Cryptorchidism associated with meningomyelocele

[Guidelines on the urological management of the adult patient with spinal dysraphism (spina bifida)]

INTRODUCTION

Improved life expectancy and prenatal screening have changed the demographics of spina bifida (spinal dysraphism) which has presently become a disease of adulthood. Urinary disorders affect almost all patients with spinal dysraphism and are still the leading cause of mortality in these patients. The aim of this work was to establish recommendations for urological management that take into account the specificities of the spina bifida population.

MATERIALS AND METHODS

National Diagnosis and Management Guidelines (PNDS) were drafted within the framework of the French Rare Diseases Plan at the initiative of the Centre de Référence Maladies Rares Spina Bifida - Dysraphismes of Rennes University Hospital. It is a collaborative work involving experts from different specialties, mainly urologists and rehabilitation physicians. We conducted a systematic search of the literature in French and English in the various fields covered by these recommendations in the MEDLINE database. In accordance with the methodology recommended by the authorities (Guide_methodologique_pnds.pdf, 2006), proposed recommendations were drafted on the basis of this literature review and then submitted to a review group until a consensus was reached.

RESULTS

Bladder dysfunctions induced by spinal dysraphism are multiple and varied and evolve over time. Management must be individually adapted and take into account all the patient's problems, and is therefore necessarily multi-disciplinary. Self-catheterisation is the appropriate micturition method for more than half of the patients and must sometimes be combined with treatments aimed at suppressing any neurogenic detrusor overactivity (NDO) or compliance alteration (anticholinergics, intra-detrusor botulinum toxin). Resort to surgery is sometimes necessary either after failure of non-invasive treatments (e.g. bladder augmentation in case of NDO resistant to pharmacological treatment), or as a first line treatment in the absence of other non-invasive alternatives (e.g. aponeurotic suburethral tape or artificial urinary sphincter for sphincter insufficiency; urinary diversion by ileal conduit if self-catheterisation is impossible).

CONCLUSION

Spinal dysraphism is a complex pathology with multiple neurological, orthopedic, gastrointestinal and urological involvement. The management of bladder and bowel dysfunctions must continue throughout the life of these patients and must be integrated into a multidisciplinary context.

Do prune-belly syndrome and neural tube defects change testicular growth? A study on human fetuses

BACKGROUND

There are no reports comparing testicular volume between normal fetuses, fetuses with prune-belly syndrome (PBS), and fetuses with anencephaly. The study hypothesis was that PBS and especially anencephaly alter the testicular volume during the human fetal period.

AIM

The objective of the study was to compare the testicular growth in fetuses with anencephaly, with PBS, and without anomalies.

STUDY DESIGN

This is a morphometric study of human fetuses. Seventy testes from fetuses without anomalies aged 11-22 weeks post-conception (WPC), 30 testes from fetuses with anencephaly aged 13-19 WPC, and eight testes from fetuses with PBS aged 13-16 WPC were studied. Testicular length, width, and thickness were evaluated with the aid of computer programs (Image Pro and ImageJ) (Figure). The fetal testicular volume was calculated using the ellipsoid formula: Testicular volume (TV) = [length × thickness × width] × 0.523. The Shapiro-Wilk test was used to ascertain the normality of the data and to compare quantitative data between normal fetuses vs. fetuses with anencephaly, while the Kruskal-Wallis test was used to assess gender and laterality differences. Simple linear correlations (LCs) were calculated for testicular volume according to fetal age, weight, and crown-rump length.

RESULTS

All 108 testes studied were abdominal. The right (p = 0.0310) and left (0.0470) testicular volumes were significantly smaller in fetuses with anencephaly than those in the control group. The linear regression analysis indicated that the right and the left testis volume in the control group (right: r² = 0.6665; left: r² = 0.6707) and PBS group (right: r² = 0.9937; left: r² = 0.9757) increased with fetal age (p < 0.0001). This analysis also indicated that the testicular volume in fetuses with anencephaly did not increase with fetal age (right: r² = 009816; left: r² = 0.07643).

