomized, placebo-controlled trials, initially in adults, and subsequently in children with sickle cell anemia (SCA). Despite the overwhelming evidence that hydroxyurea therapy is beneficial to children and adults with SCA, individuals with SCA and their families express reservations about its use, in part because of the concerns about fertility, particularly in men. As adolescent boys with SCD are now expected to reach their reproductive years, a new concern is emerging about the role of hydroxyurea therapy as a barrier to their progeny. This review will systemically evaluate compromised fertility in men with SCD, and the evidence that hydroxyurea therapy is associated with further decreasing fertility in men with SCD.

Can ultrasound help to manage patients with scrotal trauma?

Traumatic injuries to the scrotum are uncommon but, when they do occur, frequently lead to serious complications. Early complications include testicular infarction, necrosis and abscess formation; in the longer-term trauma may result in testicular atrophy and subfertility. Early surgical intervention in patients with testicular rupture can significantly improve the clinical outcome and reduce the need for delayed orchidectomy. However, clinical examination of the scrotum following trauma is difficult and frequently inaccurate; this may result in incorrect triage of patients for surgical exploration. Scrotal ultrasound can reliably assess scrotal injuries and diagnose testicular rupture with a high level of accuracy. Additionally, ultrasound can provide important information regarding testicular perfusion, which can further inform decisions on surgical management. This article reviews the sonographic findings that may be encountered in patients with scrotal trauma, with an emphasis on blunt trauma. It describes the pivotal role that ultrasound can play in the accurate triage of these patients to surgical or conservative management.

Compartment syndrome of the testicle: a case report and review of the literature

In this case report we describe a patient presenting with symptoms of right sided testicular torsion who, upon surgical exploration, was noted to no longer have a torsion of the spermatic cord but persisted in having an ischaemic testicle refractory to reperfusion. A testicular compartment syndrome was suspected and the patient underwent fasciotomy of the tunica albuginea, leading to full reperfusion and good clinical outcome at three weeks and 10 months. This case raises the question of the value of performing such fasciotomies in patients who would otherwise undergo orchidectomy. Following a review of the literature, we feel the technique may well have a place in the management of torsion, pending further study.

Databases searched were Medline, Embase, Cochrane, Trip and NHS Evidence. Search criteria included ‘compartment’, ‘testicle’, ‘testicular’, ‘syndrome’, ‘compartment syndrome’ and testis’ and combinations of these key words.

Clinical characteristics and surgical outcomes of penetrating external genital injuries

BACKGROUND

Penetrating external genital injuries, although uncommon, may present complex problems for the urologic and trauma surgeon. A paucity of data exists on the incidence, clinical characteristics, and management outcomes of these injuries because few institutions have the volume to report their experience.

METHODS

Penetrating external genital trauma presenting from 2004 to 2011 was retrospectively reviewed. Patient characteristics, operative and nonoperative management, and outcomes were analyzed while validating current guidelines. Surgical management is described in detail, and overall incidence and trends were calculated.

RESULTS

A total of 28,459 trauma patients were reviewed, of which 8,076 sustained penetrating injuries and 162 sustained penetrating external genital trauma. Penetrating external genital trauma was 0.57% of all trauma and 2.0% among penetrating trauma. Gunshot wounds accounted for the most common mechanism of injury (93%). Injury to the scrotum occurred in 78% and of these injuries, 63% resulted in a testicular injury, with bilateral testicular injuries occurring in 8%. Testicular reconstruction was performed in 65%. Penile injuries occurred in 28%, and urethral injuries occurred in 13%. For penile injuries, 62% were explored immediately. Urethral injuries were managed by immediate primary urethral repair (43%) or urinary diversion with delayed reconstruction (57%). In total, nonoperative management was performed in 26% of scrotal and 38% of penile injuries. The incidence of penetrating external genital injuries has remained constant during our study period, averaging 20.2 cases per year (R(2) = 0.99). The testicular salvage rate varied from 55% to 75% per year (R(2) = 0.06).

