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Albadawi EA, Alzaman NS, Elhassan YH, Eltahir HM, Abouzied MM, Albadrani MS. The Association between Maternal Endocrine-Disrupting Chemical Exposure during Pregnancy and the Incidence of Male Urogenital Defects: A Systematic Review and Meta-Analysis. Metabolites 2024; 14:477. [PMID: 39330484 PMCID: PMC11434617 DOI: 10.3390/metabo14090477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2024] [Revised: 08/21/2024] [Accepted: 08/26/2024] [Indexed: 09/28/2024] Open
Abstract
The increasing incidence of hypospadias and cryptorchidism, coupled with the widespread presence of endocrine-disrupting chemicals (EDCs), has raised concerns about the potential impact of these environmental factors on male urogenital development. This systematic review and meta-analysis aims to evaluate the association between maternal exposure to various EDCs and the risk of hypospadias and cryptorchidism. We conducted a comprehensive search of PubMed, Scopus, Web of Science, and Cochrane databases from inception until May 2024. We included case-control and cohort studies that examined the association between maternal EDC exposure and hypospadias or cryptorchidism, reporting adjusted odds ratios (aOR) or crude odds ratios (cOR). Data were extracted and pooled using a random effects model, and heterogeneity was assessed using the Q test and I-square statistics. The risk of bias was evaluated using the Newcastle-Ottawa Scale (NOS). A total of 48 studies were included in the systematic review, with 46 studies included in the meta-analysis. The pooled analysis revealed a significant association between maternal EDC exposure and an increased risk of hypospadias (aOR = 1.26, 95% CI: 1.18-1.35, p < 0.0001) and cryptorchidism (aOR = 1.37, 95% CI: 1.19-1.57, p < 0.001). Subgroup analyses showed that exposure to pesticides, phthalates, alkyl phenolic compounds (ALKs), and heavy metals significantly increased the risk of hypospadias. In contrast, polychlorinated biphenyls (PCBs) did not show a significant association. Significant associations were found with pesticide and PCB exposure for cryptorchidism, but not with phthalate, ALK, or heavy metal exposure. Maternal exposure to certain EDCs is associated with an increased risk of hypospadias and cryptorchidism in male children. These findings underscore the importance of addressing environmental and occupational exposures during pregnancy to mitigate potential risks. Further research is needed to elucidate the mechanisms by which EDCs affect urogenital development and to develop effective interventions to reduce exposure among vulnerable populations.
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Affiliation(s)
- Emad Ali Albadawi
- Department of Basic Medical Sciences, College of Medicine, Taibah University, Al-Madinah Al-Munawara 42354, Saudi Arabia
| | - Naweed SyedKhaleel Alzaman
- Department of Medicine, College of Medicine, Taibah University, Al-Madinah Al-Munawara 42354, Saudi Arabia
| | - Yasir Hassan Elhassan
- Department of Basic Medical Sciences, College of Medicine, Taibah University, Al-Madinah Al-Munawara 42354, Saudi Arabia
| | - Heba M. Eltahir
- Department of Pharmacology and Toxicology, College of Pharmacy, Taibah University, Al-Madinah Al-Munawara 42354, Saudi Arabia
| | - Mekky M. Abouzied
- Department of Pharmacology and Toxicology, College of Pharmacy, Taibah University, Al-Madinah Al-Munawara 42354, Saudi Arabia
- Department of Biochemistry, Faculty of Pharmacy, Minia University, Minia 2431436, Egypt
| | - Muayad Saud Albadrani
- Department of Family and Community Medicine and Medical Education, College of Medicine, Taibah University, Al-Madinah Al-Munawara 42354, Saudi Arabia
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Huen K, Richardson S. Common Pediatric Urologic Conditions: Contemporary Management of Cryptorchidism, the Retractile Testis, and Phimosis. Adv Pediatr 2024; 71:169-179. [PMID: 38944481 DOI: 10.1016/j.yapd.2023.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/01/2024]
Abstract
Undescended testis is the most common genital disorder identified at birth. Boys who do not have spontaneous descent of the testis at 6 months of age, adjusted for gestational age, should be referred to pediatric urology for timely orchiopexy. Retractile testes are at risk for secondary ascent of the testes and should be monitored by physical examination annually. If there is concern for ascent of the testis, pediatric urology referral is recommended. Most cases of phimosis can be managed medically with topical corticosteroids and manual retraction of the foreskin.
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Affiliation(s)
- Kathy Huen
- David Geffen School of Medicine at UCLA, Los Angeles, CA, USA; Department of Urology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.
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3
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Selin C, Hallabro N, Anderberg M, Börjesson A, Salö M. Orchidopexy for undescended testis-rate and predictors of re-ascent. Pediatr Surg Int 2024; 40:139. [PMID: 38806810 PMCID: PMC11133083 DOI: 10.1007/s00383-024-05729-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/23/2024] [Indexed: 05/30/2024]
Abstract
PURPOSE This study aimed to investigate the rate of re-ascent requiring re-operation after primary orchidopexy and to investigate eventual differences between the inguinal and scrotal approach as well as other potential predictors for re-ascent. METHODS A retrospective cohort study of children treated for undescended testis (UDT) with orchidopexy between 2018 and 2022 was conducted. The primary outcome was re-ascent requiring re-operation, and the secondary outcome was atrophy rate. Independent variables were age, underlying conditions, side, surgical approach, operation time, bilaterality, congenital/ascended UDT, presence of scrotal hypoplasia, presence of a patent processus vaginalis, division of external oblique, and suture of the testis. Univariate and logistic regression were used to evaluate differences between groups and risk for re-ascent. RESULTS A total of 662 testes in 554 patients were included. Re-operation occurred in 6% (7% with inguinal approach, 3% with scrotal approach, p = 0.04). Re-operation was associated with younger age, congenital UDT, and inguinal approach, but neither of these variables remained significant in multivariate analyses. Atrophy occurred in one testis. CONCLUSION The rate of re-ascent was 6% and the atrophy rate was 0.15%. A larger study may find predictors for re-ascent but with very low absolute risk. The lower rate of re-ascent with the scrotal approach is probably due to selection bias.
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Affiliation(s)
- Caroline Selin
- Department of Clinical Sciences, Pediatrics, Lund University, Lund, Sweden
| | - Nilla Hallabro
- Department of Clinical Sciences, Pediatrics, Lund University, Lund, Sweden
| | - Magnus Anderberg
- Department of Clinical Sciences, Pediatrics, Lund University, Lund, Sweden
- Department of Pediatric Surgery, Skåne University Hospital, 221 85, Lund, Sweden
| | - Anna Börjesson
- Department of Clinical Sciences, Pediatrics, Lund University, Lund, Sweden
- Department of Pediatric Surgery, Skåne University Hospital, 221 85, Lund, Sweden
| | - Martin Salö
- Department of Clinical Sciences, Pediatrics, Lund University, Lund, Sweden.
- Department of Pediatric Surgery, Skåne University Hospital, 221 85, Lund, Sweden.
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Rodprasert W, Virtanen HE, Toppari J. Cryptorchidism and puberty. Front Endocrinol (Lausanne) 2024; 15:1347435. [PMID: 38532895 PMCID: PMC10963523 DOI: 10.3389/fendo.2024.1347435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Accepted: 02/15/2024] [Indexed: 03/28/2024] Open
Abstract
Cryptorchidism is the condition in which one or both testes have not descended adequately into the scrotum. The congenital form of cryptorchidism is one of the most prevalent urogenital anomalies in male newborns. In the acquired form of cryptorchidism, the testis that was previously descended normally is no longer located in the scrotum. Cryptorchidism is associated with an increased risk of infertility and testicular germ cell tumors. However, data on pubertal progression are less well-established because of the limited number of studies. Here, we aim to review the currently available data on pubertal development in boys with a history of non-syndromic cryptorchidism-both congenital and acquired cryptorchidism. The review is focused on the timing of puberty, physical changes, testicular growth, and endocrine development during puberty. The available evidence demonstrated that the timing of the onset of puberty in boys with a history of congenital cryptorchidism does not differ from that of non-cryptorchid boys. Hypothalamic-pituitary-gonadal hormone measurements showed an impaired function or fewer Sertoli cells and/or germ cells among boys with a history of cryptorchidism, particularly with a history of bilateral cryptorchidism treated with orchiopexy. Leydig cell function is generally not affected in boys with a history of cryptorchidism. Data on pubertal development among boys with acquired cryptorchidism are lacking; therefore, more research is needed to investigate pubertal progression among such boys.
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Affiliation(s)
- Wiwat Rodprasert
- Research Centre for Integrative Physiology and Pharmacology and Centre for Population Health Research, Institute of Biomedicine, University of Turku, Turku, Finland
| | - Helena E. Virtanen
- Research Centre for Integrative Physiology and Pharmacology and Centre for Population Health Research, Institute of Biomedicine, University of Turku, Turku, Finland
| | - Jorma Toppari
- Research Centre for Integrative Physiology and Pharmacology and Centre for Population Health Research, Institute of Biomedicine, University of Turku, Turku, Finland
- Department of Pediatrics, Turku University Hospital, Turku, Finland
- Department of Growth and Reproduction, Copenhagen University Hospital—Rigshospitalet, Copenhagen, Denmark
- Centre for Research and Research Training in Endocrine Disruption of Male Reproduction and Child Health (EDMaRC), Copenhagen University Hospital—Rigshospitalet, Copenhagen, Denmark
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5
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Von Cube C, Schmidt A, Krönninger M, Hrivatakis G, Astfalk W, Fuchs J, Ellerkamp V. A closer look to the timing of orchidopexy in undescended testes and adherence to the AWMF-guideline. Pediatr Surg Int 2024; 40:60. [PMID: 38421443 PMCID: PMC10904547 DOI: 10.1007/s00383-024-05659-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/15/2024] [Indexed: 03/02/2024]
Abstract
BACKGROUND To lower the risk of testicular malignancies and subfertility, international guidelines recommend orchidopexy for undescended testis (UDT) before the age of 12-18 months. Previous studies reported low rates of 5-15% of timely surgery. Most of these studies are based on DRG and OPS code-based data from healthcare system institutions that do not distinguish between congenital and acquired UDT. METHODS In a retrospective study data of all boys who underwent orchidopexy in a university hospital and two outpatient surgical departments from 2009 to 2022 were analyzed. The data differentiates congenital from acquired UDT. RESULTS Out of 2694 patients, 1843 (68.4%) had congenital and 851 (31.6%) had acquired UDT. In 24.9% of congenital cases surgery was performed before the age of 12 months. The median age at surgery for congenital UDT was 16 months (range 7-202). Over the years there was an increased rate of boys operated on before the age of 2 (40% in 2009, 60% in 2022). The median age fluctuated over the years between 21 and 11 months without a trend to younger ages.. The covid pandemic did not lead to an increase of the median age at surgery. The median time between referral and surgery was 46 days (range 1-1836). Reasons for surgery after 12 months of age were a delayed referral to pediatric surgeries (51.2%), followed by relevant comorbidities (28.2%). CONCLUSION Compared to recent literature, out data show that a closer look at details enables a more realistic approach. Still, there is no trend towards the recommended age for surgical treatment observable, but the rate of timely operated boys with congenital UDT is significantly higher than stated in literature.
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Affiliation(s)
- C Von Cube
- Department of Pediatric Surgery and Pediatric Urology, Eberhard Karls University, Tubingen, Germany
| | - A Schmidt
- Department of Pediatric Surgery and Pediatric Urology, Eberhard Karls University, Tubingen, Germany
| | - M Krönninger
- Department of Pediatric Surgery and Pediatric Urology, Eberhard Karls University, Tubingen, Germany
| | - G Hrivatakis
- Outpatient Clinic for Pediatric and Adolescent Surgery, Stuttgart, Germany
| | - W Astfalk
- Outpatient Clinic for Surgery, Reutlingen, Germany
| | - J Fuchs
- Department of Pediatric Surgery and Pediatric Urology, Eberhard Karls University, Tubingen, Germany
| | - V Ellerkamp
- Department of Pediatric Surgery and Pediatric Urology, Eberhard Karls University, Tubingen, Germany.
- Department of Pediatric Surgery, Municipal Hospital Karlsruhe, Karlsruhe, Germany.
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Kose SI. Imaging in Male Infertility. Curr Probl Diagn Radiol 2023; 52:439-447. [PMID: 37270300 DOI: 10.1067/j.cpradiol.2023.05.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2023] [Revised: 04/04/2023] [Accepted: 05/08/2023] [Indexed: 06/05/2023]
Abstract
Infertility is defined as inability to conceive despite regular unprotected sexual intercourse for greater than 1 year. Conditions involving the male partner accounts for the infertility in approximately 50% of cases. The goals of imaging in male infertility are to detect treatable/ reversible causes, imaging for sperm retrieval from testis or epididymis for assisted reproductive techniques like in vitro fertilization or intracytoplasmic sperm injection and to provide appropriate genetic counselling for prevention of occurrence of disease in future offspring. The purpose of this article is to describe imaging features in various causes of male infertility to acquaint radiologists with various imaging appearances of causes of male infertility to avoid missing these pathologies.
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Affiliation(s)
- Snehal Ishwar Kose
- Department of Radiodiagnosis, Maulana Azad Medical College, New Delhi, India.
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Chedrawe ER, Keefe DT, Romao RLP. Diagnosis, Classification, and Contemporary Management of Undescended Testicles. Urol Clin North Am 2023; 50:477-490. [PMID: 37385709 DOI: 10.1016/j.ucl.2023.04.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/01/2023]
Abstract
This article provides a comprehensive review regarding undescended testicles and other related conditions. We have included background information summarizing variable clinical presentations, epidemiology, and the implications of undescended testis (UDT) on fertility and malignancy risk. This article has an emphasis on the approach to diagnosis and surgical management for the UDT. The purpose of this review is to provide readers with useful clinical tools for assessing and treating patients with cryptorchidism.
