Disorders of sexual development: structured radiological reporting and practical approach

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.

The role of ultrasound to evaluate the disorders of sex development: a pictorial essay

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.

Ovarian and uterine ultrasonography in pediatric patients. Pictorial essay

Ultrasonography represents the method of choice in the investigation of the female pediatric pelvis. While the investigation itself poses no real challenges, an accurate interpretation of the images must take into consideration the specific features of the ovaries and uterus at certain ages. The present essay aims to demonstrate the normal appearance of the female pelvis and the changes that occur during the various stages of development as well as the some of the most common pathological conditions.

Sonography of the pelvis in patients with primary amenorrhea

Duplex/color Doppler sonography (US) is the imaging modality of choice for the evaluation of patients with primary amenorrhea. Careful correlation with clinical history, physical examination and laboratory findings significantly narrows the diagnostic possibilities thus allowing for a more precise diagnosis. This article discusses the wide gamut of etiologies of primary amenorrhea, the US appearance of pathologic processes that result in primary amenorrhea, and helps the reader understand when additional higher tech imaging is indicated.

[Fetal juvenile granulosa cell tumor with hermaphroditism verus - prenatal diagnosis, management and outcome]

Fetal ovarian cysts are common during pregnancy and after delivery. Most of these cysts are simple cysts that involute during pregnancy or in the first months of life. However, complicated cyst with a heterogeneous structure and also possible and can result in various complications: rupture, hemorrhage, ascites, edema of the labia, compression of other viscera, and ovarian torsion. In this case report we describe rare diagnosis of a complicated fetal ovarian cyst with edema of the labia and moderate ascites. The neonate had ambiguous genitalia with clitoromegaly. The newborn underwent surgery with oophorectomy. During the operation a uterus with fallopian tubes was found. The pathological findings showed a juvenile granulosa cell tumor FIGO Ia. Karyotyping revealed a mosaic of 45, X/ 46, X mar (Y) in the peripheral blood as well as in the granulosa cell tumor. Because of a right side inguinal hernia, the child underwent a second surgery. Specimen taken from the abdominal gonad and the inguinal region showed testicular and dysplastic ovarian tissue. There were elevated levels of androgens in the child's peripheral blood due to the granulosa cell tumor. In summary, this case report describes a fetus with true hermaphroditism and a juvenile granulosa cell tumor diagnosed as a complicated ovarian cyst in the 32 (nd )week of pregnancy.

Prenatal diagnosis of 46, XX male fetus

Prenatal diagnosis of sex differentiation disorders is extremely rare and is estimated in 1/2500 analyzed gestations. A group of this disorders are the 46, XX males and its incidence is estimated in 1/20000 male neonates. We report a male XX fetus in which the diagnosis of sex determination was requested at 20 gestation weeks to clarify the real gender of the fetus. Discrepancy between cytogenetic and ultrasonographic was detected.

True hermaphroditism-the importance of ultrasonic assessment

Intersex states are associated with rare syndromes within a wide clinical spectrum, true hermaphroditism being the rarest of them all. It is a condition that is characterized by ovotestis, i.e. the presence of ovarian and testicular tissues in the same individual, either in separate gonads or in the same gonad. Diagnostic investigation of hermaphroditism involves ultrasound examination of the gonads, karyotype analysis and histological studies. We report the case of a 21-year-old individual with true hermaphroditism, in whom ovotestis was diagnosed on ultrasonography and which was later confirmed by anatomopathological study of the gonads. The role of ultrasound in the initial diagnostic investigation of intersex states, especially true hermaphroditism, is discussed.

Sonographic imaging of the paediatric female pelvis

Several conditions necessitate a pelvic ultrasound in their management. In this paper, we will first review the embryology of the female genital system and the normal morphology of the uterus and ovaries from birth to puberty. Thereafter, this paper aims to categorise pelvic pathologies based on their clinical presentations. We will consider successively ambiguous genitalia, precocious puberty, delayed puberty and amenorrhea, gynaecological masses and, finally, pelvic pain of gynaecological origin. Ultrasound is the key screening tool and often the only examination indicated. The appropriateness of other modalities, such as computed tomography and magnetic resonance imaging, will be discussed. The aim of this article is to help radiologists form a sensible imaging plan when presented with a diagnostic dilemma involving the pelvis in female children.