CONCLUSION

Penetrating external genital injuries occur at an incidence of 0.57% where scrotal injury from gunshot wounds is the most common form. Testicular preservation is possible in the majority of testicular injuries. Penile injuries were less likely to require surgical exploration compared with scrotal injuries likely because physical examination is better at confirming only superficial injury. Select patients with superficial scrotal or penile injuries may undergo nonoperative management with minimal morbidity.

LEVEL OF EVIDENCE

Therapeutic study, level IV; epidemiologic study, level IV.

Male reproductive health after childhood, adolescent, and young adult cancers: a report from the Children's Oncology Group

The majority of children, adolescents, and young adults diagnosed with cancer will become long-term survivors. Although cancer therapy is associated with many adverse effects, one of the primary concerns of young male cancer survivors is reproductive health. Future fertility is often the focus of concern; however, it must be recognized that all aspects of male health, including pubertal development, testosterone production, and sexual function, can be impaired by cancer therapy. Although pretreatment strategies to preserve reproductive health have been beneficial to some male patients, many survivors remain at risk for long-term reproductive complications. Understanding risk factors and monitoring the reproductive health of young male survivors are important aspects of follow-up care. The Children's Oncology Group Long-Term Follow-Up Guidelines for Survivors of Childhood, Adolescent, and Young Adult Cancer (COG-LTFU Guidelines) were created by the COG to provide recommendations for follow-up care of survivors at risk for long-term complications. The male health task force of the COG-LTFU Guidelines, composed of pediatric oncologists, endocrinologists, nurse practitioners, a urologist, and a radiation oncologist, is responsible for updating the COG-LTFU Guidelines every 2 years based on literature review and expert consensus. This review summarizes current task force recommendations for the assessment and management of male reproductive complications after treatment for childhood, adolescent, and young adult cancers. Issues related to male health that are being investigated, but currently not included in the COG-LTFU Guidelines, are also discussed. Ongoing investigation will inform future COG-LTFU Guideline recommendations for follow-up care to improve health and quality of life for male survivors.

Management of testicular rupture after blunt trauma in children

PURPOSE

Testicular rupture is a very rare entity in children and adolescents. The aim of this study was to evaluate the outcomes of surgical repair after testicular rupture in children.

METHODS

Between January 2000 and January 2010 seven patients were operated on because of testicular rupture. Mean age at the time of the accident was 15 years. In all patients, an emergency scrotal ultrasonography showed a rupture of the testicular capsule with a surrounding hematocele. Surgical exploration was performed to evacuate the hematocele and repair the ruptured testis.

RESULTS

Mean follow-up was 4.9 years. Average hospital stay was 2 days. Mean time between surgery and the initial trauma was 35 h. There were no major complications. Control ultrasound imaging showed that the tunica was repaired and Doppler signal confirmed vascularity in all patients. There were no significant differences in size between the right and left testes. There were no recorded cases of testicular atrophy. Semen analysis showed normospermia 6 months after surgery and anti-sperm antibodies count was within normal limits in all patients.

CONCLUSION

Prompt surgical intervention is crucial. Ruptured testis can be salvaged, with a high success rate, if surgical repair is performed within 72 h of testicular injury.

Traumatisme du testicule chez l’enfant

Introduction

Les traumatismes du testicule sont rares chez l’enfant, et la littérature est très pauvre sur ce sujet. Le but était de les analyser à partir d’une étude multicentrique rétrospective.

Matériel et méthodes

Un questionnaire sur les traumatismes du testicule survenus entre 2000 et 2009 a été envoyé dans les différents centres de chirurgie pédiatrique français. L’analyse a été effectuée à l’aide du questionnaire et du compte rendu opératoire, et n’ont été retenus que les dossiers de traumatisme vrai du testicule, excluant les plaies simples du scrotum, les traumatismes « révélateurs » d’une torsion de testicule ou d’hydatide, ou encore les dossiers incomplets.