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Affiliation(s)
- Emily R Chedrawe
- Division of Pediatric Urology, IWK Health Centre, 5850 University Avenue, P.O. Box 9700, Halifax, NS, B3K 6R8 Canada; Department of Urology, Dalhousie University, 1276 South Park Street. Room 293, 5 Victoria, Halifax, NS, B3H 2Y9, Canada
| | - Daniel T Keefe
- Division of Pediatric Urology, IWK Health Centre, 5850 University Avenue, P.O. Box 9700, Halifax, NS, B3K 6R8 Canada; Department of Urology, Dalhousie University, 1276 South Park Street. Room 293, 5 Victoria, Halifax, NS, B3H 2Y9, Canada
| | - Rodrigo L P Romao
- Division of Pediatric Urology, IWK Health Centre, 5850 University Avenue, P.O. Box 9700, Halifax, NS, B3K 6R8 Canada; Department of Urology, Dalhousie University, 1276 South Park Street. Room 293, 5 Victoria, Halifax, NS, B3H 2Y9, Canada; Division of Pediatric Surgery and Department of Surgery, IWK Health Centre, Dalhousie University, 5850 University Avenue, P.O. Box 9700, Halifax, NS, B3K 6R8.
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Schmedding A, van Wasen F, Lippert R. Are we still too late? Timing of orchidopexy. Eur J Pediatr 2023; 182:1221-1227. [PMID: 36622430 PMCID: PMC10023762 DOI: 10.1007/s00431-022-04769-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 06/06/2022] [Accepted: 12/17/2022] [Indexed: 01/10/2023]
Abstract
An undescended testis is the most common genitourinary disease in boys. The German guidelines, first published in 2009, proposed the timing of orchidopexy to be before 12 months of age. The aim of the study was to analyze the implementation of these guidelines 10 years after publication. The national cumulative statistics of hospital admissions, provided by the Institute for the Remuneration System in Hospitals (InEK), and the statistics concerning procedures performed in private pediatric surgical practices of the professional association of pediatric surgeons (BNKD) regarding the time of surgeries for the year 2019 were analyzed. Data from InEK included all German hospital admissions. Data from BNKD included data from 48 private pediatric surgical practices. The hospitals treated 6476 inpatients with undescended testis, and 3255 patients were operated in private practices. Regarding the age at treatment, 15% of the hospital patients and 5% of the private practice patients were younger than 1 year and fulfilled the guideline recommendations. Forty percent of the hospital patients and 29% of the private practice patients were 1 or 2 years of age. All other patients were 3 years of age or older at the time of orchidopexy. Conclusions: The rate of orchidopexy within the first 12 months of life is remarkably low even 10 years after the publication of the guidelines. Awareness of the existing guideline must be increased for both referring pediatric and general practitioners. What is Known: • In Germany, orchidopexy is performed by pediatric surgeons and urologists either in hospital settings or in private practices. • Most international guidelines set the age for surgical treatment of undescended testis between 12 and 18 months of age. The German guidelines, published in 2009, sets the time-limit at one year of age. Until five years after publication of the German guidelines, the number of patients treated before the first year of life was low; studies show an orchidopexy ratebetween 8% and 19% during this time. What is New: • This study the first to cover all administered hospital patients in Germany and a large group of patients treated in private practices. It contains the largest group of German patients with undescended testis. • Although almost all children participate in the routine check-up at the age of seven months, which includes investigation for undescended testis, adherence to the orchidopexy guidelines is still low. Only 15% of the hospital patients and 5% of the patients in private practice were treated before their first birthdays.
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Affiliation(s)
- Andrea Schmedding
- Department of Pediatric Surgery and Pediatric Urology, University Hospital, Goethe University Frankfurt, Theodor-Stern-Kai 7, Frankfurt am Main, 60590, Germany.
| | | | - Ralf Lippert
- Private Practice of Pediatric Surgery, Bremen, Germany
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Hildorf SE. Clinical aspects of histological and hormonal parameters in boys with cryptorchidism: Thesis for PhD degree. APMIS 2022; 130 Suppl 143:1-58. [PMID: 35822689 PMCID: PMC9542020 DOI: 10.1111/apm.13247] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Accepted: 05/09/2022] [Indexed: 11/28/2022]
Affiliation(s)
- Simone Engmann Hildorf
- Department of Pediatric Surgery and Department of PathologyCopenhagen University Hospital RigshospitaletCopenhagenDenmark
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10
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Kim JY, Chung JM. Comprehension and Practice Patterns of Korean Urologists for Retractile and Gliding Testes. J Korean Med Sci 2022; 37:e98. [PMID: 35347906 PMCID: PMC8960942 DOI: 10.3346/jkms.2022.37.e98] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Accepted: 03/02/2022] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND It is quite difficult to distinguish retractile testis from gliding testis, which requires different treatment planning in the clinic setting. We evaluated practice patterns of urologists in Korea regarding the diagnosis and management of retractile and gliding testes. METHODS We mailed or e-mailed self-completion questionnaires consisting of 20 items to 106 urologists practicing in Korean hospitals concerning the diagnosis and treatment of cryptorchidism. We collected and analyzed the responses statistically. RESULTS Responses were received from 62 urologists. The response rate was 58.5%. Thirty-seven urologists (59.7%) actually felt they had difficulty in distinguishing retractile testis from gliding testis in the clinic setting. This rate was higher for non-pediatric urologists (78.1%) than for pediatric urologists (40.0%) (P = 0.006). In cases of infant retractile testis, only five urologists (8.1%) said that they would perform orchiopexy immediately, with 54 (87.1%) urologists saying they would do follow-up. In cases of preschool-age children with retractile testis, 17 urologists (27.4%) said that they would perform orchiopexy immediately with 41 (66.1%) urologists saying they would do follow-up. In cases of infant gliding testis, 37 urologists (59.7%) said that they would perform orchiopexy immediately with 24 (38.7%) urologists saying they would do a follow-up. CONCLUSION More than half (59.7%) of Korean urologists revealed it challenging to distinguish retractile testis and gliding testis in the clinical setting. The more it was difficult to diagnose retractile testis with certainty, the more frequent surgical correction was chosen for treatment. Therefore, it is essential to prevent unnecessary surgical treatment by establishing a practical guideline.
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Affiliation(s)
- Jae Yeon Kim
- Department of Urology, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Jae Min Chung
- Department of Urology, Pusan National University Yangsan Hospital, Yangsan, Korea
- Department of Urology, Pusan National University School of Medicine, Yangsan, Korea
- Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea.
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Abstract
Cryptorchidism, i.e., undescended testis, is one of the most common genital malformations in newborn male babies. The birth rate of cryptorchidism varies from 1.6 to 9.0 %. Etiology of disrupted testicular descent is complex and predisposing causes include genetic, hormonal, environmental, lifestyle and maternal factors. Testicular descent occurs in two major steps and testicular hormones and normal function of hypothalamic-pituitary-testicular axis are important for normal descent. Several gene mutations are associated with syndromic cryptorchidism but they are rarely found in boys with isolated undescended testis. Testicular regression can also cause an empty scrotum. Normal male genital phenotype indicates that the boy has had functioning testis during development. Torsion of the testis can cause testicular regression but in many cases the reason for vanishing testis remains elusive. In this narrative review we discuss genetics of cryptorchidism and testicular regression.
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Affiliation(s)
- Heidi P Elamo
- Research Centre for Integrative Physiology and Pharmacology, Institute of Biomedicine, University of Turku, 20520 Turku, Finland; Centre for Population Health Research, University of Turku and Turku University Hospital, Turku, Finland.
| | - Helena E Virtanen
- Research Centre for Integrative Physiology and Pharmacology, Institute of Biomedicine, University of Turku, 20520 Turku, Finland; Centre for Population Health Research, University of Turku and Turku University Hospital, Turku, Finland.
| | - Jorma Toppari
- Research Centre for Integrative Physiology and Pharmacology, Institute of Biomedicine, University of Turku, 20520 Turku, Finland; Centre for Population Health Research, University of Turku and Turku University Hospital, Turku, Finland; Department of Pediatrics, Turku University Hospital, Turku, Finland.
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12
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Dinkelbach L, Lehnick D, Shavit S, Szavay P, Zundel S. Acquired undescended testis: When does the ascent occur? J Pediatr Surg 2021; 56:2027-2031. [PMID: 33248683 DOI: 10.1016/j.jpedsurg.2020.11.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 10/26/2020] [Accepted: 11/02/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND Little is known about the timeframe in which acquired undescended testes occur. To guide recommendations for screening examinations, we aimed to (1) specify the ratio of acquired undescended testes in orchiopexy cases and to (2) identify a predisposing age for the development of acquired undescended testis. METHODS Three-hundred-forty cases of orchiopexy were retrospectively analyzed and classified as congenital or acquired cases of undescended testis. In acquired cases, the time of the last documented physiological testicular position was obtained. The time of testicular ascent was approximated by calculating the mean between the last physiological finding and orchiopexy. RESULTS In 151 cases (44.4%) prior physiological position of testes was documented and acquired undescended testis was assumed. In 115 of these cases (76.2%) details on the age at last physiological position were available. Ascent occurred between the age of one and fourteen. The 50th, 75th, 85th, 90th and 95th percentile for the estimated age at ascent was 5.8, 7.3, 8.4, 8.7 and 11.1 years, respectively. CONCLUSIONS Acquired undescended testes are a common cause of cryptorchidism. Ascent occurs throughout all prepubertal ages, emphasizing the need to regular follow-up of testicular position until puberty. TYPE OF STUDY Prognosis study. LEVEL OF EVIDENCE Level II.
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Affiliation(s)
- Lars Dinkelbach
- Department of Pediatric Oncology, Hematology and Clinical Immunology, Centre for Child and Adolescent Health, Medical Faculty, Heinrich Heine University, Moorenstraße 5, 40225 Duesseldorf, Germany; Department of Pediatric Surgery, Children's Hospital Lucerne, Switzerland.
| | - Dirk Lehnick
- Clinical Trial Unit Central Switzerland / Department of Health Sciences and Medicine, University of Lucerne, Switzerland
| | - Sandra Shavit
- Department of Pediatric Surgery, Children's Hospital Lucerne, Switzerland
| | - Philipp Szavay
- Department of Pediatric Surgery, Children's Hospital Lucerne, Switzerland
| | - Sabine Zundel
- Department of Pediatric Surgery, Children's Hospital Lucerne, Switzerland
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Sonographic evaluation of fetal scrotum, testes and epididymis. Obstet Gynecol Sci 2021; 64:393-406. [PMID: 34176256 PMCID: PMC8458611 DOI: 10.5468/ogs.21040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Accepted: 06/15/2021] [Indexed: 11/16/2022] Open
Abstract
External male genitalia have rarely been evaluated on fetal ultrasound. Apart from visualization of the penis for fetal sex determination, there are no specific instructions or recommendations from scientific societies. This study aimed to review the current knowledge about prenatal diagnosis of the scrotum and internal structures, with discussion regarding technical aspects and clinical management. We conducted an article search in Medline, EMBASE, Scopus, Google Scholar, and Web of Science databases for studies in English or Spanish language that discussed prenatal scrotal pathologies. We identified 72 studies that met the inclusion criteria. Relevant data were grouped into sections of embryology, ultrasound, pathology, and prenatal diagnosis. The scrotum and internal structures show a wide range of pathologies, with varying degrees of prevalence and morbidity. Most of the reported cases have described incidental findings diagnosed via striking ultrasound signs. Studies discussing normative data or management are scarce.
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Fisher BG, Thankamony A, Mendiola J, Petry CJ, Frederiksen H, Andersson AM, Juul A, Ong KK, Dunger DB, Hughes IA, Acerini CL. Maternal serum concentrations of bisphenol A and propyl paraben in early pregnancy are associated with male infant genital development. Hum Reprod 2021; 35:913-928. [PMID: 32325494 DOI: 10.1093/humrep/deaa045] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Revised: 02/10/2020] [Indexed: 12/12/2022] Open
Abstract
STUDY QUESTION Are maternal serum phthalate metabolite, phenol and paraben concentrations measured at 10-17 weeks of gestation associated with male infant genital developmental outcomes, specifically cryptorchidism, anogenital distance (AGD), penile length and testicular descent distance, at birth and postnatally? SUMMARY ANSWER Maternal serum bisphenol A (BPA) concentration at 10-17 weeks of gestation was positively associated with congenital or postnatally acquired cryptorchidism, and n-propyl paraben (n-PrP) concentration was associated with shorter AGD from birth to 24 months of age. WHAT IS KNOWN ALREADY Male reproductive disorders are increasing in prevalence, which may reflect environmental influences on foetal testicular development. Animal studies have implicated phthalates, BPA and parabens, to which humans are ubiquitously exposed. However, epidemiological studies have generated conflicting results and have often been limited by small sample size and/or measurement of chemical exposures outside the most relevant developmental window. STUDY DESIGN, SIZE, DURATION Case-control study of cryptorchidism nested within a prospective cohort study (Cambridge Baby Growth Study), with recruitment of pregnant women at 10-17 postmenstrual weeks of gestation from a single UK maternity unit between 2001 and 2009 and 24 months of infant follow-up. Of 2229 recruited women, 1640 continued with the infancy study after delivery, of whom 330 mothers of 334 male infants (30 with congenital cryptorchidism, 25 with postnatally acquired cryptorchidism and 279 unmatched controls) were included in the present analysis. PARTICIPANTS/MATERIALS, SETTING, METHODS Maternal blood was collected at enrolment, and serum levels of 16 phthalate metabolites, 9 phenols (including BPA) and 6 parabens were measured using liquid chromatography/tandem mass spectrometry. Logistic regression was used to model the association of cryptorchidism with serum chemical concentrations, adjusting for putative confounders. Additionally, offspring AGD, penile length and testicular descent distance were assessed at 0, 3, 12, 18 and 24 months of age, and age-specific Z scores were calculated. Associations between serum chemical levels and these outcomes were tested using linear mixed models. MAIN RESULTS AND THE ROLE OF CHANCE Maternal serum BPA concentration was associated with offspring all-type cryptorchidism both when considered as a continuous exposure (adjusted odds ratio per log10 μg/l: 2.90, 95% CI 1.31-6.43, P = 0.009) and as quartiles (phet = 0.002). Detection of n-PrP in maternal serum was associated with shorter AGD (by 0.242 standard deviations, 95% CI 0.051-0.433, P = 0.01) from birth to 24 months of age; this reduction was independent of body size and other putative confounders. We did not find any consistent associations with offspring outcomes for the other phenols, parabens, and phthalate metabolites measured. LIMITATIONS, REASONS FOR CAUTION We cannot discount confounding by other demographic factors or endocrine-disrupting chemicals. There may have been misclassification of chemical exposure due to use of single serum measurements. The cohort was not fully representative of pregnant women in the UK, particularly in terms of smoking prevalence and maternal ethnicity. WIDER IMPLICATIONS OF THE FINDINGS Our observational findings support experimental evidence that intrauterine exposure to BPA and n-PrP during early gestation may adversely affect male reproductive development. More evidence is required before specific public health recommendations can be made. STUDY FUNDING/COMPETING INTEREST(S) This work was supported by a European Union Framework V programme, the World Cancer Research Fund International, the Medical Research Council (UK), Newlife the Charity for Disabled Children, the Mothercare Group Foundation, Mead Johnson Nutrition and the National Institute for Health Research Cambridge Comprehensive Biomedical Research Centre. Visiting Fellowship (J.M.): Regional Programme 'Jiménez de la Espada' for Research Mobility, Cooperation and Internationalization, Seneca Foundation-Science and Technology Agency for the Region of Murcia (No. 20136/EE/17). K.O. is supported by the Medical Research Council (UK) (Unit Programme number: MC_UU_12015/2). The authors declare no conflict of interest.
