Pitfalls in using human chorionic gonadotropin stimulation test to diagnose anorchia

Surgical treatment of undescended testes

The mainstay of therapy for undescended testes is operative treatment within the first years of life in order to avoid ongoing testicular degenerative changes. The surgical therapy for the palpable undescended testis is orchiopexy and when the testis is non-palpable, a supplementary laparoscopic approach. Success of orchiopexy for inguinal testes has been >95% and for abdominal testes >85-90% in most series.

CONCLUSION

Operation within the first year of life is a safe therapy for undescended testes.

Lost and found testes: the importance of the hCG stimulation test and other testicular markers to confirm a surgical declaration of anorchia

BACKGROUND

In patients with impalpable testes,laparoscopy or open surgery is considered conclusive in establishing the absence of testicular tissue.

METHODS

Retrospective chart review.

RESULTS

Over a 22-year period, 4 out of 82 patients with a diagnosis of bilateral anorchia by laparoscopy or laparotomy had persistent testicular tissue suggested by endocrine evaluations. The clue to the presence of testicular tissue was: (1) a pubertal rise in plasma testosterone (2 patients); (2) the presence of possible Müllerian structures and of a detectable plasma anti-Müllerian hormone (1 patient), and (3) the fact that one of the gonads had not been seen at surgery (1 patient who still had a testosterone response to hCG postoperatively). Testes were localized by venography (3 patients) and laparotomy (1 patient).

CONCLUSION

A surgical diagnosis of bilateral anorchia needs to be confirmed by hCG stimulation, gonadotropin levels, or other markers of testicular function.

Pitfalls of conventional human chorionic gonadotropin stimulation test to detect hormonally functional cryptorchid testes in midchildhood

OBJECTIVE

To report two cases misdiagnosed as bilateral anorchism in midchildhood on the basis of multiple conventional human chorionic gonadotropin (HCG) stimulation tests and sonograms of the abdomen and pelvis.

METHODS

In two young male patients with cryptorchidism who were considered to have anorchism, we describe the findings on clinical examination, the testosterone levels before and after standard HCG stimulation testing, and sonographic findings during the midchildhood period. In both cases, as the children approached puberty the diagnosis was found to be incorrect.

RESULTS

Two boys, 8 and 91/2 years old, were seen in consultation in our Pediatric Endocrine Clinic with a presumed diagnosis of anorchism. In the first case, multiple conventional HCG stimulation tests were done. In the second case, a single stimulation test was performed during routine follow-up assessments. In both cases, testosterone levels before and after HCG stimulation were consistent with the diagnosis of absent functional testicular tissue. Sonograms of the abdomen and pelvis also failed to detect the testicles. Both patients were ultimately noted to be pubertal (at 14 1/2 and >13 1/2 years, respectively) and to have early pubertal testosterone levels. A testicle was detected in one patient by abdominal computed tomographic scan and in the other by palpation of the inguinal canal.

CONCLUSION

Conventional dosing and duration of the HCG stimulation test, as widely recommended in standard textbooks and in articles in the medical literature, may not elicit positive HCG-induced testosterone responses during midchildhood for detection of functional testicular tissue. During the midchildhood period, which is characterized by low gonadotropin, low sex steroid production, and a highly sensitive hypothalamic-pituitary-gonadal axis to feedback inhibition, a prolonged HCG stimulation test-perhaps of 4 to 6 weeks' duration-may be necessary. In addition, other investigational modalities may need to be used to detect the presence of functional testicular tissue during this developmental period.

Orchiopexy for impalpable testis: high spermatic vessel division is a safe maneuver

PURPOSE

This review was performed to assess the effect of protecting the collateral circulation between spermatic and vasal vessels by leaving a strip of peritoneum attached to the lower spermatic cord in patients in whom the spermatic vessels needed to be divided to bring the testis into good scrotal position.

MATERIALS AND METHODS

Between 1983 and 1994, 22 boys were encountered in whom 1 testis was always normal in size and position, and the other was intra-abdominal and would not be in normal scrotal position after complete cord straightening. A strip of peritoneum had been left attached to the spermatic cord before full mobilization. After high division of the spermatic vessels the testes were brought in the mid scrotum during the same operation.

RESULTS

All testes remained in scrotal position except 1 which retracted and was subsequently removed. None became atrophic.