Résultats

Quinze centres ont bien voulu nous transmettre leurs observations et parmi ceux-ci, deux ont répondu n’avoir opéré aucun cas; cette étude n’est pas exhaustive, car beaucoup d’équipes ont envoyé des dossiers d’enfants opérés et aucun cas de traumatisme bénin. Parmi les 60 observations reçues, 45 ont été retenues. L’âge moyen était de 12,3 ans (2 jours–18 ans). Les circonstances du traumatisme étaient 23 coups (pied, genou, poing), 13 chutes (vélo, banc, luge), quatre accidents de la voie publique, quatre traumatismes de nature inconnue et un traumatisme obstétrical. Le traumatisme était fermé 41 fois et ouvert quatre fois. L’échographie-doppler couleur a été réalisée dans 34 cas sur 45 (75,5 %); un diagnostic exact a été possible 30 fois, alors qu’il y a eu trois faux-positifs (deux fractures du testicule et un hématome intratesticulaire non confirmés à l’intervention) et un faux-négatif (contusion de l’épididyme non vue à l’échographie). Les lésions testiculaires étaient les suivantes: 15 fractures, huit hématomes intratesticulaires, six contusions testiculaires bénignes (dont une associée à une tumeur), six hématomes du cordon, six contusions de l’épididyme, trois hématocèles isolées et une avulsion. Le traitement a été chirurgical 33 fois et non opératoire 12 fois. Parmi les 15 fractures du testicule, 13 ont été opérées (huit sutures et cinq orchidectomies partielles) et deux ont été surveillées avec de bons résultats, sans atrophie secondaire. Pour les hématomes intratesticulaires, trois ont été surveillés et cinq opérés. Seuls 20 enfants ont été suivis au-delà de quatre mois, essentiellement les fractures testiculaires, et aucune atrophie secondaire n’a été constatée.

Conclusion

Les traumatismes du testicule chez l’enfant sont rares, mais leur pronostic est plutôt bon. L’échographie-doppler permet désormais de faire un diagnostic précis dans un grand nombre de cas, devant permettre d’éviter certaines explorations chirurgicales systématiques; mais l’intervention reste indispensable en cas de doute.

Photoperiodic regulation of compensatory testicular hypertrophy in hamsters

In mammals, removal of one testis results in compensatory testicular hypertrophy (CTH) of the remaining gonad. Although CTH is ubiquitous among juveniles of many species, laboratory rats, laboratory mice, and humans unilaterally castrated in adulthood fail to display CTH. We documented CTH in pre- and postpubertally hemi-castrated Syrian and Siberian hamsters and tested whether day length affects CTH in juvenile and adult Siberian hamsters. Robust CTH was evident in long-day hemi-castrates of both species and was preceded by increased serum FSH concentrations in juvenile Siberian hamsters. In sharp contrast, CTH was undetectable in short-day hemi-castrated Siberian hamsters for several months and only made its appearance with the development of neuroendocrine refractoriness to short day lengths; serum FSH concentrations of juveniles also did not increase above sham-castrate values until the onset of refractoriness. Long-day hemi-castrated Siberian hamsters with hypertrophied testes underwent complete gonadal regression after transfer to short days, albeit at a reduced rate for the first 3 weeks of treatment. Blood testosterone concentrations of adult hamsters did not differ between long-day hemicastrates and sham-castrates 9-12 weeks after surgery. We conclude that CTH is suppressed by short day lengths in Siberian hamsters at all ages and stages of reproductive development; in short day lengths, but not long day lengths, the remaining testis produces sufficient negative feedback inhibition to restrain FSH hypersecretion and prevent CTH.

Traumatismes scrotaux : stratégie de prise en charge

Scrotal traumas are rare. Most are blunt traumas caused by a direct blow on the scrotum. The testicle is projected against the pubic arch. Early surgical investigation has considerably improved the prognosis of testicular trauma, and reduced orchidectomy rate. ULtrasonography has also improved the management of scrotal trauma. But there is a controversy about accuracy of ultrasonography in predicting presence or absence of testicular disruption. ULtrasonography should not challenge the dogma regarding systematic surgical investigation of hematocele and enlarged scrotum. Long term outcomes (testicular atrophy, infertility) may be more frequent as previously thought and should be detected.

