Familial persistent Müllerian duct syndrome

Persistent Müllerian duct syndrome: an update

Male sex differentiation is driven by two hormones, testosterone and anti-Müllerian hormone (AMH), responsible for regression of Müllerian ducts in male fetuses. Mutations inactivating AMH or AMH receptor type 2 (AMHR2) are responsible for persistent Müllerian duct syndrome (PMDS) in otherwise normally virilised 46,XY males. This review is based on published cases, including 157 personal ones. PMDS can present in one of three ways: bilateral cryptorchidism, unilateral cryptorchidism with contralateral hernia and transverse testicular ectopia. Abnormalities of male excretory ducts are frequent. Testicular malignant degeneration occurs in 33% of adults with PMDS. Cancer of Müllerian derivatives is less frequent. Fertility is rare but possible if at least one testis is scrotal and its excretory ducts are intact. Up to January 2019, 81 families with 65 different mutations of the AMH gene, mostly in exons 1, 2 and 5, have been identified. AMHR2 gene mutations comprising 64 different alleles have been discovered in 79 families. The most common mutation, a 27-bp deletion in the kinase domain, was found in 30 patients of mostly Northern European origin. In 12% of cases, no mutation of AMH or AMHR2 has been detected, suggesting a disruption of other pathways involved in Müllerian regression.

A rare case report of bilateral recurrent inguinal hernia due to persistent Müllerian duct syndrome treated by transabdominal preperitoneal repair

INTRODUCTION

Persistent Müllerian duct syndrome (PMDS) is a rare disease occurring in men with an otherwise completely normal phenotype, in which female internal sex organs are present, including a uterus, fallopian tubes, cervix, and vagina. We report a case of bilateral recurrent inguinal hernia due to PMDS treated by transabdominal preperitoneal repair (TAPP).

PATIENT CONCERNS

A 72-year-old male presented with a complaint of swelling on both sides of the groin. The patient had undergone bilateral inguinal hernia suture repair 50 years ago.

DIAGNOSIS

Bilateral recurrent inguinal hernia INTERVENTIONS:: TAPP was performed. There was a fibrous structure linking the left and right hernia orifice and a muscular structure in the hernia sac on the left. We noticed that the muscular structure was a vagina and fibrous structure was the salpinx, and we diagnosed the patient with PMDS. Supravaginal hysterectomy and right salpingectomy were performed. After that a preperitoneal mesh repair was performed for bilateral inguinal hernia.

OUTCOMES

Histologically, the diagnosis was confirmed as PMDS. The patient had an uneventful recovery.

CONCLUSION

This case is the first case of bilateral recurrent inguinal hernia due to PMDS managed by TAPP.

Persistent Mullerian Duct Syndrome: A Single-Center Experience

Context:

Persistent Mullerian duct syndrome (PMDS) is a rare disorder. It is a type of male pseudohermaphroditism, usually presenting as “Hernia Uteri Inguinalis”.

Aims:

This study aims to present our experience of PMDS, over a 7-year period.

Settings and Design:

Our center is a tertiary care facility, situated in Tamil Nadu, a southern state of India.

Subjects and Methods:

This is a retrospective study. The study period was from 2007 to 2015. Seven cases presented during that period. The difficulties in diagnosis, treatment options discussed, along with a review of literature are presented.

Results:

Seven cases of PMDS presented over 8 years. Only four were diagnosed preoperatively. Mullerian remnants were excised in five cases.

Conclusions:

PMDS is rare. Orchiopexy should be the goal of treatment.

Perspectives in Pediatric Pathology, Chapter 5. Gonadal Dysgenesis

One of the most challenging areas in pediatric testicular pathology is the appropriate understanding and pathological diagnosis of disorders of sexual development (DSD), and in particular, the issue of gonadal dysgenesis. Here we present the main concepts necessary for their understanding and appropriate classification, with extensive genetic correlations.

Robot-assisted laparoscopic hysterectomy, gonadal biopsy, and orchiopexies in an infant with persistent mullerian duct syndrome

An infant born with hypospadias and no palpable gonads was diagnosed with persistent mullerian duct syndrome (PMDS) based on history, physical examination, laboratory testing, and radiologic imaging. A robot-assisted laparoscopic hysterectomy, right gonadal biopsy, and bilateral orchiopexies were performed without incident. Final pathology confirmed the diagnosis of PMDS. To our knowledge, this is only the second report of PMDS managed through a robot-assisted laparoscopic approach.