CONCLUSIONS

Division of the spermatic vessels, the Fowler-Stephens maneuver, can safely be performed during an initial operation as long as its possible need is anticipated, and the collateral circulation between the vasal vessels and spermatics is not disrupted. Secondary orchiopexy for inadequate cord length is now rarely required. This type of open orchiopexy for high impalpable testis is safe, is easy to learn, has no increased morbidity and is generally less expensive than a laparoscopic approach.

Current Diagnostic Possibilities in Cryptorchidism

From a review of Literature on the subject, the Authors have followed developments in diagnosing cryptorchidism. The objective examination is still fundamental, but nowadays ultrasound, NMR, CT, phlebography and laparoscopy can be used. Surgical exploration remains a valid method for completing the above examinations.

The use of the hCG stimulation test in the endocrine evaluation of cryptorchidism

OBJECTIVE

To review retrospectively the value of the human chorionic gonadotrophin (hCG) test in the evaluation of prepubertal boys with bilateral impalpable testes.

SUBJECTS AND METHODS

The study comprised 31 boys investigated between 1974 and 1990 at the Hospital for Sick Children, London. All boys had an hCG test consisting of three intramuscular injections of hCG on successive days at a daily dose dependent on their age (< 1 year old, 500 units; 1-10 years, 1000 units; > 10 years, 1500 units). Blood samples were taken before the first dose and 24 h after the last dose and the level of plasma testosterone assessed and expressed as a pre/post ratio.

RESULTS

Eight boys had no response to hCG, due to anorchia. One boy had no response to hCG but had bilateral atrophic intra-abdominal testes. Twenty-two boys responded to hCG and had testes whose size was related to the degree of testosterone elevation after this stimulatory test. The hCG test therefore had a positive predictive value of 89% and a negative predictive value of 100%. There was a quantitative difference in testosterone response between 14 boys who had bilateral intra-abdominal testes of 'normal' volume (median pre/post ratio, 11.4) and nine boys who had an otherwise reduced volume of testes (dysplastic or unilateral intra-abdominal) (median pre/post ratio of 4; P = 0.02).

CONCLUSION

The hCG test is a valid indicator of the presence of functioning testicular tissue. It is predictive of anorchia and a good response to hCG suggests the presence of testes sufficiently large for orchidopexy.

Laparoscopy in 100 consecutive patients with 128 impalpable testes

OBJECTIVE

To investigate the value of laparoscopy in boys with impalpable testes, to carry out a histological examination of testicular biopsies or orchidectomy specimens, and to present a clinical description of boys with impalpable testes.

PATIENTS AND METHODS

One hundred consecutive patients underwent laparoscopy for 128 impalpable testes. They ranged in age from 2.7 to 19.3 years (median 10.8). Histological examination was performed on 39 testicular biopsies, nine primarily orchidectomized testes and 13 tissue samples from the end of blind-ending vessels and vasa deferentia. Any additional diagnoses to that of impalpable testes were recorded.

RESULTS

There were no complications associated with laparoscopy and the procedure clarified the situation in all patients. In 50% of patients either blind-ending cord structures above the internal inguinal ring or intra-abdominal testes were identified; in the remainder, cord structures could be seen passing through the ring, indicating an intracanalicular testis. The impalpable testis was absent in 77% of patients with a contralateral scrotal testis. A seminoma was found in one 18.6-year-old patient with bilateral cryptorchidism. No intratubular germ cell neoplasia (carcinoma in situ) was found. Germ cell hypoplasia or aplasia was demonstrated in 95% of patients with testicular parenchyma. Additional diagnoses were made in 49% of patients with bilaterally undescended testes (one or both of which were impalpable).

CONCLUSION

We recommend laparoscopy as a safe procedure which leads to a diagnosis in patients with impalpable testes; the advent of laparoscopic procedures makes definitive treatment possible in about 50% of such patients. Open procedures will be indicated only to ascertain the quality and treatment of intracanalicular testes.

Laparoscopic assessment and orchidectomy for the undescended testis

Cryptorchidism is the most common disorder of male sexual differentiation. Pre-operative assessment and localization of undescended testes by various investigatory modalities have been of limited clinical value. The recent use of diagnostic and therapeutic laparoscopy for undescended testis peri-operatively has been shown to be safe and informative in the planning of appropriate surgical management. The authors' initial experience with this procedure, for five patients with unilateral undescended testis, is presented.

The nonpalpable testis and the changing role of laparoscopy

OBJECTIVE

To show the reliability of laparoscopic procedures in case of cryptorchidism. It also shows the growing possibilities of laparoscopic manipulations of the cryptorchid testis obviating in a great percentage the need for open operative procedures.