Sonography in prenatal diagnosis of congenital adrenal hyperplasia

Congenital adrenal hyperplasia (CAH) is an autosomal recessive disorder with an incidence of 1/15 000. More than 90% of CAH cases result from mutations of CYP21, leading to 21-hydroxylase deficiency. In its classical form, CAH is severe and consists of the virilizing (increase of androgens) and salt-wasting (lack of aldosterone) phenotype. When a proband exists, early prenatal diagnosis for CAH can be performed by direct molecular analysis in the first trimester. We describe herein two cases suggesting that the prenatal diagnosis of CAH can be initiated by the sonographic appearance of the adrenal gland at the second-trimester scan in the absence of a family history.

[Usefulness of transrectal ultrasonography in the diagnosis of anomalies of intersexual conditions]

INTRODUCTION

Between the external genital exploration and the internal genital direct vision, through laparoscopia, there is a black point which is the pelvic floor; we have to know whether there is a vagina or not, what it is like and where it arrives at. The reason for this research is to present our experience with the transrectal ecography, which allows us a very good exploration of the pelvic floor.

MATERIAL AND METHODS

We present 6 patients, the youngest is 16 months old and the oldest is 19 years old, who have a diagnostic of 3 congenital adrenal hyperplasia (HSC), 2 gonadal dysgenesis and 1 vaginal agenesis (S. Rokitanski). Under sedation, we carried out a transrectal ecography with Aloka SSD650 ecograph and 7.5 MHz vaginal scanner. Ultrasone.

RESULTS

In case of HSC (16 months old), the transrectal ecography showed the vaginal arrival at the urethra and we were able to measure the distance from the external sphincter. In the other two HSC, which had been surgically corrected, the transrectal ecography clearly showed the vagina (length and calibre). In the two gonadal dysgenesis (two 11-and-19-year-old sisters, the first of whom had undergone vulvo-vaginoplasty, we appreciated the length of the vagina and, in the case of the sister with a relatively normal vagina, we confirmed the presence of the vagina connected to the uterus. In the vaginal agenesis, in which a neovagina with amnion membrane had been carried out, which, in its turn, ended in a situation of hematometra due to a stenosis, the transrectal ecography was really helpful to obtain vaginal dilatations.

CONCLUSIONS

Ecography is an easily available technique and provides both through and detailed information of the genital structures going through the pelvic floor, a zone which is otherwise difficult to explore. It was done under sedation for the patient's age and idiosyncrasy. The experience has just started but we are sure that in the future it will replace the genitograma.

Prenatal diagnosis of sex differentiation disorders: the role of fetal ultrasound

We describe our experience with prenatal diagnosis of sex differentiation disorders, with focus on the role of ultrasound scans for coherent assessment of prenatal diagnosis. Over a 5-yr period all cases suspected of sexual ambiguity based on abnormal ultrasonographic scans (US) or US/genotype US discrepancy were evaluated prenatally by three modalities: 1) repeated fetal US; 2) genetic studies, primarily karyotype and fluorescence in situ hybridization analysis of sex-determining region on the Y gene (SRY); and 3) hormonal assays of amniotic fluid. Of approximately 10,000 gestations, 16 fetuses underwent prenatal evaluation. Twelve were referred because of an abnormal US and 4 because of genotype-phenotype discrepancy. Five fetuses were diagnosed with female pseudohermaphroditism (21-hydroxylase deficiency in 3 and urorectal septum malformation sequence in 2). Four fetuses were diagnosed with male pseudohermaphroditism (1 with steroid sulfatase deficiency, 1 with presumed camptomelic dysplasia, and 2 undetermined). Five cases had chromosomal abnormalities, and 2 had 46,XX+SRY sex reversal. In all genetic females the uterus was observed on US. In 11 cases initial US scan was performed at 13-15 wk; in 7 of 11, although the initial scan was normal, a repeated scan later in gestation revealed an abnormality. Repeated US scans performed at 13-15 and 22-24 wk gestation are a helpful tool in prenatal diagnosis of sex differentiation disorders. Our data suggest that both size and structure anomalies of the reproductive structures may evolve throughout pregnancy, and that they represent a developmental biological process rather than a single nonprogressive pathological event. US scan after approximately 19 wk enables detection of the uterus and provides pivotal information in cases of ambiguity. If the uterus appears normal, the most likely diagnosis is a virilized karyotypic female. Prenatal diagnosis allows for early parental counseling and anticipation of medical management postnatally.