Clinical biochemistry of dihydrotestosterone

Dihydrotestosterone (DHT) is the most potent natural androgen in humans. There has been an increasing interest in this androgen and its role in the development of primary and secondary sexual characteristics as well as its potential roles in diseases ranging from prostate and breast cancer to Alzheimer's disease. Despite the range of pathologies shown to involve DHT there is little evidence for measurement of serum DHT in the management of these diseases. In this review we describe the physiology of DHT production and action, summarize current concepts in the role of DHT in the pathogenesis of various disorders of sexual development, compare current methods for the measurement of DHT and conclude on the clinical utility of DHT measurement. The clinical indications for the measurement of DHT in serum are: investigation of 5α reductase deficiency in infants with ambiguous genitalia and palpable gonads; men with delayed puberty and/or undescended testes; and to confirm the presence of active testicular tissue. Investigation is aided by the use of human chorionic gonadotrophin stimulation. Due to paucity of published data on this procedure, it is important to follow guidelines prescribed by the laboratory performing the analysis to ensure accurate interpretation.

A single base pair mutation encoding a premature stop codon in the MIS type II receptor is responsible for canine persistent Müllerian duct syndrome

Müllerian inhibiting substance (MIS), a secreted glycoprotein in the transforming growth factor-beta family of growth factors, mediates regression of the Müllerian ducts during embryonic sex differentiation in males. In persistent Müllerian duct syndrome (PMDS), rather than undergoing involution, the Müllerian ducts persist in males, giving rise to the uterus, fallopian tubes, and upper vagina. Genetic defects in MIS or its receptor (MISRII) have been identified in patients with PMDS. The phenotype in the canine model of PMDS derived from the miniature schnauzer breed is strikingly similar to that of human patients. In this model, PMDS is inherited as a sex-limited autosomal recessive trait. Previous studies indicated that a defect in the MIS receptor or its downstream signaling pathway was likely to be causative of the canine syndrome. In this study, the canine PMDS phenotype and clinical sequelae are described in detail. Affected and unaffected members of this pedigree are genotyped, identifying a single base pair substitution in MISRII that introduces a stop codon in exon 3. The homozygous mutation terminates translation at 80 amino acids, eliminating much of the extracellular domain and the entire transmembrane and intracellular signaling domains. Findings in this model could enable insights to be garnered from correlation of detailed clinical descriptions with molecular defects, which are not otherwise possible in the human syndrome.

Persistent Mullerian duct syndrome with bilateral abdominal testis: surgical approach and review of the literature

OBJECTIVE

We present two cases of persistent Mullerian duct syndrome (PMDS) with bilateral intra-abdominal testes and review the world's literature with special attention to diagnosis and surgical management.

PATIENTS AND METHODS

Two consecutive cases of PMDS with bilateral intra-abdominal testes from our institution are presented with detailed descriptions of the presentation, physical examination, laboratory profiles, surgical findings, and treatment undertaken. Follow-up at 1 year postoperatively is included.

RESULTS

Bilateral orchiopexy was accomplished in both the cases. In one case this was possible after division of the persistent Mullerian structures in the midline to achieve testicular mobility. In a subsequent case, splitting of the Mullerian complex did not provide adequate mobilization and microvascular autotransplantation was performed with an excellent surgical outcome.

CONCLUSIONS

Bilateral intra-abdominal testes in the setting of persistent Mullerian duct syndrome are a rare entity and controversy remains as to the ideal surgical treatment. Our two cases represent the first reported examples of open single-stage bilateral orchiopexy with division of the Mullerian complex and preservation of the vas deferens (1-year-old boy) and microvascular autotransplantation (5-year-old boy).

Persistent Müllerian duct syndrome: a surgical approach

Laparoscopy revealed a left inguinal testis and a right abdominal testis. Surgery revealed uterus-like structures. The bilateral testes showed primitive testis without ovarian tissue. Physical examination showed a normal and an empty scrotum with a nonpalpable gonad. Chromosome analysis revealed 46,XY. Pathological findings demonstrated the immature testis and the immature uterus.

