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Okpaise OO, Ahn H, Tonni G, Ruano R. Prenatal diagnosis and in utero treatment of congenital adrenal hyperplasia: An up-to-date comprehensive review. Prenat Diagn 2024; 44:635-643. [PMID: 38448010 DOI: 10.1002/pd.6542] [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: 10/17/2023] [Revised: 01/05/2024] [Accepted: 01/10/2024] [Indexed: 03/08/2024]
Abstract
Congenital adrenal hyperplasia (CAH) is a term that encompasses a wide range of conditions that affect the adrenals. Diagnosis and treatment before birth are important as irreparable birth defects can be avoided, decreasing the need for surgical intervention later in life, especially regarding genitalia anomalies. Although early implementation of dexamethasone in the prenatal treatment of CAH has been controversial, there is recent evidence that this treatment can reduce long-term complications.
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Affiliation(s)
| | - Hyunyoung Ahn
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology & Reproductive Sciences, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Gabriele Tonni
- Department of Obstetrics and Neonatology, Prenatal Diagnostic Centre, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), AUSL Reggio Emilia, Reggio Emilia, Italy
| | - Rodrigo Ruano
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology & Reproductive Sciences, University of Miami Miller School of Medicine, Miami, Florida, USA
- Women-Children Health Center of Excellence, Americas Group, United Health Care Brazil, São Paulo, Brazil
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2
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Kumar I, Prakash A, Aggarwal P, Chowdhary S, Verma A. Disorders of sexual development: structured radiological reporting and practical approach. Abdom Radiol (NY) 2024; 49:523-534. [PMID: 37831169 DOI: 10.1007/s00261-023-04066-x] [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] [Received: 07/23/2023] [Revised: 09/13/2023] [Accepted: 09/14/2023] [Indexed: 10/14/2023]
Abstract
Disorders of sexual development (DSD) comprise a complex group of conditions with varied clinical presentations, such as atypical genitalia, non-palpable testes, primary amenorrhea, or infertility. Besides being associated with other congenital anomalies, DSDs bear substantial ethical issues regarding assigning the sex of rearing to the child and future fertility options. Establishing the correct diagnosis is essential for the appropriate management of such cases. Various imaging modalities, such as ultrasonography, genitography, and MRI, when complemented with detailed clinical evaluation and karyotyping, are the key to diagnosing the condition. This article attempts to present a concise approach to various patterns of DSD, which will aid radiologists to solve these diagnostic dilemmas.
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Affiliation(s)
- Ishan Kumar
- Department of Radiodiagnosis and Imaging, Institute of Medical Sciences, Banaras Hindu University, Varanasi, 221005, India
| | - Adity Prakash
- Department of Radiodiagnosis and Imaging, Institute of Medical Sciences, Banaras Hindu University, Varanasi, 221005, India
| | - Priyanka Aggarwal
- Department of Pediatrics, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India
| | - Sarita Chowdhary
- Department of Pediatric Surgery, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India
| | - Ashish Verma
- Department of Radiodiagnosis and Imaging, Institute of Medical Sciences, Banaras Hindu University, Varanasi, 221005, India.
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3
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Batista RL, Inácio M, Brito VN, Sircili MHP, Bag MJ, Gomes NL, Costa EMF, Domenice S, Mendonca BB. Sexuality and fertility desire in a large cohort of individuals with 46, XY differences in sex development. Clinics (Sao Paulo) 2023; 78:100185. [PMID: 36965237 PMCID: PMC10091460 DOI: 10.1016/j.clinsp.2023.100185] [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: 11/11/2022] [Revised: 01/31/2023] [Accepted: 03/02/2023] [Indexed: 03/27/2023] Open
Abstract
OBJECTIVE To analyze aspects of sexual life and fertility desire among 46, XY DSD people, including those who changed their gender. METHODS It is a cross-sectional study including 127 adults (> 16 years of age) with 46, XY DSD (83 females; 44 males) from a Single Brazilian Tertiary-Care Medical Center. RESULTS Sexual fantasies and masturbation were more frequent in 46, XY DSD males, whereas orgasm and sexual life satisfaction were similar in both genders. More 46, XY DSD men than women had a long-term romantic relationship. 46, XY DSD women with prenatal androgen exposure reported more fear of being romantically rejected. External genitalia appearance at birth did not impact the sexuality of 46, XY DSD women after surgical genital treatment had been completed. Overall, the sexual life was similar between 46, XY men assigned as males and those who changed to the male gender. Regarding sexual orientation, most self-reported as heterosexual (91% and 92% of women and men, respectively). The desire for fertility had a similar prevalence in both genders, but more women than men considered infertility a barrier to a long-term romantic relationship. Twelve individuals (7 males) had children; 10 out of 12 have adopted children. CONCLUSION Fertility desire was shared among 46, XY DSD people, regardless of gender. Prenatal androgen exposure reduced the desire for motherhood in 46, XY women. 46, XY DSD people who changed from female to male gender presented similar sexual parameters as those assigned as males. Among females, virilized genitalia at birth did not affect sexuality once the surgical treatment is completed.
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Affiliation(s)
- Rafael Loch Batista
- Developmental Endocrinology Unit, Hormone and Molecular Genetics Laboratory (LIM/42), Endocrinology Division, Internal Medicine Department, Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil.