Mutations of the 5alpha-steroid reductase type 2 gene in six Turkish patients from unrelated families and a large pedigree of an isolated Turkish village

We describe six Turkish patients with 5alpha-steroid reductase type 2 deficiency from unrelated Turkish families and a large pedigree of one of these patients who reside north-west of Anatolia. Patients NA, KS, BD and SY presented for evaluation of bilateral inguinal masses with female phenotypes. Patient ABE had penoscrotal hypospadias with male phenotype. Homozygous mutation of the 5alphaSR2 gene was identified in five of these patients by genomic DNA analysis. These mutations were Leu55Gln in exon 1 (in patients FG, BD and ABE), deltaMet157 in exon 3 (in patient NA), and splice junction abnormality in intron 1 (in patient SY). One individual (patient KS) was found to be a compound heterozygous carrier of two different mutations, Leu55Gln in exon 1 and Arg171Ser in exon 3. Patient FG had a large pedigree with the Leu55Gln mutation in exon 1. The pedigree of this family with marital consanguinity is remarkable, and possibly due to the isolation of this family because of economic and social problems. A further 85 individuals belonging to this family were analyzed for exon 1 Leu55Gln mutations in the 5alphaSR2 gene. Forty-two of these 85 individuals (49.41%) had this alteration; 11 were homozygous (8 genetic male, 3 genetic female) and 31 heterozygous (18 genetic male, genetic female) for this mutation. It was interesting to see asymptomatic homozygous female carriers. In conclusion, according to our results and those of other Turkish patients reported by different investigators, 5aSR2 gene mutation analysis, especially for Leu55Gln in exon 1 and deltaMet157 in exon 3, must be carried out in Turkish patients with male pseudohermaphroditism. Homozygous asymptomatic female carriers must be taken into consideration in this clinical entity, especially in a closed population, because of the risk of transmitting the disease to their offspring.

Prenatal diagnosis of female pseudohermaphroditism associated with bilateral luteoma of pregnancy: case report

Female pseudohermaphroditism associated with luteoma of pregnancy (LP) is a rare condition characterized by varying degrees of masculinization of a female fetus. We describe a case, diagnosed at 13 weeks gestation. Transvaginal ultrasound at 5 weeks of gestation revealed a normal intrauterine gestational sac and an enlarged maternal right ovary. Re-examination at 13 weeks showed a fetus with male external genitalia. Cytogenetic investigation on amniotic fluid revealed a normal female karyotype 46,XX. Follow-up sonography confirmed the previous assignment of male external genitalia and a second amniocentesis was negative for the SRY gene. High levels of androgens were found in the maternal blood. A diagnosis of female pseudohermaphroditism associated with bilateral LP was made. A healthy girl was born by Caesarean section with complete masculinization of external genitalia (Prader V). Histology confirmed a bilateral LP. To the best of our knowledge this represents the first case of prenatal diagnosis of female pseudohermaphroditism associated with LP and demonstrates the feasibility of diagnosis by sonography from 13 weeks gestation. This is also the first case described of Prader V masculinization associated with LP.

Osteocraniostenosis in a fetus with a 46,XX/46,XY karyotype

Osteocraniostenosis is a disorder characterized by thin tubular bones, dymorphic facies and splenic hypoplasia/aplasia in some cases. We report a further case of this rare skeletal dysplasia in a 31 week male fetus with ambiguous external genitalia and asymmetry in whom a 46,XX/46,XY karyotype was demonstrated in both cartilage and skin.

Transabdominal pelvic sonography in the preoperative evaluation of patients with congenital adrenal hyperplasia

PURPOSE

We assessed the clinical value of transabdominal pelvic sonography in the preoperative evaluation of patients with congenital adrenal hyperplasia (CAH) who required feminizing genitoplasty.