Diagnosis and Management of Testicular Ruptures

Testicular ruptures are a common occurrence in scrotal trauma that can go undetected ifa thorough examination or scrotal ultrasonography is not performed. Timely operative exploration and reconstruction is the standard of care and leads to high testicular salvage rates with hormonal, reproductive, and cosmetic benefits for the patient.

The Metabolic Syndrome and Disturbances in Hormone Levels in Long-Term Survivors of Disseminated Testicular Cancer

Purpose

The metabolic syndrome may be an important risk factor for cardiovascular disease in long-term survivors of testicular cancer (TC). We investigated the associations between hormone levels and the metabolic syndrome in these men.

Patients and Methods

We included TC patients cured by orchidectomy and cisplatin-based chemotherapy, stage I TC patients after orchidectomy only, and healthy men of comparable age. Presence of the metabolic syndrome was determined using guidelines from the National Cholesterol Education Program Adult Treatment Panel III. Thyroid-stimulating hormone, follicle-stimulating hormone (FSH), inhibin B, luteinizing hormone (LH), total testosterone, sex-hormone–binding globulin, free testosterone, estradiol, dehydroepiandrosterone sulfate, and insulin-like growth factor 1 were determined in blood. Cortisol metabolite excretion was measured in urine.

Results

Eighty-six chemotherapy patients (median follow-up, 7 years) were compared with 44 stage I patients and 47 controls. LH and FSH were higher, and inhibin B and total and free testosterone were lower in chemotherapy patients than controls. Adrenal and thyroid hormone production were unaffected. Chemotherapy patients with the metabolic syndrome (n = 22; 26%) had a higher body mass index (BMI) pretreatment, a larger BMI increase during follow-up, lower total testosterone, and higher urinary cortisol metabolite excretion than those patients without the metabolic syndrome. BMI and insulin were associated with the metabolic syndrome, while total testosterone and urinary cortisol metabolite excretion were associated with BMI.

Conclusion

We found gonadal dysfunction, but normal adrenal and thyroid function. Through its association with BMI, testosterone may play a role in the development of the metabolic syndrome in long-term TC survivors.

Secondary IgA nephropathy presenting as nephrotic syndrome with glomerular crescentic changes and acute renal failure in a patient with autoimmune hepatitis

Patients with end-stage liver disease are prone to hemodynamic and immunologic renal injury, the latter at times manifesting as glomerulonephritis. Elevated serum immunoglobulin A (IgA) levels and mesangial IgG-IgA deposits are common in these patients, but are often clinically silent. We report a patient with autoimmune hepatitis and secondary IgA nephropathy (IgAN) who presented with nephrotic syndrome, acute renal failure (ARF), with 30% of the renal glomeruli having undergone crescentic change, and with IgA2 deposits in the glomerular mesangium. This article discusses secondary IgAN pathogenesis and its therapeutic management.

Gonadal hormones in long-term survivors 10 years after treatment for unilateral testicular cancer

OBJECTIVE

To investigate whether unilaterally orchiectomised testicular cancer survivors (TCSs) are more likely to display reduced Leydig cell function than healthy males.

METHODS

A national multi-centre survey of 1235 TCSs was performed in 1998-2000 (mean age: 44 years) treated between 1980 and 1994 (mean follow-up: 11 years). Serum hormone analyses were performed on 1183 TCSs, as 52 TCSs used androgen replacement (AR). TCSs were allocated to four treatment groups: Surgery only (251); Radiotherapy only (515); Chemotherapy 1, cisplatin </=850 mg (373); Chemotherapy 2, cisplatin >850 mg (96). The Controls were represented by 200 healthy blue-collar workers (mean age: 44 years). LH >12 IU/l and testosterone <8 nmol/l and the use of AR indicated hypogonadism.

RESULTS

Serum testosterone was similar in TCSs and Controls (16.9 vs.17.1 nmol/l), but TCSs had higher age-adjusted LH levels than the Controls (5.2 vs. 3.5 IU/l). LH increased with treatment intensity, but was elevated even in TCSs treated with surgery only. The age-adjusted odds ratio of hypogonadism was 3.8 (95%CI: 2.0-7.3) in TCSs, and increased with treatment intensity.