| | - Marlene Inácio
- Developmental Endocrinology Unit, Hormone and Molecular Genetics Laboratory (LIM/42), Endocrinology Division, Internal Medicine Department, Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil
| | - Vinicius Nahime Brito
- Developmental Endocrinology Unit, Hormone and Molecular Genetics Laboratory (LIM/42), Endocrinology Division, Internal Medicine Department, Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil
| | - Maria Helena Palma Sircili
- Developmental Endocrinology Unit, Hormone and Molecular Genetics Laboratory (LIM/42), Endocrinology Division, Internal Medicine Department, Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil
| | - Min Jeong Bag
- Developmental Endocrinology Unit, Hormone and Molecular Genetics Laboratory (LIM/42), Endocrinology Division, Internal Medicine Department, Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil
| | - Nathália Lisboa Gomes
- Developmental Endocrinology Unit, Hormone and Molecular Genetics Laboratory (LIM/42), Endocrinology Division, Internal Medicine Department, Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil
| | - Elaine Maria Frade Costa
- Developmental Endocrinology Unit, Hormone and Molecular Genetics Laboratory (LIM/42), Endocrinology Division, Internal Medicine Department, Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil
| | - Sorahia Domenice
- Developmental Endocrinology Unit, Hormone and Molecular Genetics Laboratory (LIM/42), Endocrinology Division, Internal Medicine Department, Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil
| | - Berenice Bilharinho Mendonca
- Developmental Endocrinology Unit, Hormone and Molecular Genetics Laboratory (LIM/42), Endocrinology Division, Internal Medicine Department, Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil
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4
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Hosokawa T, Tanami Y, Sato Y, Hosokawa M, Oguma E. The role of ultrasound to evaluate the disorders of sex development: a pictorial essay. J Ultrasound 2022; 25:745-755. [PMID: 34988914 PMCID: PMC9402846 DOI: 10.1007/s40477-021-00632-5] [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] [Received: 09/05/2021] [Accepted: 10/11/2021] [Indexed: 10/19/2022] Open
Abstract
Ultrasonography is usually the first modality used to evaluate patients with disorders of sex development (DSD). To determine the sex in patients with DSD, the following four categories are carefully evaluated: chromosomal, gonadal, anatomical internal genitalia, and external genitalia. However, in the clinical setting, the only information that sonographers have prior to ultrasound examination is the appearance of the external genitalia. The following DSD presentations are commonly observed: (1) male external genitalia present at birth, without testis in the scrotum or with a small penis; (2) female external genitalia present at birth, with an inguinal hernia or clitoromegaly; (3) neonates with ambiguous genitalia at birth; and (4) female or male external genitalia without sexual maturity. In this retrospective study of several clinical cases, we demonstrated an ultrasound-based sex determination approach for these clinical presentations. We found that sonographers evaluated the external genitalia in relation to the distal urethra within the corpus spongiosum and corpus cavernosum and the presence or absence of follicles within the detected gonads to determine the sex of the patient.
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Affiliation(s)
- Takahiro Hosokawa
- Department of Radiology, Saitama Children’s Medical Center, 1-2 Shintoshin Chuo-ku Saitama, Saitama, 330-8777 Japan
| | - Yutaka Tanami
- Department of Radiology, Saitama Children’s Medical Center, 1-2 Shintoshin Chuo-ku Saitama, Saitama, 330-8777 Japan
| | - Yumiko Sato
- Department of Radiology, Saitama Children’s Medical Center, 1-2 Shintoshin Chuo-ku Saitama, Saitama, 330-8777 Japan
| | - Mayumi Hosokawa
- Department of Pediatrics, Saitama City Hospital, 2460 Mimuro Midori-Ku Saitama, Saitama, 336-8522 Japan
| | - Eiji Oguma
- Department of Radiology, Saitama Children’s Medical Center, 1-2 Shintoshin Chuo-ku Saitama, Saitama, 330-8777 Japan
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5
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Hryhorczuk AL, Phelps AS, Yu RN, Chow JS. The radiologist's role in assessing differences of sex development. Pediatr Radiol 2022; 52:752-764. [PMID: 34355264 DOI: 10.1007/s00247-021-05147-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Revised: 05/26/2021] [Accepted: 06/28/2021] [Indexed: 12/29/2022]
Abstract
When infants are identified with a difference of sex development (DSD), a thoughtful approach to imaging is essential to appropriate clinical management. This review provides a comprehensive guide for radiologists who are tasked with performing this critical assignment. We review the embryologic basis of DSDs, with attention to the imaging findings that can indicate specific diagnoses. We also discuss techniques for optimal imaging, including strategies for identifying the gonads by US, tactics for performing genitograms with fluoroscopy and contrast-enhanced US, and the appropriate utilization of MRI. Finally, we review the clinical data and imaging findings that characterize some of the most common DSDs, including congenital adrenal hyperplasia, complete androgen insensitivity syndrome and gonadal dysgenesis.
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Affiliation(s)
- Anastasia L Hryhorczuk
- Section of Pediatric Radiology, C. S. Mott Children's Hospital, Department of Radiology, Michigan Medicine, 1500 E. Medical Center Drive, Ann Arbor, MI, 48109-4252, USA.
| | - Andrew S Phelps
- Department of Radiology, Oregon Health & Science University, Portland, OR, USA
| | - Richard N Yu
- Department of Urology, Boston Children's Hospital, Boston, MA, USA
| | - Jeanne S Chow
- Department of Radiology, Boston Children's Hospital, Boston, MA, USA
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6
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Fine S, Ford K, Trotter B, Le HK, Crisp M, Santiago J, Birkemeier K. Mixed gonadal dysgenesis with an ovotestis on imaging mimicking ovotesticular disorder of sexual differentiation. Proc (Bayl Univ Med Cent) 2021; 34:739-741. [PMID: 34733008 DOI: 10.1080/08998280.2021.1951052] [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: 10/20/2022] Open
Abstract
Mixed gonadal dysgenesis (MGD) is a rare disorder of sexual development. Also known as 45XO/46XY mosaicism, MGD is characterized by highly variable sexual phenotypes and an increased risk of gonadal malignancy. Patients with MGD often have a unilateral descended gonad and contralaterally either a streak gonad or no gonad. We present the case of a patient with a dysgenetic, nonpalpable gonad with imaging features of an ovotestis. These imaging features are generally more indicative of ovotesticular disorder of sexual development (previously true hermaphrodite), which is a condition with low risk of gonadal malignancy. Further evaluation with histology and genetic analysis confirmed the diagnosis of MGD. It is important to diagnose MGD to allow for early operative intervention and screening for malignancy.
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Affiliation(s)
- Samantha Fine
- College of Medicine, Texas A&M Health Science Center, Temple, Texas
| | - Kenneth Ford
- College of Medicine, Texas A&M Health Science Center, Temple, Texas
| | - Bradley Trotter
- College of Medicine, Texas A&M Health Science Center, Temple, Texas.,Department of Radiology, Baylor Scott and White Medical Center, Temple, Texas
| | - Hoang-Kim Le
- Department of Urology, Baylor Scott and White Medical Center, Temple, Texas
| | - Matthew Crisp
- College of Medicine, Texas A&M Health Science Center, Temple, Texas.,Department of Radiology, Baylor Scott and White Medical Center, Temple, Texas
| | - Jose Santiago
- College of Medicine, Texas A&M Health Science Center, Temple, Texas.,Department of Radiology, Baylor Scott and White Medical Center, Temple, Texas
| | - Krista Birkemeier
- College of Medicine, Texas A&M Health Science Center, Temple, Texas.,Department of Radiology, Baylor Scott and White Medical Center, Temple, Texas
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7
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Contrast-enhanced genitosonography and colosonography: emerging alternatives to fluoroscopy. Pediatr Radiol 2021; 51:2387-2395. [PMID: 33978789 DOI: 10.1007/s00247-020-04770-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 05/18/2020] [Accepted: 07/01/2020] [Indexed: 10/21/2022]
Abstract
Imaging plays a crucial role in evaluating newborns and infants with cloacal and urogenital malformations. Contrast-enhanced genitosonography (ceGS) and contrast-enhanced colosonography (ceCS) are sensitive and radiation-free alternatives to fluoroscopic genitography and colography for diagnosis and surgical planning. These imaging techniques are performed by instilling a US contrast agent into specific body cavities to define the genitourinary and colorectal anatomy. This review article presents the experience with ceGS and ceCS applications in children, focusing on the background, examination technique, and interpretation of imaging findings, as well as strengths and weaknesses compared to conventional techniques.