Persistence of Müllerian derivatives in males

The persistent müllerian duct syndrome is a rare, autosomal recessive disorder, characterized by the persistence of müllerian duct derivatives-uterus and fallopian tubes-in genetic males otherwise normally virilized. We have collected DNA from 69 families with this syndrome. In 45%, a mutation of the anti-müllerian hormone (AMH) gene was detected; 52% were homozygous. The level of circulating AMH was extremely low in the great majority of patients, even before puberty, when AMH levels are normally high. Single-strand conformation polymorphism (SSCP)-polymerase chain reaction (PCR) was a very effective screening method. In 39% of families, characterized by an AMH level normal for the age of the patient, a mutation of the type II receptor of AMH was detected by automatic sequencing, because SSCP-PCR was not very effective. Forty-eight percent of the mutations were homozygous. A 27-base-pair deletion in exon 10 was noted in 45% of the families. When this very common mutation is not taken into account, the proportion of recurrent mutations is 42% for the AMH gene and 33% for the AMH receptor type II gene. In 16% of families, no mutation of either the AMH or the AMH receptor gene was detectable; this group may correspond to mutations of unknown genes involved in AMH processing or in downstream AMH transduction.

Laparoscopic orchidopexy for persistent müllerian duct syndrome

Persistent müllerian duct syndrome, characterized by the presence of a uterus and fallopian tubes in a phenotypic male, frequently presents as undescended testis, either intra-abdominal or within a hernial sac. We report the first two postpubertal cases successfully managed by a one-stage laparoscopic-assisted orchidopexy. The first had one and the second had two intra-abdominal testes. All testes were brought to the scrotum after dividing the spermatic vessels while the collateral circulation was carefully preserved. The two cardinal therapeutic goals, intrascrotal placement of well-vascularized testes and normal hormonal function, were achieved. Laparoscopic surgical techniques for this condition are discussed.

Surgical management of persistent müllerian duct syndrome

OBJECTIVES

To describe the optimal surgical management of the testes and müllerian duct structures in patients with persistent müllerian duct syndrome.

METHODS

We performed a comprehensive Medline literature search regarding the surgical management of persistent müllerian duct syndrome and extracted information regarding the etiology, pathogenesis, and treatment of this disorder. We specifically assessed the risks of retained müllerian structures versus surgical excision of the infantile uterus and fallopian tubes. Using this information, we formulated a comprehensive strategy for the management of patients with persistent müllerian duct syndrome. An illustrative case is described.

RESULTS

No malignant degeneration of persistent müllerian structures has been reported. The risk of testicular neoplasia in persistent müllerian duct syndrome approximates the risk of neoplasia in other intra-abdominal gonads. Fertility has rarely been reported although virilization is unaffected. Surgical excision of the infantile uterus and fallopian tubes risks damage to vasa deferentia and the deferential blood supply to the testis.

CONCLUSIONS

Surgical excision of persistent müllerian duct structure may result in ischemic and/or traumatic damage to the vasa deferentia and testes. Optimal surgical management is orchiopexy leaving the uterus and fallopian tubes in situ. Meticulous proximal salpingectomy and hysterectomy is indicated only in patients whose müllerian structures limit intrascrotal placement of the tests. Orchiectomy is indicated for testes that cannot be mobilized to a palpable location.

Genetic analysis of the Müllerian-inhibiting substance signal transduction pathway in mammalian sexual differentiation

Müllerian-inhibiting substance (MIS) is a member of the transforming growth factor-beta (TGF-beta) gene family. MIS expression in males causes the regression of the Müllerian ducts, an essential process in male sexual differentiation. Recently, an MIS type II receptor gene has been isolated that is expressed during embryogenesis in mesenchymal cells adjacent to the Müllerian duct epithelium and in Sertoli and granulosa cells of the fetal and adult, male and female gonads, respectively. MIS receptor mutant males develop as internal pseudohermaphrodites, possessing a complete male reproductive tract and also a uterus and oviducts, a phenocopy of MIS ligand-deficient male mice. They express both MIS mRNA and protein, showing that ligand was present, but target organs were hormone-insensitive. All produce sperm, but the majority were infertile because the presence of their female reproductive organs blocks sperm transfer into females. Focal seminiferous tubule atrophy accompanied by Leydig cell hyperplasia was observed and began as early as 2 months of age. The phenotype of MIS ligand/MIS receptor double mutant males was indistinguishable from those of each single mutant. MIS receptor/alpha-inhibin double mutant males developed testicular stromal tumors and large fluid-filled uteri that were identical in phenotype to MIS ligand/alpha-inhibin double mutant males. These studies provide in vivo evidence that MIS is the only ligand of the MIS type II receptor, in contrast to the complexity of other TGF-beta gene family signaling pathways.