CONCLUSION

TCSs are at risk to develop pre-mature reduced Leydig cell function and hypogonadism. They may therefore be predisposed for the syndrome of androgen deficiency of aging males (ADAM).

Gonadal function in patients with testicular germ cell tumors

The gonadal function of 18 patients with testicular germ cell tumors was evaluated. Seminal parameters after orchiectomy were examined in 15 patients. Six of them were available for follow-up observation after 2 or 3 courses of adjuvant chemotherapy. Serum gonadal hormones before and after orchiectomy were evaluated in 7 patients (testosterone and PRL were not examined in one patient). Five of 15 (33.3%), 8 of 15 (53.3%), 13 of 15 (86.7%), 7 of 13 (53.8%), and 9 of 12 (75.0%) had abnormal values in seminal volume, sperm concentration, motility, morphology, and vitality, respectively. The sperm concentration gradually improved after chemotherapy following orchiectomy in 5 of 6 (83.3%) patients. In all the patients examined, serum levels of follicular stimulating hormone (FSH), luteinizing hormone (LH), and prolactin (PRL) increased after orchiectomy. Serum levels of testosterone increased in 4 patients, but decreased in 2 after orchiectomy. These findings suggest that several factors, including preexisting intrinsic defect and disturbance of the hypothalamus-pituitary-gonadal axis, are involved in the deterioration of gonadal function in patients with testicular germ cell tumors.

Effects of unilateral grade I testicular injury in rat

OBJECTIVES

The effect of unilateral blunt testicular trauma on subsequent testicular function is still debated. None of the experimental studies had the exact grading of testicular injury and evaluation of hormone status and hence this study was designed.

METHODS

Twenty male prepubertal (20 days old) Wistar rats were divided into two groups: group 1 (n = 10) underwent sham surgery; group 2 (n = 10) underwent blunt trauma to the right testis by a 5-g sterile weight dropped three times on the testis from a height of 10 cm. T(1)-weighted and T(2)-weighted magnetic resonance images were taken within 6 hours to confirm grade I injury. At 60 days of age, blood samples were obtained from each rat for follicle-stimulating hormone, luteinizing hormone, testosterone, and estradiol levels, and both testes of each rat were harvested separately for DNA flow cytometric analysis.

RESULTS

Group 2 rats had significantly reduced (P <0.001) haploid cell populations in both right and left testis compared with the corresponding testis of the group 1 rats. Within group 2, the right testis was significantly (P <0.001) more affected. Serum levels of testosterone were significantly lower (P <0.05) and follicle-stimulating hormone (P <0.01) and estradiol (P <0.05) levels were significantly higher in group 2 rats than in group 1 rats. However, the luteinizing hormone levels were not significantly different.

CONCLUSIONS

Grade I unilateral blunt testicular trauma in prepubertal rats significantly affected germ cell maturation in both ipsilateral and contralateral testis and altered the sex hormone profile.

Potential of MRI and 31P MRS in the evaluation of experimental testicular trauma

OBJECTIVES

To prognosticate and assess the metabolic status of germ cells of the testis after unilateral blunt testicular trauma using both magnetic resonance imaging (MRI) and magnetic resonance spectroscopy (MRS). MRI is a noninvasive technique suitable for evaluating testicular trauma, and MRS is useful in assessing the metabolic status of the testis.

METHODS

The right testis of 35 male prepubertal Wistar rats, aged 30 days, was explored through an inguinal incision. The rats were randomized into control (group 1, sham surgery, n = 10) and study (n = 25) groups. The study group received unilateral blunt testicular trauma to the right testis. T(1)- and T(2)-weighted proton MRI of the ipsilateral testis were taken 6 hours after sham surgery or injury, and the rats were stratified on the basis of the absence or presence of intratesticular hemorrhage on MRI into groups 2 (n = 14) and 3 (n = 11), respectively. At 60 days of age, the contralateral testis of each rat was evaluated by 31P MRS and histologic examination. Quantification of phosphomonoesters, phosphodiesters, phosphocreatine, and adenosine triphosphate (gamma, alpha, and beta) was done.