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Affiliation(s)
- B G Fisher
- Department of Paediatrics, University of Cambridge, Box 116, Level 8, Addenbrooke's Hospital, Hills Road, Cambridge, CB2 0QQ, UK
| | - A Thankamony
- Department of Paediatrics, University of Cambridge, Box 116, Level 8, Addenbrooke's Hospital, Hills Road, Cambridge, CB2 0QQ, UK
| | - J Mendiola
- Division of Preventive Medicine and Public Health, Department of Public Health Sciences, University of Murcia School of Medicine, IMIB-Arrixaca, Avda. Teniente Flomesta, 5, 30003 Murcia, Spain
| | - C J Petry
- Department of Paediatrics, University of Cambridge, Box 116, Level 8, Addenbrooke's Hospital, Hills Road, Cambridge, CB2 0QQ, UK
| | - H Frederiksen
- Department of Growth and Reproduction & International Center for Research and Research Training in Endocrine Disruption of Male Reproduction and Child Health (EDMaRC), Rigshospitalet, University of Copenhagen, Blegdamsvej 9, DK-2100 Copenhagen, Denmark
| | - A M Andersson
- Department of Growth and Reproduction & International Center for Research and Research Training in Endocrine Disruption of Male Reproduction and Child Health (EDMaRC), Rigshospitalet, University of Copenhagen, Blegdamsvej 9, DK-2100 Copenhagen, Denmark
| | - A Juul
- Department of Growth and Reproduction & International Center for Research and Research Training in Endocrine Disruption of Male Reproduction and Child Health (EDMaRC), Rigshospitalet, University of Copenhagen, Blegdamsvej 9, DK-2100 Copenhagen, Denmark
| | - K K Ong
- Department of Paediatrics, University of Cambridge, Box 116, Level 8, Addenbrooke's Hospital, Hills Road, Cambridge, CB2 0QQ, UK.,MRC Epidemiology Unit, University of Cambridge, Box 285, Institute of Metabolic Science, Cambridge Biomedical Campus, Cambridge, CB2 0QQ, UK
| | - D B Dunger
- Department of Paediatrics, University of Cambridge, Box 116, Level 8, Addenbrooke's Hospital, Hills Road, Cambridge, CB2 0QQ, UK.,Metabolic Research Laboratories, University of Cambridge, Box 289, Institute of Metabolic Science, Cambridge Biomedical Campus, Cambridge, CB2 0QQ, UK
| | - I A Hughes
- Department of Paediatrics, University of Cambridge, Box 116, Level 8, Addenbrooke's Hospital, Hills Road, Cambridge, CB2 0QQ, UK
| | - C L Acerini
- Department of Paediatrics, University of Cambridge, Box 116, Level 8, Addenbrooke's Hospital, Hills Road, Cambridge, CB2 0QQ, UK
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15
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Zhao TX, Liu B, Wei YX, Wei Y, Tang XL, Shen LJ, Long CL, Lin T, Wu SD, Wei GH. Clinical and socioeconomic factors associated with delayed orchidopexy in cryptorchid boys in China: a retrospective study of 2423 cases. Asian J Androl 2020; 21:304-308. [PMID: 30632485 PMCID: PMC6498732 DOI: 10.4103/aja.aja_106_18] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
We investigated the associations of clinical and socioeconomic factors with delayed orchidopexy for cryptorchidism in China. A retrospective study was conducted on cryptorchid boys who underwent orchidopexy at Children's Hospital at Chongqing Medical University in China from January 2012 to December 2017. Of 2423 patients, 410 (16.9%) received timely repair by 18 months of age, beyond which surgery was considered delayed. Univariate analysis suggested that the laterality of cryptorchidism (P = 0.001), comorbidities including inguinal hernia/scrotal hydrocele (P < 0.001) or urinary tract disease (P = 0.016), and whether patients lived in a poverty county (P < 0.001) could influence whether orchidopexy was timely or delayed. Logistic regression analysis suggested that the following factors were associated with delayed repair: unilateral rather than bilateral cryptorchidism (odds ratio [OR] = 1.752, P < 0.001), absence of inguinal hernia or hydrocele (OR = 2.027, P = 0.019), absence of urinary tract disease (OR = 3.712, P < 0.001), and living in a poverty county (OR = 2.005, P < 0.001). The duration of postoperative hospital stay and hospital costs increased with the patient's age at the time of surgery.
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Affiliation(s)
- Tian-Xin Zhao
- Department of Urology, Children's Hospital of Chongqing Medical University, Chongqing 400014, China.,Chongqing Key Laboratory of Children Urogenital Development and Tissue Engineering, Chongqing 400014, China.,Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing 400014, China.,China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing 400014, China.,Chongqing Key Laboratory of Pediatrics, Chongqing 400014, China
| | - Bin Liu
- Chongqing Key Laboratory of Children Urogenital Development and Tissue Engineering, Chongqing 400014, China.,Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing 400014, China.,China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing 400014, China.,Chongqing Key Laboratory of Pediatrics, Chongqing 400014, China
| | - Yue-Xin Wei
- Department of Urology, Children's Hospital of Chongqing Medical University, Chongqing 400014, China.,Chongqing Key Laboratory of Children Urogenital Development and Tissue Engineering, Chongqing 400014, China.,Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing 400014, China.,China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing 400014, China
| | - Yi Wei
- Department of Urology, Children's Hospital of Chongqing Medical University, Chongqing 400014, China.,Chongqing Key Laboratory of Children Urogenital Development and Tissue Engineering, Chongqing 400014, China.,Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing 400014, China.,Chongqing Key Laboratory of Pediatrics, Chongqing 400014, China
| | - Xiang-Liang Tang
- Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing 400014, China.,China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing 400014, China.,Chongqing Key Laboratory of Pediatrics, Chongqing 400014, China
| | - Lian-Ju Shen
- Chongqing Key Laboratory of Children Urogenital Development and Tissue Engineering, Chongqing 400014, China.,Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing 400014, China.,China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing 400014, China.,Chongqing Key Laboratory of Pediatrics, Chongqing 400014, China
| | - Chun-Lan Long
- Chongqing Key Laboratory of Children Urogenital Development and Tissue Engineering, Chongqing 400014, China.,Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing 400014, China.,China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing 400014, China.,Chongqing Key Laboratory of Pediatrics, Chongqing 400014, China
| | - Tao Lin
- Department of Urology, Children's Hospital of Chongqing Medical University, Chongqing 400014, China.,Chongqing Key Laboratory of Children Urogenital Development and Tissue Engineering, Chongqing 400014, China.,China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing 400014, China
| | - Sheng-De Wu
- Department of Urology, Children's Hospital of Chongqing Medical University, Chongqing 400014, China.,Chongqing Key Laboratory of Children Urogenital Development and Tissue Engineering, Chongqing 400014, China.,Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing 400014, China.,China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing 400014, China.,Chongqing Key Laboratory of Pediatrics, Chongqing 400014, China
| | - Guang-Hui Wei
- Department of Urology, Children's Hospital of Chongqing Medical University, Chongqing 400014, China.,Chongqing Key Laboratory of Children Urogenital Development and Tissue Engineering, Chongqing 400014, China.,Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing 400014, China.,China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing 400014, China.,Chongqing Key Laboratory of Pediatrics, Chongqing 400014, China
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16
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Buur LE, Laurberg VR, Ernst A, Arendt LH, Nybo Andersen AM, Olsen J, Ramlau-Hansen CH. Oral contraceptive use and genital anomalies in sons. A Danish cohort study. Reprod Toxicol 2019; 89:67-73. [PMID: 31299209 DOI: 10.1016/j.reprotox.2019.07.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Revised: 06/30/2019] [Accepted: 07/08/2019] [Indexed: 11/18/2022]
Abstract
Exposure to exogenous sex hormones with estrogenic or anti-androgen properties may influence intrauterine development of male genitals. This population-based cohort study based on data from 44,408 live-born singleton sons in the Danish National Birth Cohort (DNBC) aimed to investigate whether maternal use of oral contraceptives prior to or during early pregnancy increase the risk of cryptorchidism or hypospadias. We found no consistent association between use of oral contraceptives and cryptorchidism or hypospadias, neither in those exposed any time four months prior to conception [cryptorchidism: adjusted Odds Ratio (aOR): 1.06 (95% CI: 0.91; 1.23), hypospadias: 0.74 (95% CI: 0.53; 1.03)] nor in those exposed any time during the first trimester of pregnancy [cryptorchidism: aOR: 0.93 (95% CI: 0.53; 1.62), hypospadias: 1.02 (95% CI: 0.32; 3.23)]. Despite relatively strong exposure levels from oral contraceptive use in pregnancy, this study revealed no evidence of an increased risk of either two genital malformations.
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Affiliation(s)
- L E Buur
- Department of Public Health, Aarhus University, Aarhus, Denmark.
| | - V R Laurberg
- Department of Public Health, Aarhus University, Aarhus, Denmark
| | - A Ernst
- Department of Public Health, Aarhus University, Aarhus, Denmark
| | - L H Arendt
- Department of Public Health, Aarhus University, Aarhus, Denmark
| | - A-M Nybo Andersen
- Department of Public Health, Section of Epidemiology, University of Copenhagen, Copenhagen, Denmark
| | - J Olsen
- Department of Public Health, Aarhus University, Aarhus, Denmark; Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
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17
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Kuiri-Hänninen T, Koskenniemi J, Dunkel L, Toppari J, Sankilampi U. Postnatal Testicular Activity in Healthy Boys and Boys With Cryptorchidism. Front Endocrinol (Lausanne) 2019; 10:489. [PMID: 31396156 PMCID: PMC6663997 DOI: 10.3389/fendo.2019.00489] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Accepted: 07/04/2019] [Indexed: 01/25/2023] Open
Abstract
Cryptorchidism, or undescended testis, is a well-known risk factor for testicular cancer and impaired semen quality in adulthood, conditions which have their origins in early fetal and postnatal life. In human pregnancy, the interplay of testicular and placental hormones as well as local regulatory factors and control by the hypothalamic-pituitary (HP) axis, lead to testicular descent by term. The normal masculine development may be disrupted by environmental factors or genetic defects and result in undescended testes. Minipuberty refers to the postnatal re-activation of the HP-testicular (T) axis after birth. During the first weeks of life, gonadotropin levels increase, followed by activation and proliferation of testicular Leydig, Sertoli and germ cells. Consequent rise in testosterone levels results in penile growth during the first months of life. Testicular size increases and testicular descent continues until three to five months of age. Insufficient HPT axis activation (e.g., hypogonadotropic hypogonadism) is often associated with undescended testis and therefore minipuberty is considered an important phase in the normal male reproductive development. Minipuberty provides a unique window of opportunity for the early evaluation of HPT axis function during early infancy. For cryptorchid boys, hormonal evaluation during minipuberty may give a hint of the underlying etiology and aid in the evaluation of the later risk of HPT axis dysfunction and impaired fertility. The aim of this review is to summarize the current knowledge of the role of minipuberty in testicular development and descent.