Persistent müllerian duct syndrome: report of a case with bilateral cryptorchidism

We report on persistent müllerian duct structures (vagina, uterus, fallopian tubes) in a phenotypically normal white, infertile man with bilateral cryptorchidism. The presence of müllerian structures has been shown during a laparotomy performed because of an accident. The clinical and radio-sonographic findings are presented.

Bilateral testicular carcinoma in situ in persistent müllerian duct syndrome: a case report and literature review

Bilateral testicular carcinoma in situ in a 17-year-old patient with persistent müllerian duct syndrome is reported. The pertinent literature is reviewed and the management of both testicular carcinoma in situ and persistent müllerian duct syndrome is discussed.

Surgical and genetic aspects of persistent müllerian duct syndrome

Persistent müllerian duct syndrome (PMDS) is characterized by the presence of a uterus, cervix, and fallopian tubes in an otherwise normally differentiated 46.XY male. During embryogenesis, regression of müllerian structures in normal males is mediated by antimüllerian hormone (AMH), also called müllerian inhibiting substance (MIS), produced by fetal Sertoli's cells. PMDS has been attributed to deficient AMH activity or to abnormalities in the AMH receptor. The authors report on two patients with PMDS in whom the abnormalities were discovered during surgery for inguinal hernia and cryptorchidism. During the initial operations in each case, testicular biopsies were obtained, and the gonads and müllerian elements were replaced in the pelvis. A second operative procedure, performed several months later, included proximal salpingectomies with dissection of the vasa deferentia on pedicles of myometrium. This permitted excision of the vestigial uterine corpus, leaving a tiny remnant of cervix with the vasa deferentia. The testes were further mobilized so that bilateral orchidopexies could be completed. In the first case, a molecular abnormality was present at position 377 of the first exon of the AMH gene. Thymine replaced cytosine, which altered a CGG arginine codon to a TGG tryptophan codon, rendering the AMH molecule unstable. The molecular abnormality in the first case differs from the first abnormality in AMH reported by Knebelmann et al, thus indicating heterogeneity in this condition. The molecular basis for deficient AMH activity in the second patient has not yet been defined. No molecular abnormalities were found in the exons of this patient's AMH gene.

Persistent müllerian duct syndrome

Persistent müllerian duct syndrome is a rare form of pseudohermaphroditism, in which well developed müllerian structures are present in an otherwise normal male, possibly resulting from absence of müllerian duct inhibiting factor. Two cases of the syndrome are presented. The diagnosis, as in most cases, was confirmed at herniorrhaphy or exploration for undescended testis.

Germ cell development in neonatal mouse testes in vitro requires müllerian inhibiting substance

To study the effect of müllerian inhibiting substance on testicular germ cell development, especially on gonocytes, whole testes (156) from newborn mice were cultured for 1 to 7 days in vitro. The synthetic medium contained either 10% fetal calf serum, which itself contains endogenous müllerian inhibiting substance, or transferrin, insulin and retinoic acid. Human recombinant müllerian inhibiting substance, rabbit antiserum against müllerian inhibiting substance and/or normal rabbit serum was added to some cultures. The cultured testes were fixed in Stieve's fixative and stained with hematoxylin and eosin, and the numbers and types of germ cells per tubule were counted under a light microscope. Preliminary studies showed that germ cell development in newborn mouse testes was similar in vitro to that observed in vivo, except for delay in vitro. Normal germ cell maturation from gonocytes to primary spermatocytes occurred in testes cultured with 10% fetal calf serum only (i), 10% fetal calf serum plus müllerian inhibiting substance plus anti-müllerian inhibiting substance antibody (ii), 10% fetal calf serum plus normal rabbit serum (iii) and transferrin, insulin and retinoic acid plus müllerian inhibiting substance (iv). Maturation from gonocytes to A-type spermatogonia was arrested in testes cultured with 10% fetal calf serum plus anti-müllerian inhibiting substance antibody (p < 0.01), transferrin, insulin and retinoic acid alone (p < 0.001) and transferrin, insulin and retinoic acid plus müllerian inhibiting substance plus anti-müllerian inhibiting substance antibody (p < 0.001). The results are consistent with the hypothesis that müllerian inhibiting substance may be involved in postnatal gonocyte development and suggest that it may be useful to treat infertility associated with undescended testes.