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8
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Kingsbury H, Hegarty P. LGB+ and heterosexual-identified people produce similar analogies to intersex but have different opinions about its medicalisation. PSYCHOLOGY & SEXUALITY 2021. [DOI: 10.1080/19419899.2021.1881595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Affiliation(s)
| | - Peter Hegarty
- School of Psychology, University of Surrey, Guildford, UK
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9
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Rangarajan K, Jana M, Wadgera N, Gupta AK, Bajpai M, Kandasamy D. Role of Transperineal Ultrasound (TPUS) in Children with Ambiguous Genitalia. Indian J Radiol Imaging 2021; 31:49-56. [PMID: 34316111 PMCID: PMC8299479 DOI: 10.1055/s-0041-1729123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Objectives Accurate delineation of anatomy in children with ambiguous genitalia early in life is important. This commonly involves conventional fluoroscopic genitogram (traumatic to the child) and magnetic resonance imaging (MRI) examination (involves sedation). In this study, our objectives were twofold: (1) to describe the findings on transperineal ultrasound (TPUS) in normal children and (2) to describe the findings on TPUS in children with ambiguous genitalia and correlate them with conventional genitogram. Materials and Methods TPUS was prospectively performed in 10 children without genital ambiguity (5 girls and 5 boys). Subsequently, 15 consecutive children having disorders of sex differentiation (DSDs) with genital ambiguity underwent TPUS. The presence or absence of müllerian structures was documented. Of these patients, 14 also underwent conventional genitogram as a part of routine evaluation. The gold standard was established either by comparison with surgical findings (in patients who underwent surgery) or by comparison with a combination of findings on genitogram and transabdominal ultrasound in patients who did not undergo surgery. Results In all normal children, lower urogenital tracts could be clearly delineated on TPUS. Out of the 15 children with ambiguous genitalia, TPUS could establish the presence/absence of müllerian structures in 14. This was concordant with findings on conventional genitogram/surgery. In one patient, müllerian structure was missed on TPUS but demonstrated on genitogram. In two children, TPUS showed the müllerian structure, which was not seen on genitogram. When both the controls and the cases were combined, TPUS had an accuracy of 95% and specificity of 100% in the detection of müllerian structures. Conclusion TPUS is feasible and accurate in demonstration of lower urogenital tract anatomy in children with DSDs having ambiguous genitalia. It can be performed without sedation, and is suitable for use as a screening modality in children with ambiguous genitalia.
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Affiliation(s)
- Krithika Rangarajan
- Department of Radiology, All India Institute of Medical Sciences, New Delhi, India
| | - Manisha Jana
- Department of Radiology, All India Institute of Medical Sciences, New Delhi, India
| | - Nagesh Wadgera
- Department of Radiology, All India Institute of Medical Sciences, New Delhi, India
| | - Arun Kumar Gupta
- Department of Radiology, All India Institute of Medical Sciences, New Delhi, India
| | - Minu Bajpai
- Department of Paediatric Surgery, All India Institute of Medical Sciences, New Delhi, India
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10
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Samantray SR, Mohapatra I. Ovotesticular Disorder With Seminoma. Cureus 2020; 12:e12130. [PMID: 33489542 PMCID: PMC7813536 DOI: 10.7759/cureus.12130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/17/2020] [Indexed: 11/05/2022] Open
Abstract
Ovotesticular disorder or true hermaphroditism is defined as the presence of both ovarian and testicular tissues in the same individual irrespective of the patient's karyotype. Ovotesticular disorder represents 5% of disorders of sex development. Cases of true hermaphroditism must be treated like men or women based on their age, external genitalia and the orientation of the patient. Here we report a case of true hermaphroditism which was diagnosed with seminoma on histopathological examination. The patient underwent orchiectomy, followed by two cycles of chemotherapy.
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Affiliation(s)
- Subha R Samantray
- Obstetrics and Gynecology, Prathima Institute of Medical Sciences, Karimnagar, IND
| | - Ipsita Mohapatra
- Obstetrics and Gynecology, Prathima Institute of Medical Sciences, Karimnagar, IND
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11
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Khan S, Tafweez R, Haider A, Yaqoob M. Spectrum of external genital anomalies in disorders of Sex Development at Children Hospital & Institute of Child Health, Lahore, Pakistan. Pak J Med Sci 2020; 37:244-249. [PMID: 33437285 PMCID: PMC7794156 DOI: 10.12669/pjms.37.1.2991] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Objective: To describe the mode of presentation and frequency of external genital anomalies in disorder of sex development (DSD) Methods: This cross-sectional study was conducted at Children Hospital & Institute of Child Health, Lahore from January to December, 2016 on Children with DSD above 10 years of age. A detailed history and physical examination were done. Positive findings were recorded on a predesigned proforma and analyzed by SPSS 21. Karyotyping on blood samples was done to determine their genetic sex. Results: Out of 83 DSD children, 67% (n=56) were assigned a female sex at birth of which 9% (n=5) had ambiguous genitalia. Male sex at birth was given to 33% (n=27) of which 96% (n=26) had genital ambiguity. Mode of presentation other than ambiguous genitalia were delayed puberty, amenorrhea, hirsuitism, gynaecomastia, cyclic hematuria etc. Clitoromegaly was the main finding in 62.5% (n=5) and micropenis in 45% (n=9). Karyotypic sex of 56 female sex of rearing was 46XX 80% (n=45), 45X0 13% (n=7), XXX 2% (n=1) and 46 XY in 5% (n=3). Karyotypic sex of 27 male sex of rearing was 46XY in 78% (n=21), 46XX in 15% (n=4) and 47XXY in 7% (n=2). Conclusion: Disorders of sex development presented with a wide spectrum of external genital anomalies ranging from clitoromegaly in females to micropenis and hypospadias in males. There was also an extreme diversity in mode of presentation of these cases including pubertal delay, amenorrhea in females and gender confusion disorders.