RESULTS

A statistically significant difference (P <0.05) in the phosphomonoester/adenosine triphosphate ratio, seminiferous tubular diameter, and Johnsen score of the contralateral testis was observed, indicating decreased testicular maturation of the contralateral testis in group 3 rats compared with groups 1 and 2.

CONCLUSIONS

MRI after testicular trauma helped to stratify the extent of injury as determined by the presence or absence of intratesticular hemorrhage with prognostic value; 31P MRS and histologic examination revealed that testicular trauma significantly affects the maturation of the contralateral testis.

The functional significance of FSH in spermatogenesis and the control of its secretion in male primates

The aim of this review is to provide an integrative analysis of the role of FSH in the control of testicular function in higher primates, including man. Attention is focused on the action of FSH during neonatal development, puberty, and adulthood. Whether FSH is the major determinant of the adult complement of Sertoli cells and whether FSH is obligatory for the initiation, maintenance, and restoration of spermatogenesis is evaluated. The mechanism whereby the circulating concentration of FSH regulates spermatogonial proliferation to dictate the sperm production rate under physiological conditions in the adult is discussed in detail. Inhibin B is the major component of the testicular negative feedback signal governing FSH beta gene expression and FSH secretion, and the evidence for this view is presented. The review concludes with the presentation of a model for the operation of the FSH-inhibin B feedback control system regulating sperm production postpubertally in monkey and man, and with speculation on issues of clinical interest.

High risk of infertility and long term gonadal damage in males treated with high dose cyclophosphamide for sarcoma during childhood

BACKGROUND

Therapy with alkylating agents, such as cyclophosphamide, can be associated with irreversible gonadal toxicity in male survivors of adult cancer. To the authors's knowledge the effect of high dose therapy with cyclophosphamide during childhood on adult testicular reproductive and endocrine function has not been established.

METHODS

Gonadal function was studied in 17 adult male survivors of childhood sarcomas treated with high dose pulse cyclophosphamide therapy as part of a VAC (vincristine, actinomycin, and cyclophosphamide) or Adria-VAC (doxorubicin, vincristine, actinomycin, and cyclophosphamide) chemotherapy regimen. Patients answered a questionnaire concerning sexual functioning and underwent a comprehensive physical examination, semen analysis, and hormonal evaluation.

RESULTS

Of the 17 males who underwent semen analysis, 10 (58.8%) had azoospermia, 5 (29.4%) had oligospermia, and only 2 (11.8%) were found to have a normal sperm count. All patients treated prior to the onset of puberty had an abnormal semen analysis. The 2 patients with normal sperm counts received the lowest doses of cyclophosphamide (< 7.5 g/m(2)). The baseline follicle-stimulating hormone level was elevated in only 10 of 14 patients with abnormal sperm counts (71.4%). Testosterone levels were normal in 15 of 16 patients (93.8%); however, the baseline luteinizing hormone (LH) level was elevated in 6 of 15 patients with normal testosterone levels (40%). Gonadotropin-releasing hormone-stimulated LH levels were > 3 times that of baseline in 13 of /14 patients (92.9%), suggesting some degree of Leydig cell insufficiency.

CONCLUSIONS

The results of the current study show a high risk of gonadal dysfunction in men exposed to cyclophosphamide during childhood as part of a VAC/Adria-VAC chemotherapy regimen. Exposure prior to puberty was not found to be protective, and the risk of infertility appeared to increase with higher doses of therapy. To the authors' knowledge the clinical significance of impaired Leydig cell function beginning at a young age is unknown and merits further study.

Fertility and sexual function following orchiectomy and 2 cycles of chemotherapy for stage I high risk nonseminomatous germ cell cancer

PURPOSE

We investigate fertility and sexual function in patients following orchiectomy and adjuvant cisplatin based chemotherapy for high risk, stage I nonseminomatous germ cell tumor of the testis.