The persistent müllerian duct syndrome: a rare cause of cryptorchidism

The persistent Müllerian duct syndrome is characterized by the retention of Müllerian derivatives in patients otherwise normally virilized. Clinically, the persistence of uterus and tubes leads either to cryptorchidism or inguinal hernia, depending on whether or not the Müllerian derivatives can be mobilized during testicular descent. The condition is usually discovered at surgery, however preoperative sonography could allow the diagnosis to be made preoperatively. The molecular basis of the persistent Müllerian duct syndrome is heterogeneous, and is reflected by wide variations in the serum concentration of anti-Müllerian hormone. Some cases are apparently due to end-organ resistance, and are associated with normal serum levels of the hormone. Others, characterized by absent or low hormone concentrations, can be explained by mutations of the gene coding for anti-Müllerian hormone, which are distributed along the whole length of the coding region.

A Case of Simultaneous Bilateral Nonseminomatous Testicular Tumors in Persistent Müllerian Duct Syndrome

Persistent müllerian duct syndrome is characteristically associated with unilateral or bilateral cryptorchidism. Like other undescended testes, these gonads are at an increased risk of malignant transformation. We report a case of synchronous bilateral mixed germ cell tumors in the cryptorchid testes of a patient with the persistent müllerian duct syndrome.

Persistent müllerian duct syndrome with transverse testicular ectopia and spermatogenesis

Normal male sexual differentiation is dependent on at least 2 factors: 1) testosterone and 2) müllerian inhibiting factor. The absence of müllerian inhibiting factor is responsible for a rare form of male pseudohermaphroditism, the persistent müllerian duct syndrome or hernia uteri inguinale. Patients with this syndrome present with persistent müllerian structures and the syndrome may be associated with transverse testicular ectopia. Additionally, most patients have azoospermia. We report a case of persistent müllerian duct syndrome with transverse testicular ectopia in which sperm are documented in the ejaculate.

Serum levels of Mullerian inhibiting substance in boys with cryptorchidism

Serum levels of Mullerian inhibiting substance (MIS) were measured in boys with cryptorchidism (n = 104) and paired, age-matched controls (n = 104) using an enzyme immunoassay. Control MIS levels were high during the first year of life with a peak level at 4 to 12 months, subsequently diminishing with age. MIS levels in patients with undescended testes also declined with age, although a surge was not found in the first year. Mean MIS concentration of cryptorchid boys was significantly lower than controls (P less than .001). There was a significant reduction of the mean MIS level in children with bilateral cryptorchidism compared with those with unilateral undescended testis (P less than .05). These differences might support the hypothesis that MIS initiates transabdominal testicular descent. However, because most undescended testes are probably the result of anatomical or functional abnormalities during transinguinal testicular descent, differences in MIS levels more likely result from secondary testicular degeneration. In the future, MIS immunoassay should play an important role in the investigation of gonadal function in boys with various genital disorders, including cryptorchidism.

Persistent müllerian duct remnant in a newborn

Müllerian duct remnant in a newborn is a rare finding. The presented case illustrates well the ultrasonic and radiologic features of the entity.

Premature centromeric divisions and prominent telomeres in a patient with persistent mullerian duct syndrome

A 35-year-old, rare male pseudohermaphrodite with inguinal hernia, testis, fallopian tube and uterus, symptoms referrable to persistent Mullerian duct syndrome, is described. The patient has a 46,XY karyotype in 50% of metaphases, while the remaining metaphases show premature cnetromeric divisions and hypoploid counts.

Familial uterine hernia syndrome: report of an Arab family with four affected males

We report an Arab Bedouin family including four males with uterine hernia syndrome. All had a male chromosome constitution and phenotype, inguinal herniae, cryptochidism, and persistence of Müllerian derivatives. Histopathological studies confirmed the presence of both testicular tissue and Müllerian derivatives. The presence of two affected brothers and two affected maternal uncles suggests X-linked inheritance. Autosomal recessive determination with male sex limitation is also a possibility based on parental consanguinity in one sibship.