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Affiliation(s)
- Tanja Kuiri-Hänninen
- Department of Pediatrics, Kuopio University Hospital, Kuopio, Finland
- *Correspondence: Tanja Kuiri-Hänninen
| | - Jaakko Koskenniemi
- Research Centre for Integrative Physiology and Pharmacology, Institute of Biomedicine, University of Turku, Turku, Finland
- Department of Pediatrics, Turku University Hospital, Turku, Finland
| | - Leo Dunkel
- Barts and the London, William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
| | - Jorma Toppari
- Research Centre for Integrative Physiology and Pharmacology, Institute of Biomedicine, University of Turku, Turku, Finland
- Department of Pediatrics, Turku University Hospital, Turku, Finland
| | - Ulla Sankilampi
- Department of Pediatrics, Kuopio University Hospital, Kuopio, Finland
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18
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Bräuner EV, Hickey M, Hansen ÅM, Doherty DA, Handelsman DJ, Juul A, Hart R. In-utero Exposure to Maternal Stressful Life Events and Risk of Cryptorchidism: The Raine Study. Front Endocrinol (Lausanne) 2019; 10:530. [PMID: 31428056 PMCID: PMC6688069 DOI: 10.3389/fendo.2019.00530] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Accepted: 07/17/2019] [Indexed: 11/13/2022] Open
Abstract
Cryptorchidism, registered at birth or later, is the most common birth defect in males in western countries, estimated to affect around 2-3% of newborn boys, declining to around 2% at 3 months. We have previously described a potential association between stressful life events (SLEs) in pregnancy and reduced semen quality and testosterone levels in adult offspring. Both outcomes are believed to share a common etiology with cryptorchidism thus increased risk of cryptorchidism in boys exposed to prenatal SLEs may be plausible. The risk of cryptorchidism associated with prenatal SLE amongst 1,273 male Generation 2 offspring was estimated using the Western Australian Pregnancy (Raine) Study. SLEs are discrete experiences that disrupt an individual's usual activities causing a life change and readjustment, such as death of a relative or friend, divorce, illness or job loss. Mothers prospectively reported SLEs, during pregnancy at gestational weeks (GW) 18 and 34 using a standardized 10-point questionnaire. A boy was diagnosed as cryptorchid if one or both testes was non-palpable in the scrotum and not able to be manipulated into the scrotum. Twenty-four (2%) cryptorchid boys were identified. Mean (standard deviation) of SLE exposures in GW34 was 1.1 (1.2) for non-cryptorchid boys and slightly higher 1.5 (1.8) for cryptorchid boys, similar differences were observed in GW18. Adjusted odds ratio [OR] and 95% confidence intervals (CI) for risk of cryptorchidism in early (18-weeks) and late gestation (34-weeks) according to prenatal SLE exposures were: 1.06 (95% CI: 0.77-1.45) and 1.18 (95% CI: 0.84-1.67), respectively. This is the first-time report on the possible relationships between exposure to early and late pregnancy SLEs and risk of cryptorchidism in a birth cohort. Prenatal SLE exposure was not associated with a statistically significant increase in the risk of cryptorchidism in male offspring. A small case population limits the statistical power of the study and future larger studies are required to evaluate this potential association.
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Affiliation(s)
- Elvira V. Bräuner
- Department of Growth and Reproduction, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- The International Research and Research Training Centre in Endocrine Disruption of Male Reproduction and Child Health, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Martha Hickey
- Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, VIC, Australia
| | - Åse Marie Hansen
- Department of Public Health, University of Copenhagen, Copenhagen, Denmark
- The National Research Centre for the Working Environment, Copenhagen, Denmark
| | - Dorota A. Doherty
- Division of Obstetrics and Gynaecology, University of Western Australia, Perth, WA, Australia
| | | | - Anders Juul
- Department of Growth and Reproduction, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- The International Research and Research Training Centre in Endocrine Disruption of Male Reproduction and Child Health, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Roger Hart
- Division of Obstetrics and Gynaecology, University of Western Australia, Perth, WA, Australia
- Fertility Specialists of Western Australia, Bethesda Hospital, Claremont, WA, Australia
- *Correspondence: Roger Hart
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19
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Rodprasert W, Virtanen HE, Mäkelä JA, Toppari J. Hypogonadism and Cryptorchidism. Front Endocrinol (Lausanne) 2019; 10:906. [PMID: 32010061 PMCID: PMC6974459 DOI: 10.3389/fendo.2019.00906] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2019] [Accepted: 12/11/2019] [Indexed: 01/24/2023] Open
Abstract
Congenital cryptorchidism (undescended testis) is one of the most common congenital urogenital malformations in boys. Prevalence of cryptorchidism at birth among boys born with normal birth weight ranges from 1.8 to 8.4%. Cryptorchidism is associated with a risk of low semen quality and an increased risk of testicular germ cell tumors. Testicular hormones, androgens and insulin-like peptide 3 (INSL3), have an essential role in the process of testicular descent from intra-abdominal position into the scrotum in fetal life. This explains the increased prevalence of cryptorchidism among boys with diseases or syndromes associated with congenitally decreased secretion or action of androgens, such as patients with congenital hypogonadism and partial androgen insensitivity syndrome. There is evidence to support that cryptorchidism is associated with decreased testicular hormone production later in life. It has been shown that cryptorchidism impairs long-term Sertoli cell function, but may also affect Leydig cells. Germ cell loss taking place in the cryptorchid testis is proportional to the duration of the condition, and therefore early orchiopexy to bring the testis into the scrotum is the standard treatment. However, the evidence for benefits of early orchiopexy for testicular endocrine function is controversial. The hormonal treatments using human chorionic gonadotropin (hCG) or gonadotropin-releasing hormone (GnRH) to induce testicular descent have low success rates, and therefore they are not recommended by the current guidelines for management of cryptorchidism. However, more research is needed to assess the effects of hormonal treatments during infancy on future male reproductive health.
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Affiliation(s)
- Wiwat Rodprasert
- Research Centre for Integrative Physiology and Pharmacology, Institute of Biomedicine, University of Turku, Turku, Finland
- The Population Research Centre, University of Turku, Turku, Finland
- *Correspondence: Wiwat Rodprasert
| | - Helena E. Virtanen
- Research Centre for Integrative Physiology and Pharmacology, Institute of Biomedicine, University of Turku, Turku, Finland
- The Population Research Centre, University of Turku, Turku, Finland
| | - Juho-Antti Mäkelä
- Research Centre for Integrative Physiology and Pharmacology, Institute of Biomedicine, University of Turku, Turku, Finland
- The Population Research Centre, University of Turku, Turku, Finland
| | - Jorma Toppari
- Research Centre for Integrative Physiology and Pharmacology, Institute of Biomedicine, University of Turku, Turku, Finland
- The Population Research Centre, University of Turku, Turku, Finland
- Department of Pediatrics, Turku University Hospital, Turku, Finland
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20
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Ellerkamp V, Schmid A, Blumenstock G, Hrivatakis G, Astfalk W, Loff S, Fuchs JJ, Zundel S. Guideline implementation for the treatment of undescended testes: Still room for improvement. J Pediatr Surg 2018; 53:2219-2224. [PMID: 29884555 DOI: 10.1016/j.jpedsurg.2018.05.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Revised: 05/07/2018] [Accepted: 05/10/2018] [Indexed: 12/16/2022]
Abstract
BACKGROUND Early orchidopexy (OP) around the age of 1 year is recommended in boys with congenital undescended testis (UDT) worldwide since decades. Former retrospectives studies did not distinguish congenital from acquired UDT with a consecutive negative bias concerning the age at surgery. METHODS In a retrospective analysis, data of all boys who underwent OP in eight pediatric surgery institutions from 2009 to 2015 were analyzed. Congenital or acquired UDT were differentiated. Patients were categorized into 3 groups of age at surgery: (1) <12 months, (2) 12-24 months, (3) >24 months. Data of one institution were analyzed in detail: exact age of first referral, exact age at surgery, intraoperative findings. RESULTS Out of 4448 boys, 3270 boys had congenital UDT. In 81% (2656 cases) surgery was performed beyond the age of 1 year, in 54.4% (1780) beyond the age of 2 years. chi-Square statistics showed a higher rate of early operations in hospitals compared to outpatient services and in Germany compared to Switzerland. In 694 congenital detailed cases, median age at referral was 13 months [range 0-196], median age at surgery was 15 months [range 0-202]. CONCLUSION Delayed referral is the main reason for guideline non-conform delayed surgery in UDT. TYPE OF STUDY Clinical Research paper. LEVEL OF EVIDENCE Level III: Treatment Study.
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Affiliation(s)
- Verena Ellerkamp
- University Hospital Tuebingen, Department for Pediatric Surgery and Pediatric Urology, Germany.
| | - Andreas Schmid
- University Hospital Tuebingen, Department for Pediatric Surgery and Pediatric Urology, Germany
| | - Gunnar Blumenstock
- Eberhard Karls University of Tuebingen, Department of Clinical Epidemiology and Applied Biostatistics, Germany
| | - Georg Hrivatakis
- Outpatient Clinic for Pediatric and Adolescent Surgery, Stuttgart, Germany
| | | | - Steffan Loff
- Olga hospital Stuttgart, Pediatric Surgery Clinic, Stuttgart, Germany
| | - Joerg Jörg Fuchs
- University Hospital Tuebingen, Department for Pediatric Surgery and Pediatric Urology, Germany
| | - Sabine Zundel
- Kantonsspital Lucerne, Department of Pediatric Surgery, Lucerne, Switzerland
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21
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Koskenniemi JJ, Virtanen HE, Wohlfahrt-Veje C, Löyttyniemi E, Skakkebaek NE, Juul A, Andersson AM, Main KM, Toppari J. Postnatal Changes in Testicular Position Are Associated With IGF-I and Function of Sertoli and Leydig Cells. J Clin Endocrinol Metab 2018; 103:1429-1437. [PMID: 29408984 DOI: 10.1210/jc.2017-01889] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2017] [Accepted: 01/26/2018] [Indexed: 02/13/2023]
Abstract
CONTEXT Despite clinical guidelines calling for repetitive examination of testicular position during childhood, little is known of normal changes in testicular position during childhood, let alone factors that control it. OBJECTIVE To assess changes in and factors associated with testicular position during childhood. DESIGN Testicular position (the distance from the pubic bone to the upper pole of the testes) at birth, 3 months, 18 months, 36 months, and 7 years and reproductive hormones at 3 months were measured. SETTING Prenatally recruited, prospective longitudinal birth cohort. PARTICIPANTS A total of 2545 boys were recruited prenatally in a Danish-Finnish birth cohort and had a testicular position examination available. A subset of 680 Danish and 362 Finnish boys had serum reproductive hormone concentrations and insulin-like growth factor I (IGF-I) determined at 3 months. MAIN OUTCOME MEASURES Testicular distance to pubic bone (TDP), serum reproductive hormone, and IGF-I concentrations. RESULTS TDP increased from birth to 3 months and decreased thereafter. Length, gestational age, weight for gestational age, and penile length were positively associated with larger TDP and thus lower testicular position in a linear mixed-effect model. Furthermore, IGF-I concentration, inhibin B/follicle-stimulating hormone ratio, and testosterone/luteinizing hormone ratio were all independently and positively associated with longer TDP. CONCLUSIONS We provide longitudinal data on postnatal changes in TDP. TDP is dynamic and associated with Leydig and Sertoli cell function as well as with IGF-I levels during the first months of life at mini-puberty of infancy. TDP may thus be a useful biomarker of postnatal testicular function.
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Affiliation(s)
- Jaakko J Koskenniemi
- Departments of Physiology, Institute of Biomedicine, Research Centre for Integrative Physiology and Pharmacology, University of Turku, Turku, Finland
- Department of Pediatrics, Turku University Hospital, Turku, Finland
| | - Helena E Virtanen
- Departments of Physiology, Institute of Biomedicine, Research Centre for Integrative Physiology and Pharmacology, University of Turku, Turku, Finland
| | - Christine Wohlfahrt-Veje
- Department of Growth and Reproduction and EDMaRC, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | | | - Niels E Skakkebaek
- Department of Growth and Reproduction and EDMaRC, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Anders Juul
- Department of Growth and Reproduction and EDMaRC, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Anna-Maria Andersson
- Department of Growth and Reproduction and EDMaRC, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Katharina M Main
- Department of Growth and Reproduction and EDMaRC, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Jorma Toppari
- Departments of Physiology, Institute of Biomedicine, Research Centre for Integrative Physiology and Pharmacology, University of Turku, Turku, Finland
- Department of Pediatrics, Turku University Hospital, Turku, Finland
- Department of Growth and Reproduction and EDMaRC, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
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Kohva E, Miettinen PJ, Taskinen S, Hero M, Tarkkanen A, Raivio T. Disorders of sex development: timing of diagnosis and management in a single large tertiary center. Endocr Connect 2018; 7:595-603. [PMID: 29581155 PMCID: PMC5911703 DOI: 10.1530/ec-18-0070] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Accepted: 03/26/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND We describe the phenotypic spectrum and timing of diagnosis and management in a large series of patients with disorders of sexual development (DSD) treated in a single pediatric tertiary center. METHODS DSD patients who had visited our tertiary center during the survey period (between 2004 and 2014) were identified based on an ICD-10 inquiry, and their phenotypic and molecular genetic findings were recorded from patient charts. RESULTS Among the 550 DSD patients, 53.3% had 46,XY DSD; 37.1% had sex chromosome DSD and 9.6% had 46,XX DSD. The most common diagnoses were Turner syndrome (19.8%, diagnosed at the mean age of 4.7 ± 5.5 years), Klinefelter syndrome (14.5%, 6.8 ± 6.2 years) and bilateral cryptorchidism (23.1%). Very few patients with 46,XY DSD (7%) or 46,XX DSD (21%) had molecular genetic diagnosis. The yearly rate of DSD diagnoses remained stable over the survey period. After the release of the Nordic consensus on the management of undescended testes, the age at surgery for bilateral cryptorchidism declined significantly (P < 0.001). CONCLUSIONS Our results show that (i) Turner syndrome and Klinefelter syndrome, the most frequent single DSD diagnoses, are still diagnosed relatively late; (ii) a temporal shift was observed in the management of bilateral cryptorchidism, which may favorably influence patients' adulthood semen quality and (iii) next-generation sequencing methods are not fully employed in the diagnostics of DSD patients.