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Affiliation(s)
- Sarah Khan
- Dr. Sarah Khan, MBBS, M-Phil Anatomy Assistant Professor of Anatomy, Department of Anatomy, King Edward Medical University, Lahore, Pakistan
| | - Raafea Tafweez
- Dr. Raafea Tafweez, MBBS, M-Phil, FCPS, PhD. Professor of Anatomy, Department of Anatomy, King Edward Medical University, Lahore, Pakistan
| | - Areiba Haider
- Dr. Areiba Haider, MBBS, M-Phil. Anatomy, Assistant Professor of Anatomy, Department of Anatomy, King Edward Medical University, Lahore, Pakistan
| | - Muhammad Yaqoob
- Dr. Muhammad Yaqoob, MBBS, MCPS, PhD. Associate Professor of Genetics, Department of Genetics, The Children's Hospital & Institute of Child Health, Lahore, Pakistan
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12
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Madsen A, Bruserud IS, Bertelsen BE, Roelants M, Oehme NHB, Viste K, Bjerknes R, Almås B, Rosendahl K, Mellgren G, Sagen JV, Juliusson PB. Hormone References for Ultrasound Breast Staging and Endocrine Profiling to Detect Female Onset of Puberty. J Clin Endocrinol Metab 2020; 105:5910099. [PMID: 32961560 PMCID: PMC7571452 DOI: 10.1210/clinem/dgaa679] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Accepted: 09/18/2020] [Indexed: 11/24/2022]
Abstract
CONTEXT Application of ultrasound (US) to evaluate attainment and morphology of glandular tissue provides a new rationale for evaluating onset and progression of female puberty, but currently no hormone references complement this method. Furthermore, previous studies have not explored the predictive value of endocrine profiling to determine female puberty onset. OBJECTIVE To integrate US breast staging with hypothalamic-pituitary-gonadal hormone references and test the predictive value of an endocrine profile to determine thelarche. DESIGN SETTING AND PARTICIPANTS Cross-sectional sample of 601 healthy Norwegian girls, ages 6 to 16 years. MAIN OUTCOME MEASURES Clinical and ultrasound breast evaluations were performed for all included girls. Blood samples were analyzed by immunoassay and ultrasensitive liquid chromatography-tandem mass spectrometry (LC-MS/MS) to quantify estradiol (E2) and estrone (E1) from the subpicomolar range. RESULTS References for E2, E1, luteinizing hormone, follicle-stimulating hormone, and sex hormone-binding globulin were constructed in relation to chronological age, Tanner stages, and US breast stages. An endocrine profile index score derived from principal component analysis of these analytes was a better marker of puberty onset than age or any individual hormone, with receiver-operating characteristic area under the curve 0.91 (P < 0.001). Ultrasound detection of nonpalpable glandular tissue in 14 out of 264 (5.3%) girls with clinically prepubertal presentation was associated with significantly higher median serum levels of E2 (12.5 vs 4.9 pmol/L; P < 0.05) and a distinct endocrine profile (arbitrary units; P < 0.001). CONCLUSIONS We provide the first hormone references for use with US breast staging and demonstrate the application of endocrine profiling to improve detection of female puberty onset.
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Affiliation(s)
- Andre Madsen
- Hormone Laboratory, Department of Medical Biochemistry and Pharmacology, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Science, University of Bergen, Bergen, Norway
- Correspondence and Reprint Requests: André Madsen, PhD, Hormone Laboratory, Department of Medical Biochemistry and Pharmacology, Haukeland University Hospital, N-5021 Bergen, Norway. E-mail:
| | - Ingvild S Bruserud
- Department of Clinical Science, University of Bergen, Bergen, Norway
- Department of Pediatrics, Haukeland University Hospital, Bergen, Norway
| | - Bjørn-Erik Bertelsen
- Hormone Laboratory, Department of Medical Biochemistry and Pharmacology, Haukeland University Hospital, Bergen, Norway
| | - Mathieu Roelants
- Environment and Health, Department of Public Health and Primary Care, KU Leuven, University of Leuven, Leuven, Belgium
| | - Ninnie Helen Bakken Oehme
- Department of Clinical Science, University of Bergen, Bergen, Norway
- Department of Pediatrics, Haukeland University Hospital, Bergen, Norway
| | - Kristin Viste
- Hormone Laboratory, Department of Medical Biochemistry and Pharmacology, Haukeland University Hospital, Bergen, Norway
| | - Robert Bjerknes
- Department of Clinical Science, University of Bergen, Bergen, Norway
- Department of Pediatrics, Haukeland University Hospital, Bergen, Norway
| | - Bjørg Almås
- Hormone Laboratory, Department of Medical Biochemistry and Pharmacology, Haukeland University Hospital, Bergen, Norway
| | - Karen Rosendahl
- Department of Radiology, University Hospital of North Norway, Tromsø, Norway
- Department of Clinical Medicine, University of Tromsø, The Arctic University of Norway, Tromsø, Norway
| | - Gunnar Mellgren
- Hormone Laboratory, Department of Medical Biochemistry and Pharmacology, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Science, University of Bergen, Bergen, Norway
- Mohn Nutrition Research Laboratory, Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Jørn V Sagen
- Hormone Laboratory, Department of Medical Biochemistry and Pharmacology, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Petur B Juliusson
- Department of Clinical Science, University of Bergen, Bergen, Norway
- Department of Pediatrics, Haukeland University Hospital, Bergen, Norway
- Department of Health Registries, Norwegian Institute of Public Health, Bergen, Norway
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13
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Varianten der Geschlechtsentwicklung bei Kindern und Jugendlichen. GYNAKOLOGISCHE ENDOKRINOLOGIE 2020. [DOI: 10.1007/s10304-020-00352-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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14
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Morin J, Peard L, Vanadurongvan T, Walker J, Dönmez Mİ, Saltzman AF. Oncologic outcomes of pre-malignant and invasive germ cell tumors in patients with differences in sex development - A systematic review. J Pediatr Urol 2020; 16:576-582. [PMID: 32564942 DOI: 10.1016/j.jpurol.2020.05.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2020] [Revised: 04/14/2020] [Accepted: 05/04/2020] [Indexed: 01/28/2023]
Abstract
OBJECTIVE To describe the rates of GCNIS-free and GCT-free pathology based on age at gonadal surgery and to describe long-term oncologic outcomes in patients with DSD who have GCNIS or GCT at the time of gonadal surgery. STUDY DESIGN A systematic review was conducted using MEDLINE to identify patients with DSD who underwent gonadal surgery. DSD diagnoses were stratified based on malignancy risk. GCNIS/GCT and GCT-free survival by age of gonadal surgery, RFS and OS were calculated using the Kaplan-Meier method, with groups compared using log-rank testing. RESULTS 386 articles from 1951 to 2017 were included (2037 patients). Median age at gonadal surgery was 17 years (y) (IQR 11-20), median follow-up was 60 months (m) (IQR 30-68.1). GCNIS/GCT- and GCT-free survival at the time of gonadal surgery was lowest for those in the high/intermediate risk group (p < 0.001) but decreased sharply around age 15y, regardless of risk category. 5y RFS and OS was similar for those with no GCNIS/GCT and GCNIS and was worse for those with GCT (p < 0.001). DISCUSSION When patients undergo gonadal surgery, regardless of indication (i.e. prophylactic vs. tumor), it appears that GCTs are more commonly found when surgery is done around age 15 y or older, despite risk category. This is similar to ovarian and testicular GCTs. Patients with GCNIS can be reassured that long-term oncologic outcomes are excellent. While RFS and OS for GCTs are not as good as for ovarian and testicular GCTs (95%), they are still >80%. This similar trend was found in a COG review of 9 patients with DSD and ovarian GCT. There were several limitations to this study. This is a retrospective analysis that included aa wide time frame of publications. The indication for surgical intervention was not addressed in the majority of publications. Thus these data provide pathologic outcomes based on age at gonadal surgery rather than the age at which GCNIS/GCT develops over a lifetime, if at all. CONCLUSIONS The risk of GCNIS or GCT at the time of gonadal surgery appears to increase with age, accelerating between 15 and 20y regardless of risk category. 5y RFS and OS for those with GCNIS is equivalent to those without GCNIS/GCT but is worse for those with GCT. These data may be used when counseling families on timing of gonadal surgery and quantification of outcomes should GCNIS or malignancy be identified.