The undescended testis. Hormonal and surgical management

Cryptorchidism is the most common disorder of sexual differentiation in males, 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 10 to 40 times higher in men with cryptorchidism than in normal men and is highest in men who have had an intra-abdominal testis and in certain intersex conditions. Orchiopexy does not appear to lessen this risk. In clinical trials in the United States, hormonal therapy with hCG or GnRH has not been effective in causing testicular descent; therefore, orchiopexy remains standard treatment. However, hCG is recommended if the clinician suspects that a testis is retractile. Orchiopexy should be performed between 12 and 18 months of age to prevent the degenerative changes that are demonstrable by 2 years.

Neoseminal vesicle created from retained mullerian duct to preserve the vas in male infants

Patients with retained mullerian ducts who have a predominantly male phenotype must undergo removal of the mullerian structure in addition to preservation of male structures. Often the vas conjoins with the vaginal wall. Whereas formerly we divided the vas from the mullerian structures, we now attempt to preserve the vas to maintain as much testicular function as possible by creation of a neoseminal vesicle. This procedure can be done separately or can accompany hypospadias reconstruction.

Unusual dual genital duct remnants in true hermaphroditism

A case of true hermaphroditism is reported in which a 46,XY karyotype was associated with a testis and an ovotestis. The dual presence of a Fallopian tube and a vas deferens on the side of the ovotestis is documented as a previously unreported finding.

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.

Abnormal sexual differentiation and neoplasia

The prevalence of neoplasia is increased in individuals with certain disorders of sexual differentiation. Etiology and frequency of neoplasia vary with the particular disorder. In uncomplicated cryptorchidism, the testis is at least 10 times more likely to undergo neoplastic transformation than a normal scrotal testis. Neoplasia probably is a function of both testicular location (intraabdominal) and underlying dysgenetic structure. If cryptorchidism is unilateral, and if orchiopexy has not been performed prior to age 6-10 years, orchiectomy should be encouraged. In those forms of gonadal dysgenesis not associated with a Y chromosome (e.g., 45,X; 45,X/46,XX; 46,XX) there is no definite increase in neoplasia, suggesting that elevated gonadotropin levels per se are not carcinogenic. Gonadal tumors are found in at least 30% of individuals with XY gonadal dysgenesis and are particularly frequent (55%) in H-Y antigen-positive patients. These tumors are almost always gonadoblastomas or dysgerminomas. Similar tumors are found in 15%-20% of 45,X/46,XY individuals. In either situation the neoplastic transformation could be a) secondary to the existence of XY gonadal tissue in an inhospitable environment, or b) integrally related to that process--genetic or cytogenetic--producing the dysgenetic gonads. The risk of neoplasia is sufficiently high that most of these patients should be offered early gonadal extirpation. The prevalence of gonadal tumors is not increased in Klinefelter's syndrome, further indicating that gonadotropins are not carcinogenic per se. However, Klinefelter patients are 20 times more likely to develop a carcinoma of the breast than are 46,XY males. Extragonadal germ cell tumors also are more common. In female pseudohermaphrodites there is probably no increased risk of neoplasia, whereas, in true hermaphrodites neoplasia is unusual but does occur. Neoplasia occurs in patients with complete testicular feminization (complete androgen insensitivity) but rarely in those with incomplete testicular feminization/Reifenstein's syndrome, 5 alpha-reductase deficiency, anorchia, agonadia, or testosterone biosynthetic defects. In complete testicular feminization the risk of malignant tumors is small prior to age 25. After age 25, it is about 2%-5%. Orchiectomy is recommended after pubertal feminization.

Internal male pseudohermaphroditism in a 6 week old child

Here we describe a 6-week-old infant with internal male pseudo-hermaphroditism, detected during the repair of a left inguinoscrotal hernia. We advocate early orchidopexy during a first laparatomy and call attention to the risk of adhesions and subsequent complications if the gonads are replaced into the peritoneal cavity in advance of a precise histological and cytogenetic diagnosis.

Persistent müllerian structures in infertile male

Müllerian duct derivatives were identified in an infertile adult male patient who had long-standing azoospermia and was operated on for inguinal hernia. Persistent müllerian duct syndrome is reviewed, with special emphasis on the pathophysiologic and surgical considerations involved in the treatment of this abnormality.