METHODS

Starting from the standard diagnostic laparoscopic procedure we gradually extended its use to a full operative procedure. The standard procedure is extensively elucidated in the way we used it in sixty-one laparoscopic procedures for seventy-four non-palpable testes.

RESULTS

All laparoscopies were technically successful. Forty testes (60.3%) were found intra-abdominally. Four testes (5.5%) were found lying in the inguinal canal or in an ectopic position. Twenty-five testes were absent. The diagnosis of a vanishing testis could be established in most of these cases. In the beginning period the following open procedures were done after the diagnostic laparoscopy: sixteen open explorations, ten formal standard orchidopexies; nine orchiectomies, nine autotransplantations, and three Fowler-Stephens procedures. In recent years we proceeded with laparoscopic manipulation, performing eleven laparoscopically assisted orchidopexy procedures (LAOPs), six extended laparoscopic explorations, and two laparoscopic orchiectomies.

CONCLUSIONS

Laparoscopy is not only a safe and reliable method in diagnosing the presence of a nonpalpable testis, but also thanks to more sophisticated instruments allows us more and more to perform the complete treatment. It can facilitate the placement of surgical incisions or obviate the need for further open intervention if no spermatic vessels are visualized in the abdomen.

Bilateral undescended testes

The management of boys with undescended testes appears to be an increasingly common problem. While Scorer (1964) [11] reported an incidence of 0.8% of undescended testes in boys of one year of age, a recent survey (Radcliffe Hospital, Oxford, 1986) [18] suggests the incidence has risen to as high as 1.6%. While the etiology may be varied, it is quite clear that many cases represent disturbances of the hypothalamic-pituitary-gonadal axis and may represent a forme fruste of hypogonadotropic hypogonadism [3]. Bilateral undescended testes might logically appear to represent the worst end of such an endocrinopathy. Indeed, a review of the experience at The Children's Hospital of Philadelphia [12] of boys with bilateral undescended testes indicated a greater number of CNS abnormalities (P = 0.0000) than in boys with unilateral undescended testes (Table 1). Also consistent with bilateral cryptorchid testes representing the most severe end of the spectrum was the reported findings from that study that bilateral undescended testes also exhibit a significantly greater number of associated G-U anomalies (P = 0.0004).

Ontogeny of gonadotropin secretion in congenital anorchism: sexual dimorphism versus syndrome of gonadal dysgenesis and diagnostic considerations

The hormonal characteristics of anorchism are elevated basal levels of gonadotropins, especially follicle-stimulating hormone and a low concentration of plasma testosterone that fails to increase after the administration of human chorionic gonadotropin. However, little is known about the dynamics of plasma gonadotropin secretion in infants and children with anorchism. We analyzed plasma gonadotropin concentrations and their responses to luteinizing hormone releasing factor, along with plasma testosterone responses to human chorionic gonadotropin, in 9 children with surgically proved bilateral anorchism. Basal concentrations of gonadotropins, especially plasma follicle-stimulating hormone, are elevated above normal during the first 3 to 4 years of life, decrease gradually to normal prepubertal levels and then increase again after age 9 years. This age-dependent diphasic pattern of gonadotropin secretion is comparable to that described previously in patients with the syndrome of gonadal dysgenesis and it is consistent with steroid-independent central nervous system inhibition of pulsatile luteinizing hormone releasing factor secretion during mid childhood. Moreover, a sex difference in follicle-stimulating hormone and luteinizing hormone values was observed; the mean follicle-stimulating hormone and luteinizing hormone concentrations in anorchid boys less than 3 years old were lower than in patients with Turner's syndrome. We suggest that this sex dichotomy is a consequence, at least in part, of the actions of testosterone derived from the fetal testis on the fetal hypothalamus. Luteinizing hormone releasing factor administration to anorchid male subjects resulted in an age-dependent augmented release of gonadotropin, particularly follicle-stimulating hormone. This study emphasizes that the age of the patient must be considered when interpreting basal gonadotropin levels. We also propose that in mid childhood the luteinizing hormone releasing factor test in conjunction with the human chorionic gonadotropin stimulation test is a more accurate hormonal indicator of patients with congenital anorchism than either the human chorionic gonadotropin test or basal gonadotropin concentrations.