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Affiliation(s)
- Jacqueline Morin
- Department of Urology, University of Kentucky, Lexington, KY, USA
| | - Leslie Peard
- Department of Urology, University of Kentucky, Lexington, KY, USA
| | - Timothy Vanadurongvan
- Department of Surgery, Division of Urology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Jonathan Walker
- Department of Surgery, Division of Urology, University of Colorado School of Medicine, Aurora, CO, USA
| | - M İrfan Dönmez
- Department of Surgery, Division of Urology, University of Colorado School of Medicine, Aurora, CO, USA
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Eapen A, Chandramohan A, Simon B, Putta T, John R, Kekre A. Imaging Evaluation of Disorders of Sex Development. JOURNAL OF GASTROINTESTINAL AND ABDOMINAL RADIOLOGY 2020. [DOI: 10.1055/s-0039-3402101] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Abstract
AbstractDisorders of sex development (DSD) refer to congenital conditions with a typical development of chromosomal, gonadal, or anatomic sex. In the revised classification of DSD, there are three categories based on karyotype: 46,XX DSD; 46,XY DSD; and sex chromosome DSD. Imaging, as part of a multidisciplinary approach to management of DSD, has a key role in gender assignment. The main role of imaging is to help in identifying the gonads and the Müllerian structures. Ultrasound is useful, especially in the neonate with ambiguous genitalia. Magnetic resonance imaging is a useful modality to locate and characterize the gonads in young girls with primary amenorrhea and also to identify streak gonads, which have a risk of malignancy.
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Affiliation(s)
- Anu Eapen
- Department of Radiology, Christian Medical College, Vellore, Tamil Nadu, India
| | | | - Betty Simon
- Department of Radiology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Tharani Putta
- Department of Radiology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Reetu John
- Department of Radiology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Aruna Kekre
- Department of Obstetrics and Gynaecology, Christian Medical College, Vellore, Tamil Nadu, India
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16
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Wisniewski AB, Batista RL, Costa EMF, Finlayson C, Sircili MHP, Dénes FT, Domenice S, Mendonca BB. Management of 46,XY Differences/Disorders of Sex Development (DSD) Throughout Life. Endocr Rev 2019; 40:1547-1572. [PMID: 31365064 DOI: 10.1210/er.2019-00049] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Accepted: 07/23/2019] [Indexed: 12/11/2022]
Abstract
Differences/disorders of sex development (DSD) are a heterogeneous group of congenital conditions that result in discordance between an individual's sex chromosomes, gonads, and/or anatomic sex. Advances in the clinical care of patients and families affected by 46,XY DSD have been achieved since publication of the original Consensus meeting in 2006. The aims of this paper are to review what is known about morbidity and mortality, diagnostic tools and timing, sex of rearing, endocrine and surgical treatment, fertility and sexual function, and quality of life in people with 46,XY DSD. The role for interdisciplinary health care teams, importance of establishing a molecular diagnosis, and need for research collaborations using patient registries to better understand long-term outcomes of specific medical and surgical interventions are acknowledged and accepted. Topics that require further study include prevalence and incidence, understanding morbidity and mortality as these relate to specific etiologies underlying 46,XY DSD, appropriate and optimal options for genitoplasty, long-term quality of life, sexual function, involvement with intimate partners, and optimizing fertility potential.
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Affiliation(s)
- Amy B Wisniewski
- Psychology Department, Oklahoma State University, Stillwater, Oklahoma
| | - Rafael L Batista
- Division of Endocrinology, Department of Internal Medicine, University of São Paulo Medical School, University of São Paulo, São Paulo, Brazil
| | - Elaine M F Costa
- Division of Endocrinology, Department of Internal Medicine, University of São Paulo Medical School, University of São Paulo, São Paulo, Brazil
| | - Courtney Finlayson
- Division of Endocrinology, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Maria Helena Palma Sircili
- Division of Endocrinology, Department of Internal Medicine, University of São Paulo Medical School, University of São Paulo, São Paulo, Brazil
| | - Francisco Tibor Dénes
- Division of Urology, Department of Surgery, University of São Paulo Medical School, University of São Paulo, São Paulo, Brazil
| | - Sorahia Domenice
- Division of Endocrinology, Department of Internal Medicine, University of São Paulo Medical School, University of São Paulo, São Paulo, Brazil
| | - Berenice B Mendonca
- Division of Endocrinology, Department of Internal Medicine, University of São Paulo Medical School, University of São Paulo, São Paulo, Brazil
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Özdemir M, Kavak RP, Yalcinkaya I, Guresci K. Ovotesticular Disorder of Sex Development: An Unusual Presentation. J Clin Imaging Sci 2019; 9:34. [PMID: 31538032 PMCID: PMC6737443 DOI: 10.25259/jcis_45_2019] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Accepted: 06/03/2019] [Indexed: 11/04/2022] Open
Abstract
Disorder of sex development is an inclusive term that refers to any problem where the genital organ is atypical in relation to chromosomes or gonads. Ovotesticular disorder of sex development, which is formerly known as "true hermaphroditism," is the most rare form among all disorders of sex development in humans. It is characterized by the simultaneous presence of both ovarian and testicular tissues in the same individual and characteristically presents with ambiguous genitalia in neonates or infants. Herein, we present an unusual case of a 19-year-old individual with phenotypically nearly normal male genitalia who presented with the complaint of bilateral breast enlargement.