Persistence of müllerian ducts in male rabbits passively immunized against bovine anti-müllerian hormone during fetal life

A female rabbit was immunized against purified bovine AMH and mated. Booster injections were given at Day 8 of pregnancy to ensure a high titer of anti-AMH antibodies at the time the rabbit fetal testis begins to produce AMH. In three consecutive litters, the immunized female produced a total of 12 males, 9 of which had persistent Müllerian duct derivatives. No other significant abnormalities were detected in these animals, which were compared to the offspring of a control saline-injected female. In particular, testicular morphology was normal in most animals, and serum FSH levels did not differ from controls. This experimental model lends no support to the hypothesis that AMH controls extra-Müllerian events of male sex differentiation, nor that of the existence of a regulatory mechanism for synthesis of AMH by Sertoli cells, but it does not definitely exclude these possibilities, inasmuch as our tentative conclusions are based upon study of only one immunized female.

[Hormonal principles in normal and pathologic somatic sexual development]

Normal sexual development is the consequence of three sequential interrelated processes: establishment of genetic, gonadal and somatic sex. It is the terminal phase of sexual differentiation--the translation of gonadal into somatic sex, which is governed by the presence or absence of both testosterone and Müllerian-inhibiting hormone and of dihydrotestosterone, which is formed in its respective target tissues. Thus, despite a testis, somatic male sexual differentiation will proceed to a normal male phenotype only if all three hormones are synthesized and act during a critical period of uterine development. Many clinically distinct syndromes are the results of abnormalities in the synthesis or action of the above-mentioned hormones; these syndromes are described in detail. In contrast to male somatic differentiation, female somatic development is independent of these hormones.

Mullerian inhibiting substance: a fetal hormone with surgical implications

Mullerian Inhibiting Substance (MIS) is secreted from the fetal (and postnatal) testis and is known to cause regression of the Mullerian ducts, the anlage of the fallopian tubes, uterus and upper vagina. It is a large glycoprotein hormone, the action of which appears to be modulated by sex steroids: mainly testosterone in mammals and oestrogen in birds. Recent evidence has raised the possibility that its action may be to diminish cell surface phosphorylation and thereby change the direction of differentiation of the Mullerian duct towards regression. Other suspected functions for MIS include control of testicular descent and inhibition of malignant tumours of the female genital tract.

Testicular tumor in patient with persistent müllerian duct syndrome

A case of a yolk-sac tumor associated with an intra-abdominal testis in a patient with persistent müllerian duct syndrome is presented.

Persistent Müllerian duct syndrome. Review and report of 3 cases

Three cases of persistent Müllerian duct syndrome are reported. All were phenotypically and karyotypically male but with persistent duct remnants. Problems encountered in management and surgery are discussed.

Intra-abdominal seminomas in persistent müllerian duct syndrome

A young adult with persistent müllerian duct syndrome presented with bilateral Stage III pure seminomas in intra-abdominal testes. Treatment modalities included bilateral orchiectomy, radiotherapy, laminectomy for spinal metastases, and chemotherapy. The literature on this rare condition is reviewed.

Male pseudohermaphroditism by persistent müllerian structures

We have studied 2 cases of nonfamilial male pseudohermaphroditism by persistent müllerian ducts. The first case, found in a fourteen-year-old male, can be described as the classic form of cryptorchism which resisted hormonal treatment and in which a rudimentary uterus with fallopian tubes and atrophic testicles were found at exploratory laparotomy. The second case was discovered in a thirty-nine-year-old man who had bilateral cryptorchism. He presented with an abdominal mass which was found to be a seminoma in the right intra-abdominal testicle, and a well-defined uterus with fallopian tubes and an atrophic left testicle were seen. Neither case presented phenotype disturbances. Both karyotypes were 46 XY. A total resection of the female sexual organs and testicles was performed in both patients, and the mass was removed in the second case. The tumoral degeneration of the intra-abdominal testicles in this syndrome is found in similar proportion to the simple cryptorchid testicles. Our second case is the tenth one of a testicular tumor in pseudohermaphroditism by persistent müllerian ducts to be reported in the literature.

Familial persistent müllerian duct syndrome

We found persistent müllerian duct structures in 2 phenotypically normal brothers who had undergone an operation for inguinal hernia. The older boy had transverse testicular ectopia and his younger brother had unilateral cryptorchidism. Bilateral orchiopexy was done with excision of the fallopian tubes, uterus and upper vagina. Histological examination showed normal testes in both patients. Since there is a risk of testicular malignancy in such patients, long-term followup is mandatory.