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Affiliation(s)
- E Kohva
- Children's HospitalPediatric Research Center, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Faculty of MedicineDepartment of Physiology, University of Helsinki, Helsinki, Finland
| | - P J Miettinen
- Children's HospitalPediatric Research Center, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - S Taskinen
- Children's HospitalPediatric Research Center, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Department of Pediatric SurgeryChildren's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - M Hero
- Children's HospitalPediatric Research Center, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - A Tarkkanen
- Children's HospitalPediatric Research Center, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Faculty of MedicineDepartment of Physiology, University of Helsinki, Helsinki, Finland
| | - T Raivio
- Children's HospitalPediatric Research Center, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Faculty of MedicineDepartment of Physiology, University of Helsinki, Helsinki, Finland
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Bergbrant S, Omling E, Björk J, Hagander L. Cryptorchidism in Sweden: A Nationwide Study of Prevalence, Operative Management, and Complications. J Pediatr 2018; 194:197-203.e6. [PMID: 29331326 DOI: 10.1016/j.jpeds.2017.09.062] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Revised: 08/25/2017] [Accepted: 09/22/2017] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To review the cumulative prevalence, operative management, and complications of treatment for cryptorchidism in Sweden. STUDY DESIGN A nationwide observational study from longitudinal register data of all Swedish-born boys 0-18 years of age, diagnosed with cryptorchidism from 2001 to 2014. Primary outcomes were occurrence and age at primary surgery. Secondary outcomes included type of procedure and surgical site infection. RESULTS Of 20 375 boys diagnosed with cryptorchidism in 2001-2014, 12 766 were surgically treated. The cumulative childhood prevalence was 1.8% (95% CI, 1.5-2.0), with a higher prevalence in boys born prematurely, small for gestational age, or with low birth weight. The median age at treatment decreased from 6.2 years in 2001 to 3.4 years in 2014 (P < .001). Still, 94.1% (95% CI, 92.7-95.6) had surgery after the recommended 1 year of age in 2014. Variations in age at surgery between Swedish counties were great (range, 2.9-5.9 years of age). There were no deaths within 30 days after surgery and the frequency of surgical site infection was low (1.4%; 95% CI, 1.1-1.6). CONCLUSIONS The cumulative childhood prevalence of cryptorchidism was high, and complications were rare. Few boys underwent surgery in a timely manner according to clinical guidelines, and standards of care varied considerably across the country. Further research and collective actions are needed to improve the detection and management of congenital cryptorchidism.
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Affiliation(s)
- Susanna Bergbrant
- Lund University, Skåne University Hospital, World Health Organization Collaborating Center for Surgery and Public Health, Department of Clinical Sciences Lund, Pediatric Surgery, Lund, Sweden
| | - Erik Omling
- Lund University, Skåne University Hospital, World Health Organization Collaborating Center for Surgery and Public Health, Department of Clinical Sciences Lund, Pediatric Surgery, Lund, Sweden
| | - Jonas Björk
- Lund University, Skåne University Hospital, Department of Laboratory Medicine, Lund, Sweden; Clinical Studies Sweden, Forum South, Skåne University Hospital, Lund, Sweden
| | - Lars Hagander
- Lund University, Skåne University Hospital, World Health Organization Collaborating Center for Surgery and Public Health, Department of Clinical Sciences Lund, Pediatric Surgery, Lund, Sweden.
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Chen J, Sørensen HT, Miao M, Liang H, Ehrenstein V, Wang Z, Yuan W, Li J. Cryptorchidism and increased risk of neurodevelopmental disorders. J Psychiatr Res 2018; 96:153-161. [PMID: 29065375 DOI: 10.1016/j.jpsychires.2017.10.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Revised: 10/08/2017] [Accepted: 10/12/2017] [Indexed: 12/13/2022]
Abstract
Male congenital malformations as cryptorchidism may contribute to the development of neurodevelopmental disorders directly or via shared familial genetic and/or environmental factors, but the evidence is sparse. Using population-based health registries, we conducted a cohort study of all liveborn singleton boys in Denmark during 1979-2008. Boys with a diagnosis of cryptorchidism were categorized into the exposed cohort and the other boys into the unexposed comparison cohort. The outcomes were diagnoses of any neurodevelopmental disorders and their subtypes. We used Cox proportional hazards regression to compute hazard ratios (HRs), taking into consideration several potential confounders. Among 884,083 male infants, 27,505 received a diagnosis of cryptorchidism during follow-up. Boys with cryptorchidism were more likely to be diagnosed with intellectual disability (HR = 1.77; 95%confidence interval [CI]:1.59,1.97), autism spectrum disorders (ASD) (HR = 1.24; 95% CI:1.13,1.35), attention-deficit hyperactivity disorder (ADHD) (HR = 1.17; 95% CI: 1.08,1.26), anxiety (HR = 1.09; 95% CI: 1.01,1.17), and other behavioral/emotional disorders (HR = 1.16; 95% CI: 1.08,1.26) compared to boys without cryptorchidism. The observed risks of intellectual disability, ASD, and ADHD were increased further in boys with bilateral cryptorchidism. Except for anxiety, cryptorchid boys had higher risks of neurodevelopmental disorders than their non-cryptorchid full brothers. The observed increased risks were similar among boys who underwent orchiopexy, as well as among those with shorter waiting times for this surgery. Cryptorchidism may be associated with increased risks of intellectual disability, ASD, ADHD, and other behavioral/emotional disorders. Cryptorchidism and neurodevelopmental disorders may have shared genetic or in-utero/early postnatal risk factors, which need to be further investigated.
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Affiliation(s)
- Jianping Chen
- Key Lab. of Reproduction Regulation of NPFPC, SIPPR, IRD, Fudan University, Shanghai, China; Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - Henrik Toft Sørensen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - Maohua Miao
- Key Lab. of Reproduction Regulation of NPFPC, SIPPR, IRD, Fudan University, Shanghai, China
| | - Hong Liang
- Key Lab. of Reproduction Regulation of NPFPC, SIPPR, IRD, Fudan University, Shanghai, China
| | - Vera Ehrenstein
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - Ziliang Wang
- Key Lab. of Reproduction Regulation of NPFPC, SIPPR, IRD, Fudan University, Shanghai, China
| | - Wei Yuan
- Key Lab. of Reproduction Regulation of NPFPC, SIPPR, IRD, Fudan University, Shanghai, China.
| | - Jiong Li
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
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Abstract
UNLABELLED The authors compared the age and referral patterns of pediatric patients undergoing surgical intervention for cryptorchidism at a rural, West Virginia University, versus urban, Johns Hopkins University, tertiary center. A retrospective review of patients undergoing surgical evaluation for cryptorchidism was performed. Patients treated for reasons unrelated to cryptorchidism or referred for multiple urologic diagnoses were excluded. The patients at each institution were then divided into four groups based on their corrected gestational age at time of surgery. Referral times and provider specialties were also obtained. A total of 131 cases at the urban center and 100 cases at the rural center were identified. At the rural center, the average age of referral and surgery were 48.3 and 53.8 months, respectively, compared to 59.6 and 65.2 months at the urban center. Only 40% of patients at the rural site and 29% at the urban institution underwent intervention at less than 18 months of age. There was no significant difference in time of referral to surgery between the institutions. The majority of referrals were made by private practice pediatricians. CONCLUSION In this study, a pattern of delayed referral and intervention was observed at both institutions despite differing geographic regions and heterogeneous patient populations. It is important that referring providers realize that scrotal U/S does not change management of UDT and should not delay prompt referral. What is known: • Significant referral delay is a challenging issue in the management of cryptorchidism. • Ultrasound is not a valid method for the detection of cryptorchidism. What is new: • The rural and urban management of cryptorchidism is not that different. • More emphasis should be put on the detection management of cryptorchidism.
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Abstract
Undescended testis - known as cryptorchidism - is one of the most common congenital abnormalities observed in boys, and is one of the few known risk factors for testicular cancer. The key factors that contribute to the occurrence of cryptorchidism remain elusive. Testicular descent is thought to occur during two hormonally-controlled phases in fetal development - between 8-15 weeks (the first phase of decent) and 25-35 weeks gestation (the second phase of descent); the failure of a testis to descend permanently is probably caused by disruptions to one or both of these phases, but the causes and mechanisms of such disruptions are still unclear. A broad range of putative risk factors have been evaluated in relation to the development of cryptorchidism but their plausibility is still in question. Consistent evidence of an association with cryptorchidism exists for only a few factors, and in those cases in which evidence seems unequivocal the factor is likely to be a surrogate for the true causal exposure. The relative importance of each risk factor could vary considerably between mother-son pairs depending on an array of genetic, maternal, placental and fetal factors - all of which could vary between regions. Thus, the role of causative factors in aetiology of cryptorchidism requires further research.
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Savoie KB, Bachier-Rodriguez M, Schurtz E, Tolley EA, Giel D, Feliz A. Health Disparities in the Appropriate Management of Cryptorchidism. J Pediatr 2017; 185:187-192.e1. [PMID: 28408128 DOI: 10.1016/j.jpeds.2017.03.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2016] [Revised: 01/09/2017] [Accepted: 03/01/2017] [Indexed: 10/19/2022]
Abstract
OBJECTIVE To assess regional practices in management of cryptorchidism with regard to timely fixation by the current recommended age of 18 months. STUDY DESIGN A retrospective study was performed. Charts of all patients who underwent surgical correction for cryptorchidism by a pediatric general surgeon or urologist within a tertiary pediatric hospital in an urban setting were systematically reviewed. RESULTS We identified 1209 patients with cryptorchidism. The median age of surgical correction was 3.7 years (IQR: 1.4, 7.7); only 27% of patients had surgical correction before 18 months of age. Forty-six percent of our patients were white, 40% were African American, and 8% were Hispanic. African American and Hispanic patients were less likely to undergo timely repair (P?=?.01), as were those with public or no insurance (P?<?.0001). A majority (72%) of patients had no diagnostic imaging prior to surgery. A majority of patients had palpable testes at operation (85%) and underwent inguinal orchiopexy (76%); 82% were operated on by a pediatric urologist. Only 35 patients (3%) experienced a complication; those repaired late were significantly less likely to develop a complication (P?=?.03). There were no differences in age at time of surgery by surgeon type. CONCLUSIONS A majority of our patients were not referred for surgical intervention in a timely manner, which may reflect poor access to care in our region. Public and self-pay insurance status was associated with delayed repair. Education of community physicians and families could be potentially beneficial.
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Affiliation(s)
- Kate B Savoie
- Department of General Surgery, University of Tennessee Health Science Center, Memphis, TN; Le Bonheur Foundation, Le Bonheur Children's Hospital, Memphis, TN.
| | - Marielena Bachier-Rodriguez
- Department of General Surgery, University of Tennessee Health Science Center, Memphis, TN; Le Bonheur Foundation, Le Bonheur Children's Hospital, Memphis, TN
| | - Elleson Schurtz
- Department of Urology, University of Tennessee Health Science Center, Memphis, TN
| | - Elizabeth A Tolley
- Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis, TN
| | - Dana Giel
- Department of Urology, University of Tennessee Health Science Center, Memphis, TN
| | - Alexander Feliz
- Department of General Surgery, University of Tennessee Health Science Center, Memphis, TN
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Mittal PK, Little B, Harri PA, Miller FH, Alexander LF, Kalb B, Camacho JC, Master V, Hartman M, Moreno CC. Role of Imaging in the Evaluation of Male Infertility. Radiographics 2017; 37:837-854. [DOI: 10.1148/rg.2017160125] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
Affiliation(s)
- Pardeep K. Mittal
- From the Department of Radiology and Imaging Sciences (P.K.M., B.L., P.A.H., L.F.A., J.C.C., C.C.M.) and Department of Urology (V.M.), Emory University School of Medicine, 1364 Clifton Rd NE, Atlanta, GA 30322; Department of Radiology, Northwestern University Feinberg School of Medicine, Chicago, Ill (F.H.M.); Department of Medical Imaging, University of Arizona School of Medicine, Tucson, Ariz (B.K.); and Department of Radiology, West Penn Allegheny Health System, Pittsburgh, Pa (M.H.)
| | - Brent Little
- From the Department of Radiology and Imaging Sciences (P.K.M., B.L., P.A.H., L.F.A., J.C.C., C.C.M.) and Department of Urology (V.M.), Emory University School of Medicine, 1364 Clifton Rd NE, Atlanta, GA 30322; Department of Radiology, Northwestern University Feinberg School of Medicine, Chicago, Ill (F.H.M.); Department of Medical Imaging, University of Arizona School of Medicine, Tucson, Ariz (B.K.); and Department of Radiology, West Penn Allegheny Health System, Pittsburgh, Pa (M.H.)
| | - Peter A. Harri
- From the Department of Radiology and Imaging Sciences (P.K.M., B.L., P.A.H., L.F.A., J.C.C., C.C.M.) and Department of Urology (V.M.), Emory University School of Medicine, 1364 Clifton Rd NE, Atlanta, GA 30322; Department of Radiology, Northwestern University Feinberg School of Medicine, Chicago, Ill (F.H.M.); Department of Medical Imaging, University of Arizona School of Medicine, Tucson, Ariz (B.K.); and Department of Radiology, West Penn Allegheny Health System, Pittsburgh, Pa (M.H.)
| | - Frank H. Miller
- From the Department of Radiology and Imaging Sciences (P.K.M., B.L., P.A.H., L.F.A., J.C.C., C.C.M.) and Department of Urology (V.M.), Emory University School of Medicine, 1364 Clifton Rd NE, Atlanta, GA 30322; Department of Radiology, Northwestern University Feinberg School of Medicine, Chicago, Ill (F.H.M.); Department of Medical Imaging, University of Arizona School of Medicine, Tucson, Ariz (B.K.); and Department of Radiology, West Penn Allegheny Health System, Pittsburgh, Pa (M.H.)
| | - Lauren F. Alexander
- From the Department of Radiology and Imaging Sciences (P.K.M., B.L., P.A.H., L.F.A., J.C.C., C.C.M.) and Department of Urology (V.M.), Emory University School of Medicine, 1364 Clifton Rd NE, Atlanta, GA 30322; Department of Radiology, Northwestern University Feinberg School of Medicine, Chicago, Ill (F.H.M.); Department of Medical Imaging, University of Arizona School of Medicine, Tucson, Ariz (B.K.); and Department of Radiology, West Penn Allegheny Health System, Pittsburgh, Pa (M.H.)