DISCUSSION

This article is the first to report testicular volume correlations with fetal parameters in fetuses with anencephalic and fetuses with PBS. Significant alterations were observed in testicular growth in the anencephalic group compared with the control group, and it was also observed that the bilateral cryptorchidism in PBS does not alter the testicular development and growth during the fetal period. The unequal WPC distribution between fetuses with PBS, fetuses with anencephaly, and controls and the small sample size are limitations of this study. Further studies should be performed to confirm this study's findings.

CONCLUSIONS

Testicular growth is slower and does not show significant correlations with fetal parameters in fetuses with anencephalic. Significant differences in testicular development in fetuses with PBS was not observed.

Sexual dysfunction and infertility in the male spina bifida patient

Spina bifida is a congenital neural tube defect with many neurological implications, as well as decreased sexual function and infertility. Few studies have directly investigated infertility in men with spina bifida. Infertility in this special patient population is primarily the result of spermatogenic defects and/or failure of sperm transport due to erectile or ejaculatory dysfunction. The severity of sexual and reproductive dysfunction seems to correlate with higher level of spina cord lesion and presence of hydrocephalus. Phosphodiesterase 5 inhibitors (PDE5is) have been shown to be effective for erectile dysfunction in some men with spina bifida. Surgical sperm retrieval from the genitourinary tract and rectal probe electroejaculation can serve as methods for collecting sperm from those with ejaculatory dysfunction or retrograde ejaculation. Assisted reproductive technology such as intracytoplasmic sperm injection allows isolated sperm from men with infertility to achieve fertilization. Since most spina bifida patients are surviving into adolescence and adulthood due to improved medical and surgical advancements, it is paramount for healthcare professionals to address issues related their sexual and reproductive function.

Spina Bifida Health-care Guidelines for Men's Health

Spina bifida has traditionally been regarded as a pediatric health issue with little regard to adult consequences of the disorder. The congenital neurologic and urologic anomalies, as well as sequelae of bladder management, can have a profound impact on adult male sexual function. Abnormalities in testicular descent, development, and function; fertility; penile sensation; erectile function; ejaculatory function; and orgasmic function are common. Prostate cancer has been diagnosed in men with spina bifida, but little data are available to guide screening, diagnosis, and treatment efforts. The Spina Bifida Association has supported development of guidelines for health care providers to address male health issues in individuals with spina bifida throughout their lives.

Anorectal malformations associated spinal cord anomalies

PURPOSE

The present study aims to identify clinical and pathological factors that can predict the risk of spinal cord anomalies (SCA) in patients with anorectal malformations (ARM), the need for neurosurgery, and to define the impact of SCA on the outcome of patients with ARM.

METHODS

A 16-year retrospective analysis of all patients treated at a single tertiary children's Hospital with diagnosis of ARM. Data were collected to assess the impact of defined clinical characteristics on prevalence of SCA (detected at MRI). Children surgically treated or not for SCA were compared for age, clinical symptoms and type of anomalies at surgery or at last follow-up, respectively. Moreover, patients with intermediate/high ARMs, with or without SCA were compared for neurogenic bladder (NB), constipation, soiling and need for bowel management (BM).

RESULTS

Two hundred and seventy-five children were treated for ARM in the study period, 142 had spinal MRI that showed SCA in 85. Patients with SCA had significantly higher prevalence of preterm birth (p < 0.05), cardiac anomalies (p = 0.02), vertebral anomalies (p = 0.0075), abnormal sacrum (p < 0.0001), and VACTERL association (p = 0.0233). Ten patients were surgically treated for SCA. The prevalence of neurological bladder and neuro-motor deficits, of vertebral and genital anomalies, particularly cryptorchidism, was significantly higher in the operated group (p < 0.01, for each analysis). In patients with intermediate/high ARMs, no significant difference was observed between those with or without SCA, in terms of prevalence of NB, intestinal function and need for BM.

CONCLUSIONS

In patients with ARM, factors that can predict a higher prevalence of SCA and also determine an increased indication to neurosurgery may be identified. SCA by itself does not seem to affect the functional prognosis of children with intermediate/high ARM. These data may help physicians in stratifying the clinical and diagnostic pathway of patients with ARM.