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Affiliation(s)
- Meltem Özdemir
- Department of Radiology, University of Health Sciences, Dışkapı Yıldırım Beyazıt Training and Research Hospital, Ankara, Turkey
| | - Rasime Pelin Kavak
- Department of Radiology, University of Health Sciences, Dışkapı Yıldırım Beyazıt Training and Research Hospital, Ankara, Turkey
| | - Ihsan Yalcinkaya
- Department of Radiology, University of Health Sciences, Dışkapı Yıldırım Beyazıt Training and Research Hospital, Ankara, Turkey
| | - Kursat Guresci
- Department of Radiology, University of Health Sciences, Dışkapı Yıldırım Beyazıt Training and Research Hospital, Ankara, Turkey
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Plea for a standardized imaging approach to disorders of sex development in neonates: consensus proposal from European Society of Paediatric Radiology task force. Pediatr Radiol 2019; 49:1240-1247. [PMID: 31123767 DOI: 10.1007/s00247-019-04414-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Accepted: 04/12/2019] [Indexed: 12/13/2022]
Abstract
This consensus article elaborated by the European Society for Paediatric Radiology task force on gastrointestinal and genitourinary imaging is intended to standardize the imaging approach in newborns with disorders of sex development. These newborns represent a difficult and stressful situation necessitating a multidisciplinary team approach. Imaging plays an important role in the work-up but needs to be optimized and customized to the patient. Ultrasound plays the central role in assessing the genital anatomy. The examination must be conducted in a detailed and systematic way. It must include transabdominal and transperineal approaches with adapted high-resolution transducers. The pelvic cavity, the genital folds, the inguinal areas and the adrenals must be evaluated as well as the rest of the abdominal cavity. A reporting template is proposed. The indications of magnetic resonance imaging and cysto- and genitography are discussed as well as they may provide additional information. Imaging findings must be reported cautiously using neutral wording as much as possible.
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Hiort O, Marshall L, Bacia A, Bouteleux M, Wünsch L. Besonderheiten der Geschlechtsentwicklung bei Kindern und Jugendlichen. Monatsschr Kinderheilkd 2019. [DOI: 10.1007/s00112-019-0718-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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20
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Imaging of diseases of the vagina and external genitalia in children. Pediatr Radiol 2019; 49:827-834. [PMID: 30612158 DOI: 10.1007/s00247-018-4324-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2018] [Revised: 10/29/2018] [Accepted: 12/09/2018] [Indexed: 10/27/2022]
Abstract
A wide range of congenital or acquired conditions, some pretty rare, may affect the vulva and vagina in children. Swelling, visible or palpable masses and abnormal discharges are common symptoms of conditions affecting the vulva and/or the lower genital tract. The majority of these diseases are benign. Ultrasonography is pivotal to elucidate the anatomical origin of these conditions and make the diagnosis. Magnetic resonance imaging can be relevant to improve diagnostic confidence and, if needed, to plan more accurate surgical treatment. The aim of this pictorial essay is to review the related imaging findings to help make radiologists familiar with these conditions.
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Song Y, Fan L, Gong C. Phenotype and Molecular Characterizations of 30 Children From China With NR5A1 Mutations. Front Pharmacol 2018; 9:1224. [PMID: 30425642 PMCID: PMC6218886 DOI: 10.3389/fphar.2018.01224] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Accepted: 10/08/2018] [Indexed: 01/31/2023] Open
Abstract
Background: Patients harboring NR5A1 mutations have a wide spectrum of phenotypes. Objective: To investigate the phenotype of patients with NR5A1 gene mutations from a 30 Chinese patient cohort. Methods: We reported the clinical features of children with NR5A1 gene mutations and compared them between two groups of patients with social genders of male (boys group) and female (girls group). Results: Thirty patients with NR5A1 mutations ranging from 2 months to 17 years of age were studied. There were 11 boys and 19 girls who were identified when they visited the hospital. The patients were verified as having testes without a uterus and ovaries by B-mode ultrasound. There was no difference between boys and girls in terms of the Prader stage (p = 0.086), but the position of the testes was higher in girls than in boys (p = 0.013). The patients’ average height is −0.43 SDS according to the normal boys’ height with SDS (while their average target height was 0.07 SDS). However, there was no such difference between boys and girls (p > 0.05). Although the basal LH and post-hCG testosterone (T) levels were not different (p > 0.05), but the basal FSH level, LH/FSH ratio, and INHB level were decreased in girls (p = 0.002; p = 0.001; p = 0.006). All of the mothers of the patients reported to have normal pregnancies. We found 24 patients (80%) with de novo mutations in the NR5A1 gene; 5 patients had inherited mutations from their mothers, and one inherited from the father. Only the mothers of patients 16 and 18 showed premature ovarian failure at the time of reporting. Among 26 disease associated mutations, 14 novel mutations that have been reported the first time and p.R87C is the most common Among the other 12 had had been reported,the p.R313C is the most common. Conclusion: Patients with 46, XY NR5A1 mutations presented a wide spectrum of external genitalia characteristics and severe Sertoli cell impairment. The p.R87C and p.R313C mutations appeared to be common (10%) in this group, and 14 new mutations were identified, improving our understanding the genotype phenotype correlations.
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Affiliation(s)
- Yanning Song
- Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Lijun Fan
- Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Chunxiu Gong
- Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China.,Beijing Key Laboratory for Genetics of Birth Defects, Beijing Children's Hospital, Capital Medical University, Beijing, China
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22
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Ponnatapura J. Hernia uteri inguinalis in ovotesticular disorder of sexual differentiation: A rare complication and role of imaging. Indian J Radiol Imaging 2018; 28:41-44. [PMID: 29692525 PMCID: PMC5894317 DOI: 10.4103/ijri.ijri_178_17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Neonate with ambiguous genitalia can cause great apprehension for the family as well as for healthcare providers. We report a rare complication of delayed diagnosis of hernia uteri inguinalis in ovotesticular disorder of sexual differentiation (DSD) in 20-year-old male patient who presented with pain and swelling in left inguinal region since 1 month. He had a past surgical history of repair of hypospadias 10 years back. On imaging, the left inguinal hernia sac contained nonfunctioning uterus and one ovary in the left scrotal sac and one testis in the right scrotal sac. Further investigation confirmed genotypically female (46XX) with negative sex determining region-Y gene on fluorescence in situ hybridization. The patient was given psychiatric counseling and wished to remain as male. The left inguinal hernia was repaired with excision of nonfunctioning uterus, ovary, and fallopian tube. Hernia uteri inguinalis is rare complication seen in DSD with only three cases being reported worldwide thus far, including our case.
