Complete androgen insensitivity syndrome: report of a case with solitary pelvic kidney

Bilateral inguinal masses or hernias in a female teenager with delayed menarche: Think of Complete Androgen Insensitivity Syndrome (CAIS), a case report

INTRODUCTION

Complete Androgen Insensitivity Syndrome (CAIS) is a rare sexual development disorder with X-linked recessive inheritance. It is prevalent in 1:20400 to 1:99000 of female phenotypes, yet characterized by an XY genotype. Cases of CAIS usually present with primary amenorrhea together with unilateral/bilateral inguinal hernias.

CASE PRESENTATION

A previously healthy 19 year old sexually inactive girl presents to our clinics for delay in menarche and bilateral palpable inguinal masses 3 years ago. She has normal female habitus, tanner stage 3 and external female genetalia with sparse pubic hair. She has a family history of 2 aunts (mother side) having infertility with Bilateral inguinal hernias surgery. Hormonal tests showed male range testosterone levels. MRI showed bilateral inguinal masses with Mullerian structures agenesis and a misdiagnosis of Mayer-Rokitansky-Küster-Hauser syndrome (MRHKS) was interpreted. While karyotype showed XY genotype. She is then planned for bilateral orchiectomy. Final pathology of the 2 specimens taken showed testicular tissue correlating with CAIS.

DISCUSSION

CAIS patients presents with near normal female external genetalia, absence of Mullerian structures, taller status than regular females and testosterone levels equal or higher than male levels. Different imaging types together with karyotyping are crucial in diagnosing and differentiating CAIS from other entities such as MRHKS and Swyer syndrome. Treatment debates include prepubertal or postpubertal gonadectomy correlating with the age related malignancy rate and site of testis followed by Hormonal replacement therapy. CAIS management needs a multidisciplinary approach and decisions by the patient or his family sometimes.

CONCLUSION

CAIS must be suspected in any case of young females with bilateral inguinal hernias as in our case, and precise diagnostics tests such as MRI and Karyotyping must be done followed by biopsy or excision for diagnosis and then adequate treatment. Hormonal therapy must be continued after gonadectomy that is best to be postpubertal.

The evaluation and management of the boy with DSD

Atypical genitalia in a boy may have a very wide and diverse aetiology and a definitive diagnosis is often challenging to reach. Detailed clinical evaluation integrated with extensive biochemical and genetic studies play an important role in this process. Such care should be undertaken in highly specialized centres that can also provide access to a multidisciplinary team for optimal long-term care.

Novel associations in disorders of sex development: findings from the I-DSD Registry

CONTEXT

The focus of care in disorders of sex development (DSD) is often directed to issues related to sex and gender development. In addition, the molecular etiology remains unclear in the majority of cases.

OBJECTIVE

To report the range of associated conditions identified in the international DSD (I-DSD) Registry.

DESIGN, SETTING, AND PATIENTS

Anonymized data were extracted from the I-DSD Registry for diagnosis, karyotype, sex of rearing, genetic investigations, and associated anomalies. If necessary, clarification was sought from the reporting clinician.

RESULTS

Of 649 accessible cases, associated conditions occurred in 168 (26%); 103 (61%) cases had one condition, 31 (18%) had two conditions, 20 (12%) had three conditions, and 14 (8%) had four or more conditions. Karyotypes with most frequently reported associations included 45,X with 6 of 8 affected cases (75%), 45,X/46,XY with 19 of 42 cases (45%), 46,XY with 112 of 460 cases (24%), and 46,XX with 27 of 121 cases (22%). In the 112 cases of 46,XY DSD, the commonest conditions included small for gestational age in 26 (23%), cardiac anomalies in 22 (20%), and central nervous system disorders in 22 (20%), whereas in the 27 cases of 46,XX DSD, skeletal and renal anomalies were commonest at 12 (44%) and 8 (30%), respectively. Of 170 cases of suspected androgen insensitivity syndrome, 19 (11%) had reported anomalies and 9 of these had confirmed androgen receptor mutations.

CONCLUSIONS

Over a quarter of the cases in the I-DSD Registry have an additional condition. These associations can direct investigators toward novel genetic etiology and also highlight the need for more holistic care of the affected person.

Specific management of acute renal failure caused by an upper ureteral stone in a solitary pelvic kidney

A 36-year-old man presented with left lumbosacral region pain and 2 days of oliguria. Acute renal failure of a solitary pelvic kidney was diagnosed after a blood creatinine test, color Doppler ultrasonography, and magnetic resonance imaging. The cause of the acute renal failure was not clear; however, acute ureteral obstruction was presumed and emergency surgery was performed. The unusual anatomy of the kidney required specific management to find and relieve the cause of the obstruction. We found and cleared an upper ureteral stone by endoscopic surgery after exploring the kidney through open surgery.

Complete androgen insensitivity: the role of the surgeon

PURPOSE

This is a retrospective series of the surgical management of complete androgen insensitivity at a single institution.

MATERIALS AND METHODS

The records of 16 patients 4 to 63 years old with complete androgen insensitivity were extracted from an institutionally approved database. We determined whether each patient underwent vaginoplasty, age at vaginoplasty, vaginal depth before vaginoplasty, age at gonadectomy and whether the patient was sexually active. These data were pooled with those from a prior study at our institution to yield a total of 29 patients.

RESULTS

All patients had undergone gonadectomy with no evidence of malignancy in any pathology specimens. Of the 27 patients in whom the date of surgery was known 20 underwent surgery in late adolescence/adulthood, while 7 had the testes removed in childhood. Of the 29 patients 11 (38%) have undergone vaginal reconstruction. Average vaginal depth in postpubertal patients without reconstruction was 6.6 cm (range 1.5 to 10). Preoperative vaginal depth in patients with was between 2 and 4 cm. Ten postpubertal patients have undergone vaginoplasty and 7 (70%) are sexually active. Of the postpubertal patients 15 have not undergone vaginoplasty, of whom 12 (80%) are sexually active.

CONCLUSIONS

A delayed approach to gonadectomy and vaginal reconstruction respects patient autonomy and allows a more mature patient to handle the psychological and physical trauma of surgery and rehabilitation. Since we recognize the small number of patients in this series, strict guidelines cannot be proposed.