Cryptorchidism in the orl rat is associated with muscle patterning defects in the fetal gubernaculum and altered hormonal signaling

Cryptorchidism, or undescended testis, is a common male genital anomaly of unclear etiology. Hormonal stimulation of the developing fetal gubernaculum by testicular androgens and insulin-like 3 (INSL3) is required for testicular descent. In studies of the orl fetal rat, one of several reported strains with inherited cryptorchidism, we studied hormone levels, gene expression in intact and hormone-stimulated gubernaculum, and imaging of the developing cremaster muscle facilitated by a tissue clearing protocol to further characterize development of the orl gubernaculum. Abnormal localization of the inverted gubernaculum was visible soon after birth. In the orl fetus, testicular testosterone, gubernacular androgen-responsive transcript levels, and muscle-specific gene expression were reduced. However, the in vitro transcriptional response of the orl gubernaculum to androgen was largely comparable to wild type (wt). In contrast, increases in serum INSL3, gubernacular INSL3-responsive transcript levels, expression of the INSL3 receptor, Rxfp2, and the response of the orl gubernaculum to INSL3 in vitro all suggest enhanced activation of INSL3/RXFP2 signaling in the orl rat. However, DNA sequence analysis did not identify functional variants in orl Insl3. Finally, combined analysis of the present and previous studies of the orl transcriptome confirmed altered expression of muscle and cellular motility genes, and whole mount imaging revealed aberrant muscle pattern formation in the orl fetal gubernaculum. The nature and prevalence of developmental muscle defects in the orl gubernaculum are consistent with the cryptorchid phenotype in this strain. These data suggest impaired androgen and enhanced INSL3 signaling in the orl fetus accompanied by defective cremaster muscle development.

[Follow-up of adult patients with myelomeningocele]

The adult outcome of spina bifida patients is fraught with multiple problems reflecting the multisystemic nature of the disease. These problems result in both mortality, actually caused in most cases by the shunt, and morbidity, mostly affecting locomotion and sphincter control. These patients can thus lose ambulation and suffer from worsening incontinence and kidney function. The result in the vast majority of cases is a poor functional and socioprofessional outcome. The patients' demands regarding their occupational and affective lives, as well as procreation, must be heard. This requires a multidisciplinary approach, and pediatric and adult, as well as patient education and financial support for maintaining the patient's autonomy and medical acts allowing the viability of continued medical care.

Sensory, motor somatic, and autonomic neurons projecting to the porcine cremaster muscle

The location of sensory, somatic, and autonomic neurons projecting to the pig cremaster muscle (CM) was studied by means of the retrograde neuronal tracer Fast Blue (FB) technique. FB was randomly injected in the left CM of four impuberal pigs and serial sections of sensory and autonomic ganglia and spinal cord were examined under a fluorescence microscope. Additionally, some indications about the number and size of labeled neurons were given. Sensory pseudounipolar somata were located ipsilaterally in the L2-L6 and S1-S2 dorsal root ganglia, their total number ranging between 125 and 194, their mean diameter between 24 and 89 microm. Somatic multipolar motoneurons were located ipsilaterally in the L2-L4 neuromeres of the spinal cord, their total number ranging between 53 and 169, their mean diameter between 29 and 53 microm. Autonomic multipolar paravertebral ganglia neurons were located ipsilaterally from L1 to S4 and contralaterally from L2 to S2. Their total number ranged from 2,015 to 3,067 and their mean diameter between 25 and 55 microm. The multipolar caudal mesenteric ganglia neurons were located bilaterally, their total number ranging between 14 and 1,408 and their diameter from 22 to 39 microm. In two subjects only, multipolar neurons were also found ipsilaterally in the microganglia of pelvic plexus (2 and 13 neurons). Their mean diameter ranged between 28 and 54 microm. Our study documented that the CM-projecting neurons were located at different neural levels, with a predominance in the autonomic ganglia.