METHODS

From 1987 to 1998, 31 patients with female pseudohermaphroditism due to CAH underwent feminizing genitoplasty. The median age of the patients was 9 months (range, 1-18 years). Radiologic evaluation performed before surgical reconstruction included retrograde genitography in the first 10 patients and sonographic examination in all 31 patients. Imaging was used to evaluate the anatomic positions and the length of the vagina, whether the junction of the vagina and the urogenital sinus occurred distal or proximal to the pelvic floor, and the presence of internal genitalia.

RESULTS

Abdominal sonography identified internal female genitalia in all 31 patients, identified the anatomic shape and position of the vagina in 30 patients (97%), and confirmed the site of communication between the vagina and the urogenital sinus relative to the pelvic floor in 28 patients (90%). Sonographic findings were confirmed by intraoperative panendoscopy. Genitography was less useful than sonography, identifying the site of communication between the vagina and urogenital sinus in only 6 (60%) of 10 patients.

CONCLUSIONS

In patients with CAH undergoing vaginal reconstruction, sonography provides adequate information about the anatomy of the vagina and urogenital sinus for surgical decision-making.

Abnormal prostatic utricle configuration in hypospadias and intersex patients

A retrospective clinical trial was performed to evaluate the incidence, clinical characteristics, diagnosis and treatment methods of abnormal prostatic utricle configuration (APUC) in hypospadias and intersex patients. Forty-five hypospadias and 72 intersex patients in whom the configuration of prostatic utricle (PU) was evaluated by radiological and endoscopic investigations formed the study group out of 380 hypospadias and 160 intersex patients who were treated between 1975 and 1996. Enlargement of PU (EPU) was classified into four grades based on the radiological configuration. The term vagina masculina (VM) was used to define the presence of unregressed müllerian duct structures. The incidence of APUC (either enlarged PU: EPU or VM) was 13.3% (n = 6) and 16.6% (n = 12) in hypospadias and intersex patients, respectively. The incidence and grade of EPU increased significantly with the severity of hypospadias. Urinary infection, obstruction and enuresis were the most common symptoms in both groups. Medical treatment consisting of appropriate antibiotics associated with follow-up of the APUC by means of radiological and endoscopic investigations was carried out in 4 patients with Grade I EPU successfully. Surgical excision of the Grade II, III and/or VM through perineal (n = 5), transabdominal extravesical (n = 5) and perineal plus transabdominal extravesical (n = 3) approaches was done while one patient was lost for follow-up before treatment. We emphasize that surgical treatment of EPU and VM must aim at complete excision without damaging continence and sexual potency mechanisms. The selection of the surgical treatment method should be individualized according to the grade of APUC which must be defined by preoperative radiological and endoscopic investigations. The optimal surgical method is the one which allows the best visualization of the involved anatomy, facilitates accurate suture placement with complete removal of the EPU and VM and avoids inadvertent injury to the adjacent tissues. Guidance by urethral and utricular catheters is essential for safe and elegant dissection in all surgical methods.

Prenatal diagnosis of Smith-Lemli-Opitz syndrome in a pregnancy with low maternal serum oestriol and a sex-reversed fetus

A cytogenetically normal male fetus was subsequently found to have female external genitalia, a cardiac malformation and mid-trimester intra-uterine growth retardation by ultrasound examination. The maternal serum oestriol level was low. The combination of low oestriol and sonographic findings suggested Smith Lemli Opitz syndrome (SLO), which was confirmed by a markedly increased amniotic fluid level of 7-dehydrocholesterol. We review the differential diagnosis of apparent sex reversal in a fetus and low maternal serum oestriol level. To further examine the specificity of low maternal oestriol level as a marker for SLO a follow-up study of 12141 pregnancies screened for Down syndrome using three biochemical markers: alpha-fetoprotein, beta-human chorionic gonadotrophin and oestriol was performed. 26 pregnancies had an oestriol level that was 0.25 MoM or less. SLO was not diagnosed clinically in any of the liveborn children ascertained through a low maternal oestriol level. Nine of the pregnancies ended in spontaneous miscarriage. Although the frequency of SLO in pregnancies with low maternal oestriol levels or sex-reversed fetuses is unknown, the diagnosis of SLO should, nevertheless, be considered in both clinical settings.

[Utility of ultrasonography in patients with ambiguous external genitalia: a clinical case]

We report a case in which the use of ultrasonography in the perinatal evaluation of ambiguous genitalia could have avoided psychological, physiological and also medico-legal problems for the patient.