Cryptorchidism: isolated and associated with other genitourinary defects

Cryptorchidism is the most common disorder of sexual differentiation in male children, with an incidence of 3.4 per cent in the term newborn, decreasing to 0.8 per cent at 1 year of age. The mechanisms of normal testicular descent are multifactorial and include an intact hypothalamic-pituitary-testicular axis, as well as a normal gubernaculum and epididymis. In boys with cryptorchidism, the testes demonstrate degenerative changes histologically as early as 1 to 2 years of age. Both testes may be affected, even with a unilateral undescended testis. The most important long-term complications of cryptorchidism include infertility and testicular cancer. The risk of malignancy is approximately 40 times higher in male subjects with cryptorchidism than in normal men, and is highest in male subjects who have had an intra-abdominal testis and in certain intersex conditions. Orchiopexy does not appear to lessen this risk. Hormonal therapy with HCG or LH-RH has remained unproven in clinical trials in the United States; therefore, orchiopexy remains standard treatment. HCG is recommended if the clinician suspects that a testis is retractile, however. Orchiopexy should be performed between 12 and 18 months of age to prevent the degenerative changes that are demonstrable by 2 years.

The assessment of diminished testicular function in boys of pubertal age

Nine boys with anorchia and 9 individuals with diminished testicular function were followed between ages 10 and 18 with serial determinations of urine gonadotrophins and serum testosterone. Ten hCG stimulation tests were performed in eight of these patients. Adult levels of LH (greater than 500 mIU/h) and low measurements of serum testosterone (less than 54 ng/dl) confirmed the anorchic state. Boys with diminished testicular reserve exhibited urinary gonadotrophin changes similar to peripubertal anorchic patients but testosterone levels increased progressively with age (90-715 ng/dl). FSH attained adult castrate levels (greater than 1700 mIU/h) by age 13 in these boys and served to distinguish them from normal controls. The longitudinal assessment of basal hormone levels can separate anorchia from diminished testicular reserve in boys of pubertal age and testing with hCG is not required for evaluation.

Elevation of serum gonadotropins establishes the diagnosis of anorchism in prepubertal boys with bilateral cryptorchidism

Of more than 500 boys with bilateral cryptorchidism who presented during a 10-year period 28 prepubertal patients less than 11 years old who had no palpable testes after human chorionic gonadotropin therapy were studied to assess the ability of serum gonadotropin levels to identify patients with anorchism. Of the boys 21 had a normal testosterone response to human chorionic gonadotropin therapy and all of them had testes at exploration. The serum luteinizing hormone levels ranged from 2 to 6 mIU per ml., with a mean of 3.7 mIU per ml., and the serum follicle-stimulating hormone levels ranged from 1.6 to 6.2 mIU per ml., with a mean of 3.7 mIU per ml. Seven patients showed no testosterone response to human chorionic gonadotropin and all but 1 underwent exploration, at which time no testes were found. Of these 7 patients 6 had elevated gonadotropin levels that averaged 3 standard deviations above the mean. For comparison, 2 pubertal patients with nonpalpable gonads and 3 castrated prepubertal boys also were studied. From the study we concluded that in boys with nonpalpable gonads 1) abnormally elevated serum gonadotropin levels before puberty are indicative of anorchism, 2) neither exploration nor human chorionic gonadotropin stimulation tests are essential for diagnosis in these select patients, 3) serum gonadotropin levels alone are not sufficient for a definitive diagnosis after puberty and 4) all boys with normal serum gonadotropin levels must undergo exploration regardless of the outcome of a human chorionic gonadotropin stimulation test.

Preoperative laparoscopic localization of the nonpalpable testis

Laparoscopic examination was performed successfully on 14 patients with 17 nonpalpable testes. The procedure was successful in determining the location in 16 of 17 nonpalpable testes, and this information was beneficial for selecting the subsequent operative approach. Laparoscopy was safe in the younger child (10 patients were 3 years old or less and 7 patients were less than 2 years old), and it added an insignificant increase in operative time.

Familial functional anorchism: a review of etiology and management

Identical male twins with small penes and bilateral unpalpable gonads were unresponsive to human chorionic gonadotropin stimulation. Both infants had elevated levels of gonadotropins. The size of the penis did not meet fully the criteria for micropenis and the organ was responsive to testosterone therapy. The use of primary human chorionic gonadotropin stimulation followed by testosterone measurements is indicated for children with cryptorchidism in whom the etiology of micropenis is in doubt. We report the first observation of anorchism in identical twins.