MATERIALS AND METHODS

Between 1985 and 1994, 59 patients with stage I nonseminomatous germ cell tumor and poor prognostic factors were treated with 2 cycles of cisplatin, vinblastine and bleomycin, or bleomycin, etoposide and cisplatin after orchiectomy. At least 32 months following treatment all patients were contacted and asked to complete a questionnaire regarding fertility and sexual activity, and to volunteer for a semen and hormonal analysis.

RESULTS

Of the 59 patients 49 (83%) completed the questionnaire. Before chemotherapy 18 (37%) patients had fathered children, 6 (12%) were involuntarily childless and none had a major sexual dysfunction. After treatment 11 (22%) patients fathered children, and 5 (10%) were involuntarily childless, with 4 involuntarily childless before chemotherapy. There were no significant alterations in sexual function. Semen analysis in 27 patients was normal in 23, and revealed mild oligospermia in 2 and azoospermia in 2. In 18 patients with hormone analysis median values for luteinizing hormone and free testosterone were normal but median value for follicle-stimulating hormone was slightly increased.

CONCLUSIONS

Two cycles of cisplatin based adjuvant chemotherapy do not seem to affect adversely fertility or sexual activity.

Dynamics of the follicle-stimulating hormone (FSH)-inhibin B feedback loop and its role in regulating spermatogenesis in the adult male rhesus monkey (Macaca mulatta) as revealed by unilateral orchidectomy

The purpose of this study was to document the morphological changes in the seminiferous epithelium that underlie the compensatory testicular hypertrophy observed in response to unilateral orchidectomy (UO) in the adult rhesus monkey and to describe the concomitant response in the endocrine feedback loops controlling testicular function in this species. Adult male monkeys were implanted with indwelling venous catheters; seven animals were then subjected to UO (data are presented from six) and three to sham UO. Profiles of circulating concentrations of FSH, LH, testosterone (T), inhibin B, and pro-alpha-C were monitored in 12-h series of sequential blood samples collected before, on the day of UO (day 0), and on days 1, 2, 4, 8, 16, 32, and 42 or 43 after UO. In the UO monkeys, the remaining testis was taken on day 44. Sertoli and germ cells in the removed and remaining testes were counted and expressed either as number per testis or, in the case of the differentiated spermatogonia (B1, B2, B3, and B4), as number per cross-section of the seminiferous tubule. UO was associated with a marked increase in the number of all germ cells more mature than undifferentiated spermatogonia (Ap) in the remaining testis. Sertoli cell number, on the other hand, did not change, and it is therefore reasonable to propose that the primary locus of the spermatogenic compensation was the differentiated spermatogonia. The additional finding that the relationship between the number of Sertoli cells and total germ cells in the remaining testis became robust (r = 0.92; P < 0.01 vs. r = 0.44; P > 0.05 for the removed testis) indicated that in the monkey, spermatogenesis does not normally operate at its ceiling. The increased drive to the seminiferous tubule of the remaining testis is hypothesized to be mediated by the sustained increase in FSH secretion that was observed after UO, although a role for increased testicular T production cannot be excluded. The stimulus for increased FSH secretion was presumably provided by the abrupt, 50% decline in circulating inhibin B levels. Interestingly, inhibin B secretion by the remaining testis was not dramatically affected by UO, and therefore, the deficit in circulating levels of this hormone and thus the error signal to FSH secretion were maintained for the duration of the experiment. In contrast, the changes in circulating LH and T concentrations were only transient, and within 48 h of UO, these hormonal parameters had returned to control values. The mechanisms by which the remaining testis rapidly acquires the capacity to double T production in the face of an unchanging LH drive remains to be determined. The foregoing body of evidence suggests that sperm output by the monkey testis is regulated by the circulating concentration of FSH and that in physiological situations, FSH secretion is insufficient to stimulate spermatogenesis to its ceiling. The results also indicate that FSH secretion is controlled by a feedback system in which the feedforward arm (FSH-inhibin B) is less robust than the feedback loop (inhibin B-FSH). Thus, a decrease in the inhibin B feedback signal results in a sustained increase in FSH secretion that drives the testes toward their spermatogenic ceiling, which is presumably set by Sertoli cell number.