Congenital bilateral anorchia: clinical, hormonal and imaging study in 12 cases

Twelve anorchid pre-pubertal and post-pubertal patients, aged between 8.5 and 41 years, were studied. The FSH and LH basal levels as well as their responses to Gn-RH (100 micrograms i.v.) were increased and prolonged in the post-pubertal patients. The testosterone levels were in the pre-pubertal range and failed to increase after HCG administration (1500 I.U. t.i.d. for 3 days). Ultrasonography of the pelvis was performed in all the patients. Computed tomography and magnetic resonance of the abdomen were also performed in 6 and 5 patients respectively. These techniques failed to show any testicular tissue. Lastly, in 4 patients, surgical exploration confirmed the absence of testicular structure.

Case report: A rapidly expanding testicular mass due to a ruptured ovarian follicle

An ovotestis is the commonest gonad in the small number of patients who are true hermaphrodites. In the majority of ovotestes, testicular and ovarian tissue is arranged end-to-end. There has been only one previous report of the sonographic appearances of an ovotestis. We present the sonographic findings in a patient who developed a rapidly enlarging upper pole testicular mass, which was found on histology to be a ruptured ovarian follicle with spermatogenesis occurring within the adjacent testicular tissue.

[Possibilities of ultrasonography in the diagnosis of sex differentiation disorders in children]

Ninety-five children with different forms of hermaphroditism aged 3 months to 14 years were examined to assess the potentialities of echography. Ultrasonic examinations of the kidneys, adrenals, pelvic organs (with full bladder, during and after miction), scrotum, and inguinal area were carried out. Echographic picture of urogenital organs in mixed ovarian dysgenesis, congenital deficiency of testosterone biosynthesis or metabolism due to enzymatic deficit, testicular feminization, congenital adrenocortical dysfunction was analyzed and criteria of differential diagnosis of these conditions discussed. The informative value of the method was assessed. Ultrasonic findings were compared with the data other diagnostic methods and reliability and high sensitivity of ultrasonography was demonstrated.

Accuracy of ultrasonic detection of the uterus in normal newborn infants: implications for infants with ambiguous genitalia

Every year approximately one in 5000 babies is born with ambiguous genitalia, a condition that requires immediate sex assignment if possible. We investigated whether transabdominal ultrasonography with the use of a linear array high-resolution 7.5-MHz transducer would enhance the accuracy of detecting the uterus in the newborn. One hundred mothers who delivered normal, term infants (> 36 weeks and > 2500 g) gave their informed consent for the investigation. Each infant was placed in an unmarked bassinet, external genitalia were covered, and ultrasound examinations were performed by the same examiner (R.S.) who was blinded to the sex of the infant. The neonatal uterus was identified in 47 of 50 female infants (94% sensitivity) and the absence of a uterus was correctly predicted in 49 of 50 male infants (specificity 98%). The average length of the neonatal uteri 1 day after birth was 3.2 +/- 0.5 cm and the total volume was 3.5 +/- 0.9 cm3. An endometrial strip could be identified in 98% of neonatal uteri. We conclude that the use of the high-resolution 7.5-MHz transducer available in commercial ultrasound equipment is an accurate method for the detection of the neonatal uterus. Infants born with ambiguous genitalia who have a uterus will almost always be assigned the female sex. Infants with ambiguous genitalia but without a uterus will have male pseudohermaphroditism.