| | - Bobby Kalb
- From the Department of Radiology and Imaging Sciences (P.K.M., B.L., P.A.H., L.F.A., J.C.C., C.C.M.) and Department of Urology (V.M.), Emory University School of Medicine, 1364 Clifton Rd NE, Atlanta, GA 30322; Department of Radiology, Northwestern University Feinberg School of Medicine, Chicago, Ill (F.H.M.); Department of Medical Imaging, University of Arizona School of Medicine, Tucson, Ariz (B.K.); and Department of Radiology, West Penn Allegheny Health System, Pittsburgh, Pa (M.H.)
| | - Juan C. Camacho
- From the Department of Radiology and Imaging Sciences (P.K.M., B.L., P.A.H., L.F.A., J.C.C., C.C.M.) and Department of Urology (V.M.), Emory University School of Medicine, 1364 Clifton Rd NE, Atlanta, GA 30322; Department of Radiology, Northwestern University Feinberg School of Medicine, Chicago, Ill (F.H.M.); Department of Medical Imaging, University of Arizona School of Medicine, Tucson, Ariz (B.K.); and Department of Radiology, West Penn Allegheny Health System, Pittsburgh, Pa (M.H.)
| | - Viraj Master
- From the Department of Radiology and Imaging Sciences (P.K.M., B.L., P.A.H., L.F.A., J.C.C., C.C.M.) and Department of Urology (V.M.), Emory University School of Medicine, 1364 Clifton Rd NE, Atlanta, GA 30322; Department of Radiology, Northwestern University Feinberg School of Medicine, Chicago, Ill (F.H.M.); Department of Medical Imaging, University of Arizona School of Medicine, Tucson, Ariz (B.K.); and Department of Radiology, West Penn Allegheny Health System, Pittsburgh, Pa (M.H.)
| | - Matthew Hartman
- From the Department of Radiology and Imaging Sciences (P.K.M., B.L., P.A.H., L.F.A., J.C.C., C.C.M.) and Department of Urology (V.M.), Emory University School of Medicine, 1364 Clifton Rd NE, Atlanta, GA 30322; Department of Radiology, Northwestern University Feinberg School of Medicine, Chicago, Ill (F.H.M.); Department of Medical Imaging, University of Arizona School of Medicine, Tucson, Ariz (B.K.); and Department of Radiology, West Penn Allegheny Health System, Pittsburgh, Pa (M.H.)
| | - Courtney C. Moreno
- From the Department of Radiology and Imaging Sciences (P.K.M., B.L., P.A.H., L.F.A., J.C.C., C.C.M.) and Department of Urology (V.M.), Emory University School of Medicine, 1364 Clifton Rd NE, Atlanta, GA 30322; Department of Radiology, Northwestern University Feinberg School of Medicine, Chicago, Ill (F.H.M.); Department of Medical Imaging, University of Arizona School of Medicine, Tucson, Ariz (B.K.); and Department of Radiology, West Penn Allegheny Health System, Pittsburgh, Pa (M.H.)
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29
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Kristensen DM, Mazaud-Guittot S, Gaudriault P, Lesné L, Serrano T, Main KM, Jégou B. Analgesic use - prevalence, biomonitoring and endocrine and reproductive effects. Nat Rev Endocrinol 2016; 12:381-93. [PMID: 27150289 DOI: 10.1038/nrendo.2016.55] [Citation(s) in RCA: 105] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Paracetamol and NSAIDs, in particular acetylsalicylic acid (aspirin) and ibuprofen, are among the most used and environmentally released pharmaceutical drugs. The differences in international trends in the sale and consumption of mild analgesics reflect differences in marketing, governmental policies, habits, accessibility, disease patterns and the age distribution of each population. Biomonitoring indicates ubiquitous and high human exposure to paracetamol and to salicylic acid, which is the main metabolite of acetylsalicylic acid. Furthermore, evidence suggests that analgesics can have endocrine disruptive properties capable of altering animal and human reproductive function from fetal life to adulthood in both sexes. Medical and public awareness about these health concerns should be increased, particularly among pregnant women.
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Affiliation(s)
- David M Kristensen
- Genomic and Molecular Biomedicine, Department of Biology, University of Copenhagen, Ole Maaløes Vej 5, DK-2200 Copenhagen N, Denmark
| | - Séverine Mazaud-Guittot
- Institut national de la santé et de la recherche médicale (Inserm), Institut de recherche en santé, environnement et travail (Irset-Inserm UMR 1085), 9 Avenue Léon Bernard, F-35042 RENNES, France
| | - Pierre Gaudriault
- Institut national de la santé et de la recherche médicale (Inserm), Institut de recherche en santé, environnement et travail (Irset-Inserm UMR 1085), 9 Avenue Léon Bernard, F-35042 RENNES, France
| | - Laurianne Lesné
- Institut national de la santé et de la recherche médicale (Inserm), Institut de recherche en santé, environnement et travail (Irset-Inserm UMR 1085), 9 Avenue Léon Bernard, F-35042 RENNES, France
| | - Tania Serrano
- Institut national de la santé et de la recherche médicale (Inserm), Institut de recherche en santé, environnement et travail (Irset-Inserm UMR 1085), 9 Avenue Léon Bernard, F-35042 RENNES, France
- Ecole des hautes études en santé publique (EHESP), Avenue Léon Bernard, F-35043 RENNES, France
| | - Katharina M Main
- Department of Growth and Reproduction, University of Copenhagen, Section GR5064, Blegdamsvej 9, Rigshospitalet, DK-2100 Copenhagen, Denmark
| | - Bernard Jégou
- Institut national de la santé et de la recherche médicale (Inserm), Institut de recherche en santé, environnement et travail (Irset-Inserm UMR 1085), 9 Avenue Léon Bernard, F-35042 RENNES, France
- Ecole des hautes études en santé publique (EHESP), Avenue Léon Bernard, F-35043 RENNES, France
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30
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Thankamony A, Pasterski V, Ong KK, Acerini CL, Hughes IA. Anogenital distance as a marker of androgen exposure in humans. Andrology 2016; 4:616-25. [PMID: 26846869 PMCID: PMC6225986 DOI: 10.1111/andr.12156] [Citation(s) in RCA: 145] [Impact Index Per Article: 18.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2015] [Revised: 12/06/2015] [Accepted: 12/09/2015] [Indexed: 12/20/2022]
Abstract
Abnormal foetal testis development has been proposed to underlie common disorders of the male reproductive system such as cryptorchidism, hypospadias, reduced semen quality and testicular germ cell tumour, which are regarded as components of a 'testicular dysgenesis syndrome'. The increasing trends and geographical variation in their incidence have been suggested to result from in utero exposure to environmental chemicals acting as endocrine disruptors. In rodents, the anogenital distance (AGD), measured from the anus to the base of genital tubercle, is a sensitive biomarker of androgen exposure during a critical embryonic window of testis development. In humans, several epidemiological studies have shown alterations in AGD associated with prenatal exposure to several chemicals with potential endocrine disrupting activity. However, the link between AGD and androgen exposure in humans is not well-defined. This review focuses on the current evidence for such a relationship. As in rodents, a clear gender difference is detected during foetal development of the AGD in humans which is maintained thereafter. Reduced AGD in association with clinically relevant outcomes of potential environmental exposures, such as cryptorchidism or hypospadias, is in keeping with AGD as a marker of foetal testicular function. Furthermore, AGD may reflect variations in prenatal androgen exposure in healthy children as shorter AGD at birth is associated with reduced masculine play behaviour in preschool boys. Several studies provide evidence linking shorter AGD with lower fertility, semen quality and testosterone levels in selected groups of adults attending andrology clinics. Overall, the observational data in humans are consistent with experimental studies in animals and support the use of AGD as a biomarker of foetal androgen exposure. Future studies evaluating AGD in relation to reproductive hormones in both infants and adults, and to gene polymorphisms, will help to further delineate the effect of prenatal and postnatal androgen exposures on AGD.
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Affiliation(s)
- Ajay Thankamony
- Department of Paediatrics, Addenbrooke’s Hospital, University of Cambridge, Cambridge, CB2 0QQ, UK
| | - Vickie Pasterski
- Department of Paediatrics, Addenbrooke’s Hospital, University of Cambridge, Cambridge, CB2 0QQ, UK
- Department of Psychology, University of Cambridge, Cambridge, CB2 3RQ, UK
| | - Ken K Ong
- MRC Epidemiology Unit, Institute of Metabolic Science, University of Cambridge, Cambridge, CB2 0QQ, UK
| | - Carlo L Acerini
- Department of Paediatrics, Addenbrooke’s Hospital, University of Cambridge, Cambridge, CB2 0QQ, UK
| | - Ieuan A Hughes
- Department of Paediatrics, Addenbrooke’s Hospital, University of Cambridge, Cambridge, CB2 0QQ, UK
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Rod J, Marret JB, Dupont C, Ravasse P. [The surgical management of undescended testis between 6 and 12 months: A difficult message to convey]. Arch Pediatr 2016; 23:477-80. [PMID: 27017360 DOI: 10.1016/j.arcped.2016.02.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2015] [Revised: 12/23/2015] [Accepted: 02/09/2016] [Indexed: 11/25/2022]
Abstract
PURPOSE The undescended testis (UT) is the most common congenital malformation of the genital apparatus in male infants. The main objective of the management of these patients is to reduce the risk of infertility and cancer. Since these risks increase with age of operation, learned societies have recommended earlier intervention. Following the publication in 2007 of the Nordic consensus that called for an intervention between 6 and 12 months of age, we issued this message to medical students in the Lower Normandy region of France. The aim of this study was to evaluate the implementation of this teaching through the evolution of the number of children operated between 6 and 12 months for a congenital UT in our center. MATERIAL AND METHODS Between 2005 and 2014, we evaluated the yearly percentage of children operated for UT between 6 and 12 months compared to the percentage of children operated on between 12 and 24 months. A statistical study using the Chi(2) test was used to compare the 2005-2008 and 2009-2012 periods. RESULTS The percentage of children operated on between 6 and 12 months of age increased from 13.7 % between 2005 and 2008 to 17.2 % between 2009 and 2014. From 2012 on, the number of children operated on between 6 and 12 months was consistently higher than the number of children operated on between 12 and 24 months. The proportion of children operated beyond 2 years remained stable over the study period. CONCLUSION Since we implemented teaching of early surgery for children with UT, we have observed a gradual increase in the number of children operated between 6 and 12 months of age. Nevertheless, there are still many children operated between 12 and 24 months and beyond.
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Affiliation(s)
- J Rod
- Service de chirurgie pédiatrique, CHU de Caen, avenue Côte-de-Nacre, 14000 Caen, France; Université de Caen Basse-Normandie, UFR de médecine, 14000 Caen, France.
| | - J-B Marret
- Service de chirurgie pédiatrique, CHU de Caen, avenue Côte-de-Nacre, 14000 Caen, France; Université de Caen Basse-Normandie, UFR de médecine, 14000 Caen, France
| | - C Dupont
- Université de Caen Basse-Normandie, UFR de médecine, 14000 Caen, France; Service de pédiatrie, CHU de Caen, 14000 Caen, France
| | - P Ravasse
- Service de chirurgie pédiatrique, CHU de Caen, avenue Côte-de-Nacre, 14000 Caen, France; Université de Caen Basse-Normandie, UFR de médecine, 14000 Caen, France
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Schneuer FJ, Holland AJA, Pereira G, Jamieson S, Bower C, Nassar N. Age at Surgery and Outcomes of an Undescended Testis. Pediatrics 2016; 137:e20152768. [PMID: 26801912 DOI: 10.1542/peds.2015-2768] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/16/2015] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Undescended testis (UDT) is the most common genital anomaly in boys. Current guidelines recommend surgery before 12 months of age to maximize fertility and potentially reduce the risk of future malignancy. We investigated the prevalence of UDT and examined rates of surgery and age at surgery in an Australian population. METHODS UDT was identified from all live-born infants in New South Wales, Australia, from 2001 to 2011 using routinely collected record-linked birth and hospital data. The prevalence of UDT, surgery rates, age at surgery, postsurgical outcomes, and risk factors for surgery performed later than the recommended age were evaluated. RESULTS There were 10 875 (2.1%) boys with a recorded diagnosis of UDT. Corrective surgery was performed in 4980 (45.8%), representing a cumulative prevalence of 9.6 per 1000 male births. Five percent of surgeries were orchidectomies, and 9% of boys had revision surgery. Median age at surgery was 16.6 months (interquartile range 11.8 to 31.0 months), decreasing from 21 months for boys born in 2001 to 13 months for boys born in 2010. Among those boys having surgery before 36 months (n = 3897), 67% had corrective surgery after the recommended 12 months of age; socioeconomic disadvantage, regional/remote area of residence, and lack of private health insurance were risk factors for having corrective surgery after 12 months. CONCLUSIONS One in 50 boys born are diagnosed with UDT; two-thirds had no report of corrective surgery. The age at surgery is decreasing; however, two-thirds of surgeries are performed after 12 months of age.