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Affiliation(s)
- Janardhana Ponnatapura
- Department of Radiodiagnosis, Kempegowda Institute of Medical Sciences, Bengaluru, Karnataka, India
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23
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Phenotypic Variation of 46,XX Late Identified Congenital Adrenal Hyperplasia among Indonesians. J ASEAN Fed Endocr Soc 2018; 33:6-11. [PMID: 33442105 PMCID: PMC7784163 DOI: 10.15605/jafes.033.01.02] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Accepted: 01/09/2018] [Indexed: 11/17/2022] Open
Abstract
Objectives To describe the phenotype variation in Indonesian 46,XX late-identified congenital adrenal hyperplasia (CAH) and the correlation between 17-hydroxyprogesterone (17-OHP) and genital virilization. Methodology Retrospective study of 39 cases with five salt-wasting (SW) and 34 simple virilizing (SV) types. Results The median age of the patients was 9.83 years (range, 0.58 to 44 years) with Prader score 2 to 5. Clitoromegaly (100%) and skin hyperpigmentation (87%) were the most common features. Lack of breast development (Tanner 1 to 2) and menstrual disorders occurred in 9 patients (teenagers and adults). Short stature (6), low voice (14), prominent Adam’s apple (9) and hirsutism (4) were found only in SV types. Rapid growth (7) and precocious puberty (8) were identified in children. Male gender on admission was found in 13 patients. The mean of 17-OHP level was 304.23 nmol/L [standard deviation (SD) 125.03 nmol/L]. There was no correlation between 17-OHP levels and virilization (r=0.19, p>0.05). Conclusion Late-identified CAH showed severe virilization and irreversible sequelae, with clitoromegaly and skin hyperpigmentation as the most commonly seen features. Masculinization of CAH females created uncertainty with regard to sex assignment at birth, resulting in female, male and undecided genders. There is no significant correlation between 17-OHP levels with the degree of virilization in CAH females.
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Posada Y, Sánchez M, Granda J, Camargo M, Burgos G, Ibarra A. Case report: Male phenotype with incomplete Y chromosome and X chromosome double dosage. FORENSIC SCIENCE INTERNATIONAL GENETICS SUPPLEMENT SERIES 2017. [DOI: 10.1016/j.fsigss.2017.09.225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Indyk JA. Disorders/differences of sex development (DSDs) for primary care: the approach to the infant with ambiguous genitalia. Transl Pediatr 2017; 6:323-334. [PMID: 29184813 PMCID: PMC5682373 DOI: 10.21037/tp.2017.10.03] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
The initial management of the neonate with ambiguous genitalia can be a very stressful and anxious time for families, as well as for the general practitioner or neonatologist. A timely approach must be sensitive and attend to the psychosocial needs of the family. In addition, it must also effectively address the diagnostic dilemma that is frequently seen in the care of patients with disorders of sex development (DSDs). One great challenge is assigning a sex of rearing, which must take into account a variety of factors including the clinical, biochemical and radiologic clues as to the etiology of the atypical genitalia (AG). However, other important aspects cannot be overlooked, and these include parental and cultural views, as well as the future outlook in terms of surgery and fertility potential. Achieving optimal outcomes requires open and transparent dialogue with the family and caregivers, and should harness the resources of a multidisciplinary team. The multiple facets of this approach are outlined in this review.
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Affiliation(s)
- Justin A Indyk
- Section of Endocrinology, Nationwide Children's Hospital, the Ohio State University, Columbus, Ohio 43205, USA
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27
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Liu H, Tong XM. [Clinical evaluation and management of neonates with disorder of sexual development]. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2016; 18:1313-1318. [PMID: 27974129 PMCID: PMC7403084 DOI: 10.7499/j.issn.1008-8830.2016.12.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Accepted: 09/02/2016] [Indexed: 06/06/2023]
Abstract
Disorder of sexual development or disorder of sex differentiation (DSD) refers to the inconsistency between karyotype and gonad phenotype and/or gonad anatomy in neonates and is manifested as the difficulty in identifying neonates' sex. According to the karyotype, DSD is classified as 46,XY DSD, 46,XX DSD, and sex chromosome DSD. A combination of detailed medical history, physical examination, and laboratory and imaging examinations is required for the diagnosis and comprehensive assessment of neonatal DSD and the determination of potential causes in clinical practice. Sex identification can only be made after all diagnostic evaluations have been completed. Sex identification of DSD neonates is influenced by various medical and social factors, including genotype (karyotype), sex hormones (levels of testosterone, dihydrotestosterone, and adrenal steroids), sex phenotype (appearance of internal and external genitals), reproduction (fertility potential), feelings of their parents, and even social acceptance and religious customs. A team with multidisciplinary cooperation is required, and patients must be involved in the whole process of sex identification. The major task of neonatal physicians for DSD is to assess the condition of neonates and provide management.
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Affiliation(s)
- Hui Liu
- Department of Pediatrics, Peking University Third Hospital, Beijing 100191, China.
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Alaniz VI, Kobernik EK, Dillman J, Quint EH. Utility of Ultrasound and Magnetic Resonance Imaging in Patients with Disorders of Sex Development Who Undergo Prophylactic Gonadectomy. J Pediatr Adolesc Gynecol 2016; 29:577-581. [PMID: 27079912 DOI: 10.1016/j.jpag.2016.03.007] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2016] [Revised: 03/15/2016] [Accepted: 03/21/2016] [Indexed: 10/22/2022]
Abstract
STUDY OBJECTIVE To evaluate ultrasonography and magnetic resonance imaging (MRI) in identifying gonads in patients with disorders of sex development (DSD) who undergo prophylactic gonadectomy, and to assess the capacity of preoperative imaging to detect premalignant and malignant transformation. DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort at a tertiary referral center of 39 patients with DSD who underwent MRI and/or ultrasonography before prophylactic gonadectomy. INTERVENTIONS None. MAIN OUTCOME MEASURES Identification of gonads on preoperative imaging. RESULTS Thirty-three patients underwent ultrasonography, which identified 54% (35/65) of gonads and 14 patients had MRI, which identified 41% (11/27) of gonads. There was no significant difference between imaging modalities in the proportion of gonads identified (P = .25). The proportion of pathology-confirmed dysgenetic gonads identified was higher on ultrasound compared with MRI (51% vs 8%; P = .02). There was no difference in the proportion of pathology-confirmed testes identified on ultrasound and MRI (54% vs 71%; P = .33). Eleven out of 39 patients (28%) were diagnosed with a premalignant lesion, and there were no distinguishing characteristics documented on imaging reports to suggest transformation. The only diagnosed malignancy in this series had imaging describing a "normal-sized ovary." CONCLUSION Ultrasonography and MRI identified 40%-50% of gonads in patients with DSD who underwent prophylactic gonadectomy, with no significant difference between the 2 modalities. Clinicians should, therefore, consider ultrasonography as a first-line imaging modality. Premalignant lesions were not detected on either imaging modality. The only malignancy was described as a "normal-sized ovary" which should raise concern in a patient with complete gonadal dysgenesis expected to have streak gonads.