Prenatal diagnosis of Smith-Lemli-Opitz syndrome, type II

Smith-Lemli-Opitz syndrome, type II (SLOS-II) is a severe autosomal recessive disorder characterized by a distinctive face, unusual cleft palate, postaxial polydactyly, congenital heart defects, renal anomalies, and male pseudohermaphroditism. We present the first report of prenatal diagnosis of SLOS-II, as well as an additional report of prenatal detection of multiple anomalies, in which a positive diagnosis of SLOS II was made postnatally. In neither case was the pregnancy known prospectively to be at risk for SLOS-II. In the former case, targeted sonographic examination at 31 weeks of gestation showed intrauterine growth retardation, atrioventricular septal defect, mesomelic shortening of the arms, small kidneys, overlapping fingers, and female external genitalia; a 46,XY chromosome constitution had been ascertained previously. A provisional diagnosis of SLOS-II was made prenatally. In the latter case, targeted sonographic examination at 18 weeks of gestation showed severe oligohydramnios, atrioventricular septal defect, and Dandy-Walker malformation. The kidneys and bladder were not visualized. The chromosome constitution was 46,XX. The diagnosis of SLOS-II was made postnatally. In both cases, additional findings compatible with SLOS-II were noted postnatally. Prenatal detection of congenital heart defects and renal abnormalities, in combination with certain additional findings (most notably, female external genitalia in the presence of a 46,XY karyotype, polydactyly, disproportionately short limbs, or intrauterine growth retardation) and a normal karyotype, suggests the diagnosis of SLOS-II, and warrants further investigation.

The ovary. Computed tomography and magnetic resonance imaging

CT and MR imaging can both contribute valuable clinical information in women with benign and malignant ovarian masses; the superior soft tissue contrast and multiplanar capabilities provided by MR imaging make it a valuable tool to evaluate the normal ovary, polycystic ovaries, endometriosis, and disorders of sexual differentiation. CT is currently the recommended modality to stage ovarian carcinoma, and peritoneal implants as small as 5 mm can be visualized. With the addition of contrast-enhanced images to conventional MR sequences, however, improved visualization of intratumoral architecture has also allowed for accurate MR characterization of benign versus malignant ovarian masses. Fat saturation techniques used with conventional MR sequences can also be used for definitive characterization of benign fat-containing teratomas and differentiate these tumors from hemorrhagic ovarian cysts or endometriomas. Finally, the detailed visualization of the normal-sized ovary on MR images provided by both the body coil and the new phased-array coil allows detection of the normal ovaries, ovarian follicles, and ovarian cysts throughout the premenopausal and postmenopausal years. Findings of polycystic ovarian syndrome, which cannot be evaluated by CT, are characteristic on MR images. MR is unparalleled in the evaluation of disorders of sexual differentiation because MR images can depict ectopic and normally positioned gonads and provide multiplanar depiction of the other pelvic organs and perineum as well. CT and MR imaging can provide valuable and specific clinical information about the ovary and benign and malignant ovarian disease.

17 alpha-Hydroxylase deficiency with persistence of müllerian ducts in a genotypic male and paradoxical aldosterone secretion

We report a case of congenital adrenal hyperplasia due to 17 alpha-hydroxylase deficiency in a Chinese genotypic male patient. Despite the male genotype, normal female external genitalia were present and with the introduction of cyclical oestrogen therapy withdrawal bleeding occurred, confirming the presence of functional endometrial tissue. We believe this to be the first report of persistent Mullerian duct structures in a genotypic male with 17 alpha-hydroxylase deficiency. It could be explained by either impaired secretion or impaired action of anti-Mullerian hormone. Further, contrary to the usual finding of suppressed aldosterone secretion, this patient had measurable levels of plasma aldosterone.

Radiological findings in three cases of persistent müllerian duct syndrome

We report three cases of persistent Müllerian duct syndrome, which is a rare form of inherited male pseudohermaphroditism characterized by the presence of a uterus and tubes in otherwise normally virilized 46,XY males. We emphasize the usefulness of ultrasonographic study of the pelvis and inguinal areas in the preoperative diagnosis, which is difficult. We recommend that ultrasound be performed routinely in bilaterally cryptorchid patients.

Prostate visualization studies in males homozygous and heterozygous for 5 alpha-reductase deficiency