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Affiliation(s)
- Francisco Javier Schneuer
- Clinical and Population Perinatal Health Research, Kolling Institute, The University of Sydney, Northern Sydney Local Health District, St. Leonards, New South Wales, Australia; Menzies Centre for Health Policy, School of Public Health, Sydney Medical School,The University of Sydney, New South Wales, Australia and
| | - Andrew J A Holland
- Discipline of Paediatrics and Child Health, The Children's Hospital at Westmead, Sydney Medical School, The University of Sydney, New South Wales, Australia
| | - Gavin Pereira
- School of Public Health, Curtin University, Bentley, Western Australia; and
| | - Sarra Jamieson
- Telethon Kids Institute, The University of Western Australia, Crawley, Western Australia
| | - Carol Bower
- Telethon Kids Institute, The University of Western Australia, Crawley, Western Australia
| | - Natasha Nassar
- Clinical and Population Perinatal Health Research, Kolling Institute, The University of Sydney, Northern Sydney Local Health District, St. Leonards, New South Wales, Australia; Menzies Centre for Health Policy, School of Public Health, Sydney Medical School,The University of Sydney, New South Wales, Australia and
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Abstract
Congenital cryptorchidism, that is, undescended testis, is one of the most common urogenital abnormalities observed in newborn boys. In addition to the congenital form, there is also acquired form of cryptorchidism. Fertility potential of patients with cryptorchidism has been evaluated by testicular histology and volume, semen quality, reproductive hormone levels, time to conception, and paternity rates. Cryptorchidism is associated with abnormalities in testicular development, and early treatment is recommended to optimize the fertility potential of the patients.
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Affiliation(s)
- Helena E Virtanen
- Department of Physiology, Institute of Biomedicine, University of Turku, Kiinamyllynkatu 4-8, Turku FI-20520, Finland.
| | - Jorma Toppari
- Department of Physiology, Institute of Biomedicine, University of Turku, Kiinamyllynkatu 4-8, Turku FI-20520, Finland; Department of Pediatrics, Turku University Hospital, Kiinamyllynkatu 10, Turku FI-20520, Finland
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Boehm U, Bouloux PM, Dattani MT, de Roux N, Dodé C, Dunkel L, Dwyer AA, Giacobini P, Hardelin JP, Juul A, Maghnie M, Pitteloud N, Prevot V, Raivio T, Tena-Sempere M, Quinton R, Young J. Expert consensus document: European Consensus Statement on congenital hypogonadotropic hypogonadism--pathogenesis, diagnosis and treatment. Nat Rev Endocrinol 2015; 11:547-64. [PMID: 26194704 DOI: 10.1038/nrendo.2015.112] [Citation(s) in RCA: 509] [Impact Index Per Article: 56.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Congenital hypogonadotropic hypogonadism (CHH) is a rare disorder caused by the deficient production, secretion or action of gonadotropin-releasing hormone (GnRH), which is the master hormone regulating the reproductive axis. CHH is clinically and genetically heterogeneous, with >25 different causal genes identified to date. Clinically, the disorder is characterized by an absence of puberty and infertility. The association of CHH with a defective sense of smell (anosmia or hyposmia), which is found in ∼50% of patients with CHH is termed Kallmann syndrome and results from incomplete embryonic migration of GnRH-synthesizing neurons. CHH can be challenging to diagnose, particularly when attempting to differentiate it from constitutional delay of puberty. A timely diagnosis and treatment to induce puberty can be beneficial for sexual, bone and metabolic health, and might help minimize some of the psychological effects of CHH. In most cases, fertility can be induced using specialized treatment regimens and several predictors of outcome have been identified. Patients typically require lifelong treatment, yet ∼10-20% of patients exhibit a spontaneous recovery of reproductive function. This Consensus Statement summarizes approaches for the diagnosis and treatment of CHH and discusses important unanswered questions in the field.
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Affiliation(s)
- Ulrich Boehm
- University of Saarland School of Medicine, Germany
| | | | | | | | | | | | - Andrew A Dwyer
- Endocrinology, Diabetes and Metabolism Sevice of the Centre Hospitalier Universitaire Vaudois (CHUV), du Bugnon 46, Lausanne 1011, Switzerland
| | | | | | | | | | - Nelly Pitteloud
- Endocrinology, Diabetes and Metabolism Sevice of the Centre Hospitalier Universitaire Vaudois (CHUV), du Bugnon 46, Lausanne 1011, Switzerland
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Abstract
BACKGROUND Cryptorchidism (undescended testis) is a common anomaly with largely unexplained etiology. Animal studies have suggested maternal emotional stress as a potential risk factor, but this has not been studied in humans. We aimed to investigate whether maternal bereavement due to the death of a close relative in the antenatal period increases the occurrence of cryptorchidism in the offspring. METHODS In a population-based cohort, we studied death of a close relative as the exposure and cryptorchidism entries in nationwide medical registries as the outcome. Danish national registries included 898,961 (23,609 exposed) boys born from 1978 to 2008 with a maximum of 30 years of follow-up. RESULTS A total of 20,947 boys had cryptorchidism, of whom 13,524 also underwent corrective surgery. We found no increased occurrence of cryptorchidism in the offspring (hazard ratio = 1.02 [95% confidence interval = 0.92-1.14]). Results were similar when the diagnosis was verified with surgery. We adjusted for maternal and paternal age, birth year, and family history of cryptorchidism. CONCLUSION We observed no association between maternal bereavement before and during pregnancy and the occurrence of cryptorchidism in the offspring.
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36
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Xian H, Xian Y, Liu L, Wang Y, He J, Huang J. Expression of β-nerve growth factor and homeobox A10 in experimental cryptorchidism treated with exogenous nerve growth factor. Mol Med Rep 2014; 11:2875-81. [PMID: 25434417 DOI: 10.3892/mmr.2014.3005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2014] [Accepted: 10/24/2014] [Indexed: 11/06/2022] Open
Abstract
With the exception of standard inguinal orchidopexy, treatment of cryptorchidism with human chorionic gonadotropin has been performed for several years; however, its side effects have limited its application. The β‑nerve growth factor (NGF) and homeobox A10 (HoxA10) genes are closely associated with the development of the testes. To the best of our knowledge, whether exogenous NGF alters the endogenous levels of NGF and HoxA10 in cryptorchidism in rats remains to be elucidated. The aim of the present study was to evaluate the gene and protein expression of NGF and HoxA10 in experimental cryptorchidism following treatment with exogenous NGF. A unilateral mechanical cryptorchidism model in Sprague-Dawley rats was established and different concentrations of exogenous NGF were administered to observe the effects of NGF on cryptorchidism. Changes in the gene and protein expression levels of NGF and HoxA10 in the cryptorchid tissues of each group were identified using one step reverse transcription-quantitative polymerase chain reaction, in situ hybridization with digoxigenin‑labeled‑β‑NGF RNA probes, immunofluorescence and immunohistochemistry, respectively. The expression levels of NGF and HoxA10 were markedly higher in the group treated with a high dose of exogenous NGF compared with the group treated with a low dose of exogenous NGF and the group treated with human chorionic gonadotropin. These results confirmed the potential therapeutic effect of exogenous NGF in human cryptorchidism.
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Affiliation(s)
- Hua Xian
- Department of Pediatric Surgery, Affiliated Hospital of Nantong University, Nantong, Jiangsu 226001, P.R. China
| | - Yun Xian
- Department of Public Health College, Nantong University, Nantong, Jiangsu 226001, P.R. China
| | - Lili Liu
- Department of Pediatric Surgery, Affiliated Hospital of Nantong University, Nantong, Jiangsu 226001, P.R. China
| | - Yongjun Wang
- Jiangsu Key Laboratory of Neuroregeneration, Nantong University, Nantong, Jiangsu 226001, P.R. China
| | - Jianghong He
- Jiangsu Key Laboratory of Neuroregeneration, Nantong University, Nantong, Jiangsu 226001, P.R. China
| | - Jianfei Huang
- Department of Pathology, Affiliated Hospital of Nantong University, Nantong, Jiangsu 226001, P.R. China
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Hougaard KS, Larsen AD, Hannerz H, Andersen AMN, Jørgensen KT, Toft GV, Bonde JP, Jensen MS. Socio-occupational class, region of birth and maternal age: influence on time to detection of cryptorchidism (undescended testes): a Danish nationwide register study. BMC Urol 2014; 14:23. [PMID: 24581337 PMCID: PMC4016268 DOI: 10.1186/1471-2490-14-23] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2013] [Accepted: 02/15/2014] [Indexed: 11/25/2022] Open
Abstract
Background Cryptorchidism (undescended testes) is associated with poor male fertility, but can be alleviated and fertility preserved to some degree by early detection and treatment. Here we assess the influence of socio-occupational class, geographical region, maternal age and birth cohort on time to detection and correction of cryptorchidism. Methods All boys born in Denmark, 1981 to 1987 or 1988 to 1994, with a diagnosis of cryptorchidism were identified in nationwide registers. The boys were followed for a diagnosis until their 16th birthday. The age at first diagnosis was noted and used as proxy for time to detection of cryptorchidism. Parental employment in the calendar year preceding birth was grouped into one of five socio-occupational classes. Geographical region was defined by place of birth in one of 15 Danish counties. Detection rate ratios of cryptorchidism were analyzed as a function of parental socio-occupational group, county, maternal age and birth cohort by use of Poisson regression. Results Some 6,059 boys in the early and 5,947 boys in the late cohort received a diagnosis of cryptorchidism. Time to detection was independent of parental socio-occupational group and maternal age but differed slightly between geographical regions. A similar pattern was obtained for surgical correction after a diagnosis. Age at diagnosis decreased by 2.7 years from the early to the late cohort. Conclusions These results indicate that childhood socio-occupational inequality in detection and correction of cryptorchidism would play a negligible role in male infertility in a life course perspective. Geographical region may have exerted some influence, especially for the oldest cohort.
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Affiliation(s)
- Karin Sørig Hougaard
- The National Research Centre for the Working Environment, Lersø Parkallé 105, DK-2100 Copenhagen, Denmark.
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Thankamony A, Lek N, Carroll D, Williams M, Dunger DB, Acerini CL, Ong KK, Hughes IA. Anogenital distance and penile length in infants with hypospadias or cryptorchidism: comparison with normative data. ENVIRONMENTAL HEALTH PERSPECTIVES 2014; 122:207-11. [PMID: 24316680 PMCID: PMC3915266 DOI: 10.1289/ehp.1307178] [Citation(s) in RCA: 96] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/05/2013] [Accepted: 12/03/2013] [Indexed: 05/04/2023]
Abstract
BACKGROUND Anogenital distance (AGD) in animals is a sensitive biomarker of fetal endocrine disruption and the associated testicular dysgenesis syndrome (TDS). However, AGD in human infants with cryptorchidism and hypospadias, which are potential manifestations of TDS during childhood, is not clearly described. OBJECTIVE Our aim was to compare AGD in boys with cryptorchidism or hypospadias against normative data. METHODS Boys with isolated cryptorchidism (n = 71, age 13.4 ± 5.8 months) or hypospadias (n = 81, age 11.4 ± 6.2 months) were recruited from a tertiary center for measurement of AGD and penile length; they were compared with 487 healthy full-term boys from a birth cohort by deriving age-specific standard deviation scores (SDS). RESULTS Boys with cryptorchidism were older (p = 0.048) compared with boys with hypospadias. Boys with hypospadias had shorter mean AGD and penile length SDS than healthy boys (both p < 0.0001). Mean AGD and penile length SDS values in boys with cryptorchidism were longer than mean values in boys with hypospadias (both p < 0.01) and shorter than mean values in healthy boys (both p < 0.0001). Mean penile length SDS decreased as the severity of hypospadias increased (ptrend = 0.078). CONCLUSIONS In the study population, AGD and penile length were reduced in boys with hypospadias or cryptorchidism relative to normative data derived from a longitudinal birth cohort. The findings support the use of AGD as a quantitative biomarker to examine the prenatal effects of exposure to endocrine disruptors on the development of the male reproductive tract.
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Affiliation(s)
- Ajay Thankamony
- Department of Paediatrics, University of Cambridge, Addenbrooke's Hospital, Cambridge, United Kingdom
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39
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Dumoucel S, Gauthier-Villars M, Stoppa-Lyonnet D, Parisot P, Brisse H, Philippe-Chomette P, Sarnacki S, Boccon-Gibod L, Rossignol S, Baumann C, Aerts I, Bourdeaut F, Doz F, Orbach D, Pacquement H, Michon J, Schleiermacher G. Malformations, genetic abnormalities, and Wilms tumor. Pediatr Blood Cancer 2014; 61:140-4. [PMID: 23970395 DOI: 10.1002/pbc.24709] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2013] [Accepted: 07/05/2013] [Indexed: 11/07/2022]
Abstract
BACKGROUND Wilms Tumor (WT) can occur in association with tumor predisposition syndromes and/or with clinical malformations. These associations have not been fully characterized at a clinical and molecular genetic level. This study aims to describe clinical malformations, genetic abnormalities, and tumor predisposition syndromes in patients with WT and to propose guidelines regarding indications for clinical and molecular genetic explorations. PROCEDURE This retrospective study analyzed clinical abnormalities and predisposition syndromes among 295 patients treated for WT between 1986 and 2009 in a single pediatric oncological center. RESULTS Clinically identified malformations and predisposition syndromes were observed in 52/295 patients (17.6%). Genetically proven tumor predisposition syndromes (n = 14) frequently observed were syndromes associated with alterations of the chromosome WT1 region such as WAGR (n = 6) and Denys-Drash syndromes (n = 3), syndromes associated with alterations of the WT2 region (Beckwith-Wiedeman syndrome, n = 3), and Fanconi anemia (n = 2). Hemihypertrophy and genito-urinary malformations (n = 12 and n = 16, respectively) were the most frequently identified malformations. Other different syndromes or malformations (n = 10) were less frequent. Median age of WT diagnosis was significantly earlier for children with malformations than those without (27 months vs. 37 months, P = 0.0009). There was no significant difference in terms of 5-year EFS and OS between WT patients without or with malformations. CONCLUSIONS The frequency of malformations observed in patients with WT underline the need of genetic counseling and molecular genetic explorations for a better follow-up of these patients, with a frequently good outcome. A decisional tree, based on clinical observations of patients with WT, is proposed to guide clinicians for further molecular genetic explorations.