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Affiliation(s)
- V I Alaniz
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan.
| | - E K Kobernik
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan
| | - J Dillman
- Department of Radiology, Section of Pediatric Radiology, University of Michigan, Ann Arbor, Michigan
| | - E H Quint
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan
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Torres-de la Roche LA, Devassy R, Gopalakrishnan S, de Wilde MS, Herrmann A, Larbig A, De Wilde RL. Plastic neo-vaginal construction in Mayer-Rokitansky-Küster-Hauser syndrome: an expert opinion paper on the decision-making treatment process. GMS INTERDISCIPLINARY PLASTIC AND RECONSTRUCTIVE SURGERY DGPW 2016; 5:Doc08. [PMID: 26904393 PMCID: PMC4740437 DOI: 10.3205/iprs000087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Vaginal agenesis is a congenital anomaly that affects the life of one of each four thousand women around the world. There is a trend that patients request immediate surgical correction, instead of passive vaginal dilatation. Therefore a differentiated counselling should be provided. We present a comparative chart, based on published evidence, with aspect to the available techniques, which will facilitate the decision-making process in the clinical practice. From our point of view, the best results are achieved with techniques that combine the advantages of the minimal-invasive surgery with those derived of the use of peritoneum as covering tissue of the neovagina. Nevertheless there is a lack on interdisciplinary consensus about the best option to restore the physical and sexual quality of life.
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Affiliation(s)
- Luz Angela Torres-de la Roche
- Clinic of Gynecology, Obstetrics and Gynecological Oncology, University Hospital for Gynecology, Pius-Hospital Oldenburg, Medical Campus University of Oldenburg, Germany
| | - Rajesh Devassy
- Dubai-London Specialty Hospital, Jumeirah, Dubai, United Arab Emirates
| | | | - Maya Sophie de Wilde
- Clinic of Gynecology, Obstetrics and Gynecological Oncology, University Hospital for Gynecology, Pius-Hospital Oldenburg, Medical Campus University of Oldenburg, Germany
| | - Anja Herrmann
- Clinic of Gynecology, Obstetrics and Gynecological Oncology, University Hospital for Gynecology, Pius-Hospital Oldenburg, Medical Campus University of Oldenburg, Germany
| | - Angelika Larbig
- Clinic of Gynecology, Obstetrics and Gynecological Oncology, University Hospital for Gynecology, Pius-Hospital Oldenburg, Medical Campus University of Oldenburg, Germany
| | - Rudy Leon De Wilde
- Clinic of Gynecology, Obstetrics and Gynecological Oncology, University Hospital for Gynecology, Pius-Hospital Oldenburg, Medical Campus University of Oldenburg, Germany
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Gould SW, Epelman M. Magnetic Resonance Imaging of Developmental Anomalies of the Uterus and the Vagina in Pediatric Patients. Semin Ultrasound CT MR 2015; 36:332-47. [PMID: 26296484 DOI: 10.1053/j.sult.2015.05.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Developmental anomalies of the uterus and the vagina are associated with infertility and miscarriage and are most commonly detected in the postpubertal age-group. These conditions may also present in younger patients as a mass or pain owing to obstruction of the uterus or the vagina. Associated urinary tract anomalies are common, as well. Accurate diagnosis and thorough description of these anomalies is essential for appropriate management; however, evaluation may be difficult in an immature reproductive tract. Magnetic resonance imaging technique pertinent to imaging of the pediatric female reproductive tract is presented and illustrated along with the findings associated with various anomalies.
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Affiliation(s)
- Sharon W Gould
- Department of Medical Imaging, Nemours/A.I. duPont Hospital for Children, Wilmington, DE.
| | - Monica Epelman
- Department of Medical Imaging/Radiology, Nemours Children׳s Hospital, Orlando, FL
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Turo R, Derbyshire LF, Smolski M, Collins GN, Lynch N, Lewinski M, Brough RJ, Sinclair AM. Embryology and adult urology - Not always mutually exclusive: A case report on true hermaphroditism at an adult urology clinic. Can Urol Assoc J 2014; 8:E650-3. [PMID: 25295140 DOI: 10.5489/cuaj.2035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
True hermaphrodite (TH) is one of the rarest varieties of disorders of sexual differentiation. Most patients present early in the life and are managed by pediatricians. We present a rare case of an adult TH which was first diagnosed by a urologist. We discuss the pathology of TH and its clinical relevance. Knowledge and awareness of embryology are vital to all specialties.
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Affiliation(s)
- Rafal Turo
- Urology Department, St. James's University Hospital, Leeds, West Yorkshire, United Kingdom
| | | | - Michal Smolski
- Urology Department, Stepping Hill Hospital, Stockport, Cheshire
| | | | - Niall Lynch
- Radiology Department, Stepping Hill Hospital, Stockport, Cheshire
| | - Maryna Lewinski
- Radiology Department, Stepping Hill Hospital, Stockport, Cheshire
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Rothkopf AC, John RM. Understanding disorders of sexual development. J Pediatr Nurs 2014; 29:e23-34. [PMID: 24796516 DOI: 10.1016/j.pedn.2014.04.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2014] [Revised: 04/03/2014] [Accepted: 04/07/2014] [Indexed: 11/18/2022]
Abstract
Studies estimate that the incidence of genital anomalies could be as high as 1 in 300 births. While it is rare for an infant to present with truly ambiguous genitalia, it is plausible that the pediatric nurse will encounter a patient with disorders of sexual development in his or her career. Cases of disorders of sexual development are challenging due to complexities of diagnosis, gender assignment, uncertain outcomes, treatment options, and psychosocial stressors. This article discusses the evaluation and management of children with disorders of sexual development and the nurse's role as child advocate and family educator.
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Nogueira J, de Los Llanos Moreno R, Sánchez JM, González G. [Chimeric disorders of sex development ovotesticular]. Med Clin (Barc) 2014; 143:91-2. [PMID: 24286811 DOI: 10.1016/j.medcli.2013.09.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2013] [Revised: 09/18/2013] [Accepted: 09/26/2013] [Indexed: 10/26/2022]
Affiliation(s)
- Jessica Nogueira
- Departamento de Ginecología y Obstetricia, Hospital General Universitario de Albacete, Albacete, España.
| | | | - José María Sánchez
- Departamento de Ginecología y Obstetricia, Hospital General Universitario de Albacete, Albacete, España
| | - Gaspar González
- Departamento de Ginecología y Obstetricia, Hospital General Universitario de Albacete, Albacete, España
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