Male pseudohermaphrodites with 5 alpha-reductase deficiency have ambiguous genitalia and nonpalpable prostates on rectal examination, suggesting the dihydrotestosterone dependency of these structures. To clearly delineate the status of the prostate, male pseudohermaphrodites with 5 alpha-reductase deficiency had transrectal sonography of the prostate performed, and the results were compared to that of age-matched male controls. In six male pseudohermaphrodites, magnetic resonance imaging studies of the prostate were also performed. Heterozygote fathers also had transrectal sonography of the prostate performed and the results compared to age-matched controls. The prostates of the male pseudohermaphrodites appeared as platelike soft tissue structures posterior to the urethra on both prostatic ultrasound and magnetic resonance imaging. Prostatic volume, as determined on prostatic ultrasound by two different methods, was significantly smaller (approximately one-tenth) than the volume of age-matched controls. Transurethral ultrasound guided biopsy of the prostate in two affected subjects revealed stromal tissue. These results correlate with undetectable prostate-specific antigen in affected subjects, suggesting atrophic epithelium or lack of epithelial differentiation. This study demonstrates the dihydrotestosterone dependence of the prostate for normal differentiation and growth. The presence of some prostatic tissue in the male pseudohermaphrodites may be due to the fact that there is a decrease and not an absence of 5 alpha-reductase activity, and/or that the increased level of testosterone in subjects with this condition partially compensates for the decreased level of dihydrotestosterone. There was no difference, however, in prostate size between heterozygous fathers and age-matched control males. The heterozygote fathers had dihydrotestosterone production sufficient for normal prostate growth and development.

Acute renal failure associated with contrast medium administration in a dog

Intravenous administration of an ionic radiographic contrast medium was believed to have caused acute oliguric renal failure in a young dog. Intravenous pyelography was done on a healthy 14-month-old female Lhasa Apso prior to reconstructive surgery for pseudohermaphroditism. Within 24 hours of the radiographic procedure, acute oliguric renal failure developed. Cause for the renal failure was not found other than the recent IV administration of radiographic contrast medium. Treatment with fluids, furosemide, and dopamine was successful in returning renal function to normal. Various adverse reactions to IV administration of contrast media in human beings and animals have been reported; however, to our knowledge, acute renal dysfunction induced by IV administration of contrast material has not been reported in dogs.

True hermaphroditism: sonographic demonstration of ovotestes

A 15-year-old boy with normal external genitalia presented with severe bilateral gynecomastia, intermittent painful scrotal swelling, and a recent history of scrotal trauma. Ultrasound (US) revealed testicles of normal size with diffusely heterogeneous echotexture due to scattered cysts. Ovotestes were found at surgery and pathologic examination. Bilateral partial gonadectomies were performed. Four months later he had testicular pain and swelling. US revealed bilateral multiseptate cystic masses. After repeat surgery, he is now free of symptoms. The diagnosis of true hermaphroditism and ovotestis should be considered in a phenotypic male adolescent with gynecomastia when testicular parenchyma is heterogeneous at US because of multiple scattered cysts.

The anatomy of intersexuality

A description of anatomical lesions in the intersexual states has been made based on clinical and anatomical observations. This study provides the anatomical basis which is necessary before surgical genital reconstruction can be carried out.

[Value and importance of genital urography in the diagnosis of intersexuality and other malformations of the urogenital tract]

The accuracy of genital urography in the diagnosis of intersex and for the demonstration of the internal genitalia has been studied in 16 patients. It was found that the radiological appearances agreed in all cases with the surgical findings. Individual malformations of the genitals have been considered with reference to the classification of Shopfner and Prader and the advantages and disadvantages of various examination techniques are discussed.

The demonstration of true hermaphroditism by computed tomography

Intersex states are rare but if unsuspected may cause diagnostic confusion. We describe one such patient with true hermaphroditism which was misdiagnosed on computed tomography (CT). Laparotomy revealed a female genital tract and histology confirmed the presence of ovatestes, despite a male phenotype.

[Genitography of sexual ambiguities in children]

In children with pseudo or true hermaphroditisms genitography is easy to perform and reliable. This examination helps in determining the morphological sex and becomes necessary if surgery of the genital tract is considered.

[Significance of a nonionic renographic contrast medium (Iopamidol 300) in the roentgen diagnosis of the kidneys and urinary tract in children]

The ionic contrast media used so far have been associated with considerable risks in infants and children. The high osmolality of these media did not always permit a dosage sufficient for kidney imaging in the nephrographic and in the pyelographic phase. The new non-ionic contrast media have largely reduced these risks so that their general application in infants and young children should be recommended. Intravenous urographies using the non-ionic contrast medium Iopamidol 300 (Solutrast 300) were performed in 195 children aged one day to 12 years. Good to superior urograms were obtained in 85% of the investigations. No adverse reactions caused by the osmolality of the contrast media had been observed in spite of the relative high dosage. As a result of their low osmolality and non-ionic property a safe application of high doses was possible.