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Affiliation(s)
- S Dumoucel
- Department of Pediatric Oncology, Institut Curie, Paris, France
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Sperm Concentration, Testicular Volume and Age Predict Risk of Carcinoma In Situ in Contralateral Testis of Men with Testicular Germ Cell Cancer. J Urol 2013; 190:2074-80. [DOI: 10.1016/j.juro.2013.06.023] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/07/2013] [Indexed: 11/17/2022]
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Hutson JM, Southwell BR, Li R, Lie G, Ismail K, Harisis G, Chen N. The regulation of testicular descent and the effects of cryptorchidism. Endocr Rev 2013; 34:725-52. [PMID: 23666148 DOI: 10.1210/er.2012-1089] [Citation(s) in RCA: 118] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
The first half of this review examines the boundary between endocrinology and embryonic development, with the aim of highlighting the way hormones and signaling systems regulate the complex morphological changes to enable the intra-abdominal fetal testes to reach the scrotum. The genitoinguinal ligament, or gubernaculum, first enlarges to hold the testis near the groin, and then it develops limb-bud-like properties and migrates across the pubic region to reach the scrotum. Recent advances show key roles for insulin-like hormone 3 in the first step, with androgen and the genitofemoral nerve involved in the second step. The mammary line may also be involved in initiating the migration. The key events in early postnatal germ cell development are then reviewed because there is mounting evidence for this to be crucial in preventing infertility and malignancy later in life. We review the recent advances in what is known about the etiology of cryptorchidism and summarize the syndromes where a specific molecular cause has been found. Finally, we cover the recent literature on timing of surgery, the issues around acquired cryptorchidism, and the limited role of hormone therapy. We conclude with some observations about the differences between animal models and baby boys with cryptorchidism.
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Affiliation(s)
- John M Hutson
- Urology Department, Royal Children's Hospital, Parkville 3052, Victoria, Australia.
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42
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Serrano T, Chevrier C, Multigner L, Cordier S, Jegou B. International geographic correlation study of the prevalence of disorders of male reproductive health. Hum Reprod 2013; 28:1974-86. [DOI: 10.1093/humrep/det111] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
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Kollin C, Granholm T, Nordenskjöld A, Ritzén EM. Growth of spontaneously descended and surgically treated testes during early childhood. Pediatrics 2013; 131:e1174-80. [PMID: 23530172 DOI: 10.1542/peds.2012-2902] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE To investigate whether in congenital unilateral cryptorchidism the growth of a spontaneously descended testis is normal, compared with the contralateral scrotal testis or similar to the growth of testes that failed to descend spontaneously and later underwent orchidopexy. METHODS Ninety-one boys with congenital unilateral cryptorchidism with later spontaneous descent of the initially retained testis were followed from birth (0-3 weeks) up to 5 years of age and compared with boys randomized to surgery at either 9 months (n = 78) or 3 years (n = 85) of age. Testicular volume was determined with ultrasonography. RESULTS Eighty-two percent of spontaneous descent occurred before 2 months of age. Twenty-two percent of these descended testes were later again found in a retained position. The spontaneously descended testis was smaller than its scrotal counterpart at all ages (P < .001). We also showed a significant difference in the testicular volume between the early and late treated boys from age 2 years and onward. At 2, 4, and 5 years of age, the volumes of the spontaneously descended testes were significantly larger than those of boys operated on at 3 years but similar to those operated on at 9 months. CONCLUSIONS We have shown that in boys with congenital unilateral cryptorchidism with later spontaneous descent, the originally retained testes show impaired growth compared with its scrotal counterpart from birth and onwards. Also, they are prone to later ascent to a retained position. Furthermore, the longer testes remain untreated the more they exhibit impaired growth.
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Affiliation(s)
- Claude Kollin
- Department of Women's and Children's Health, Center of Molecular Medicine, Karolinska Institutet, SE-17176, Stockholm, Sweden.
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45
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Virtanen HE, Adamsson A. Cryptorchidism and endocrine disrupting chemicals. Mol Cell Endocrinol 2012; 355:208-20. [PMID: 22127307 DOI: 10.1016/j.mce.2011.11.015] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2011] [Revised: 11/11/2011] [Accepted: 11/11/2011] [Indexed: 10/15/2022]
Abstract
Prospective clinical studies have suggested that the rate of congenital cryptorchidism has increased since the 1950s. It has been hypothesized that this may be related to environmental factors. Testicular descent occurs in two phases controlled by Leydig cell-derived hormones insulin-like peptide 3 (INSL3) and testosterone. Disorders in fetal androgen production/action or suppression of Insl3 are mechanisms causing cryptorchidism in rodents. In humans, prenatal exposure to potent estrogen diethylstilbestrol (DES) has been associated with increased risk of cryptorchidism. In addition, epidemiological studies have suggested that exposure to pesticides may also be associated with cryptorchidism. Some case-control studies analyzing environmental chemical levels in maternal breast milk samples have reported associations between cryptorchidism and chemical levels. Furthermore, it has been suggested that exposure levels of some chemicals may be associated with infant reproductive hormone levels.
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46
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Meij-de Vries A, Goede J, van der Voort L, Heij HA, Meijer RW, Hack WWM. Long-term testicular position and growth of acquired undescended testis after prepubertal orchidopexy. J Pediatr Surg 2012; 47:727-35. [PMID: 22498388 DOI: 10.1016/j.jpedsurg.2011.10.073] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2011] [Revised: 09/29/2011] [Accepted: 10/23/2011] [Indexed: 10/28/2022]
Abstract
PURPOSE The aim of the study was to determine long-term testicular position and growth of acquired undescended testis (UDT) after prepubertal orchidopexy. METHODS Patients who had undergone prepubertal orchidopexy for acquired UDT at our hospital between 1986 and 1999 were recruited to assess long-term testicular position and volume. Testis position was assessed by physical examination. Testis volume was measured with Prader orchidometry and ultrasound and was compared with normative values reported in the literature. RESULTS A total of 105 patients (aged 14.0-31.6 years) were included with 137 acquired UDT (32 bilateral, 33 left sided, and 40 right sided). All but 1 of the orchidopexied testes (99.3%) were in low scrotal position. The mean volume of the orchidopexied testes in unilateral UDT (n = 73, 10.57 ± 3.74 mL) differed significantly from the size of the testes at the contralateral side (14.11 ± 4.23 mL) (P = .000). The operated testes (10.28 ± 3.45 mL) were smaller than the mean adult testis volume reported in the literature (13.4-13.6 mL; cutoff, 13.2 mL). CONCLUSION Testis position after prepubertal orchidopexy for acquired UDT was nearly always low scrotal. The volume of the orchidopexied testes was smaller than both the volume of the contralateral testes and the normative values reported in the literature.
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Affiliation(s)
- Annebeth Meij-de Vries
- Department of Surgery Wilhelminalaan, Medical Centre Alkmaar, 12 1815 JD Alkmaar, The Netherlands.
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47
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Wohlfahrt-Veje C, Andersen HR, Jensen TK, Grandjean P, Skakkebaek NE, Main KM. Smaller genitals at school age in boys whose mothers were exposed to non-persistent pesticides in early pregnancy. ACTA ACUST UNITED AC 2012; 35:265-72. [PMID: 22394112 DOI: 10.1111/j.1365-2605.2012.01252.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Endocrine disrupting chemicals are believed to play a role in the development of the testicular dysgenesis syndrome. Many pesticides are known to have endocrine disrupting abilities. In a previous study, sons of women who were occupationally exposed to non-persistent pesticides in early pregnancy showed signs of impaired reproductive function (reduced genital size and altered serum hormone concentrations) at three months of age. To assess the possible long-term effects of prenatal pesticide exposure, the boys were re-examined at 6-11 years. The 94 boys (59 exposed, 35 unexposed) underwent genital examinations including ultrasound of testicular volumes, puberty staging (Tanner), anthropometry, and blood sampling. Only a few of the boys had reached puberty (n = 3). Among prepubescent boys, testicular volume and penile length (age- and weight-adjusted) were reduced if mothers were exposed to pesticides. The effects were associated with the maternal exposure levels, so that high-exposed boys had smaller genitals than medium-exposed boys, who had smaller genitals than those who were unexposed. Boys of mothers in the high exposure group (n = 23) had 24.7% smaller testes (95% CI: -62.2; -10.1) and 9.4% shorter penile length (95% CI: -16.8; -1.1) compared with the unexposed. The testicular volume and penile length at school age could be tracked to measures from the same boys made at 3 months, e.g. those that had small testes at school age also had small testes at 3 months. Pituitary and testicular hormone serum concentrations did not differ between exposed and unexposed boys. Eight prenatally exposed boys had genital malformations (no unexposed). These boys had smaller testis, shorter penile length and lower inhibin B concentrations than prepubertal boys without genital malformations. The findings support the results obtained at three months of age and indicate that prenatal pesticide exposure has long-term effects on reproductive function in boys.
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Affiliation(s)
- C Wohlfahrt-Veje
- University Department of Growth and Reproduction, Rigshospitalet, Copenhagen Ø, Denmark.
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48
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Gabel P, Jensen MS, Andersen HR, Baelum J, Thulstrup AM, Bonde JP, Toft G. The risk of cryptorchidism among sons of women working in horticulture in Denmark: a cohort study. Environ Health 2011; 10:100. [PMID: 22082298 PMCID: PMC3250937 DOI: 10.1186/1476-069x-10-100] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2011] [Accepted: 11/14/2011] [Indexed: 05/31/2023]
Abstract
BACKGROUND Androgens are crucial for normal testicular descent. Studies show that some pesticides have estrogenic or antiandrogenic effects, and that female workers exposed to pesticides have increased risk of having a boy with cryptorchidism. The main objective of the present study was to investigate whether pregnant women exposed to pesticides due to their work in horticulture experience excess risk of having sons with cryptorchidism. METHODS We conducted a cohort study of pregnant women working in horticulture using four cohorts including one cohort established with data from the departments of occupational medicine in Jutland and Funen and three existing mother-child cohorts (n=1,468). A reference group was established from the entire Danish population of boys born in the period of 1986-2007 (n=783,817). Nationwide Danish health registers provided information on birth outcome, cryptorchidism diagnosis and orchiopexy. The level of occupational exposure to pesticides was assessed by expert judgment blinded towards outcome status. Risk of cryptorchidism among exposed horticulture workers compared to the background population and to unexposed horticulture workers was assessed by Cox regression models. RESULTS Pesticide exposed women employed in horticulture had a hazard ratio (HR) of having cryptorchid sons of 1.39 (95% CI 0.84; 2.31) and a HR of orchiopexy of 1.34 (0.72; 2.49) compared to the background population. Analysis divided into separate cohorts revealed a significantly increased risk of cryptorchidism in cohort 2: HR 2.58 (1.07;6.20) and increased risk of orchiopexy in cohort 4: HR 2.76 (1.03;7.35), but no significant associations in the other cohorts. Compared to unexposed women working in horticulture, pesticide exposed women had a risk of having sons with cryptorchidism of 1.34 (0.30; 5.96) and of orchiopexy of 1.93 (0.24;15.4). CONCLUSIONS The data are compatible with a slightly increased risk of cryptorchidism in sons of women exposed to pesticides by working in horticulture.
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Affiliation(s)
- Pernille Gabel
- Danish Ramazzini Center, Department of Occupational medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Morten Søndergaard Jensen
- Danish Ramazzini Center, Department of Occupational medicine, Aarhus University Hospital, Aarhus, Denmark
- Perinatal Epidemiology Research Unit, Department of Pediatrics, Aarhus University Hospital Skejby, Denmark
| | - Helle Raun Andersen
- Institute of Public Health, Environmental Medicine, University of Southern Denmark, Odense, Denmark
| | - Jesper Baelum
- Department of Occupational and Environmental Medicine, Odense University Hospital, Denmark
| | - Ane Marie Thulstrup
- Danish Ramazzini Center, Department of Occupational medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Jens Peter Bonde
- Department of Occupational and Environmental Medicine, Bispebjerg University Hospital, Copenhagen, Denmark
| | - Gunnar Toft
- Danish Ramazzini Center, Department of Occupational medicine, Aarhus University Hospital, Aarhus, Denmark
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49
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Impact of Anatomical and Socioeconomic Factors on Timing of Urological Consultation for Boys With Cryptorchidism. J Urol 2011; 186:1601-5. [DOI: 10.1016/j.juro.2011.03.102] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2010] [Indexed: 11/24/2022]
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50
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Goede J, van der Voort-Doedens LM, Sijstermans K, Hack WWM. The volume of retractile testes. J Urol 2011; 186:2050-4. [PMID: 21944090 DOI: 10.1016/j.juro.2011.07.020] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2011] [Indexed: 11/27/2022]
Abstract
PURPOSE We used ultrasound to determine the volume of retractile testes in boys and compared these volumes with normative testicular volume values. MATERIALS AND METHODS A total of 171 boys were enrolled in the study, of whom 14 were excluded from analysis. The 157 boys included (age 0.8 to 11.5 years) were recruited from 2 different populations. The first subgroup comprised 92 boys previously excluded from a study aimed at obtaining normative values of ultrasonographically scanned testes. The second group included 65 boys who had been referred to our outpatient clinic for nonscrotal testis and who were diagnosed with retractile testis. Testicular volume was measured by ultrasound in a scrotal position or in an inguinal position. Three separate transverse and longitudinal images of each testis were recorded. Length, width and height were measured, and the volume was calculated with the formula for an ellipsoid, π/6 × length × width × height. The highest value of the 3 testicular volumes was determined and taken as the volume measurement. RESULTS The volumes measured by ultrasound for the 157 boys with 276 retractile testes ranged from 0.18 to 1.49 ml (mean 0.50). The volumes of the retractile testes were significantly smaller than normative values (p <0.001). Furthermore, the testicular volumes of retractile testes measured in an inguinal position were significantly smaller than those measured in a scrotal position (p <0.001). CONCLUSIONS The volumes of retractile testes are significantly smaller than recently determined normative values.
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Affiliation(s)
- J Goede
- Department of Paediatrics, Medical Centre Alkmaar, Alkmaar, The Netherlands.
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