The cryptorchism (undescended testicle)
Cryptorchism is a congenital anomaly characterized by the absence at the time of boy’s birth of the one or both testicles in the scrotum, which is due to the delay in their lowering through the inguinal canal from the retroperitoneal space. Cryptorchism is manifested by asymmetry of the scrotum, lack of a testicle in palpation, aching pain in the groin or abdomen. Diagnosis in cryptorchism includes ultrasound of the scrotum organs, MRI, scintigraphy of the testicles, angiography of the abdominal aorta, and venography of the testicle vein. The main way to treat cryptorchism is the operative: the lowering of the undescended testicle and its fixation to the scrotum.
The causes of cryptorchism
The laying and formation of testicles in the fetus occurs in the abdominal cavity. In the last trimester of pregnancy, testicles descend into the scrotum through the inguinal canal. It is believed that timely independent reduction of testes is determined by a number of mechanisms – intra-abdominal pressure, local testosterone level, the condition of the testicular ligament and its attachment to the scrotum. After the birth, further normal development of testicles is possible only when they are in the scrotum, where the temperature is 2-3 ° C lower than in the abdominal cavity. This difference in temperature is a necessary condition for normal spermatogenesis. Usually an undescended testicle has smaller dimensions than a lowered testicle in time.
The causes of delayed descent of testis and the development of cryptorchism are unknown. As possible prerequisites are considered endocrine, mechanical and genetic factors contributing to this anomaly.
Endocrine mechanisms of cryptorchism development include the presence of hormonal imbalance in the pregnant (in particular, type 1, type 2 diabetes or gestational, pituitary dysfunction, thyroid gland) or testicles in the embryo. These conditions can inhibit the timely omission of testicles in the scrotum and cause the development of bilateral cryptorchidism.
Among the mechanical factors responsible for cryptorchidism are the narrow or obstructed inguinal canal, the shortening of the testicles or the spermatic cord, the underdevelopment of the testicular ligament apparatus, intraperitoneal adhesions,
In some cases, cryptorchidism is associated with the mutation of the GTD gene (306190, Xp21), Down’s syndrome, intrauterine defects in the development of the anterior abdominal wall.
Classifications of the cryptorchidism
There are false and true cryptorchism known. With false cryptorchidism (a migrating testis) under the influence of muscle tension or cold, the testicle can be displaced into the inguinal canal or abdominal cavity. False cryptorchidism occurs in 25-50% of cases from all observations. It is characterized by symmetry and normal development of the scrotum; migration of the testicle to the inguinal ring or lower third of the inguinal canal; the possibility of unimpeded re-entry of the testicle into the scrotum during palpation or its self-lowering under the influence of heat or in the relaxed calm state of the child.
The migrating testis is a variant of the physiological norm and is explained by the small diameter of the testicle as compared to the diameter of the outer inguinal ring. Therefore, when the corresponding muscles contract, the testicle is easily pulled up to the inguinal fold. False cryptorchidism does not require treatment and disappears independently at pubertal age.
The true cryptorchidism is said when it is impossible to manual bringing down the testicle into the scrotum. In this case, the testicle is most often located in the region of the inguinal ring (40%), in the inguinal canal (20%), the abdominal cavity (10%). If one of the testicles is not involved, they speak of one-sided true cryptorchidism; in the case of a delay in the omission of both, a bilateral anomaly. Bilateral true cryptorchidism is often combined with hypogonadism, pituitary-hypothalamic insufficiency (hypopituitarism), inguinal hernia.
From true cryptorchism should be distinguished such a state as an ectopia testis. In the case of ectopia, the testicle after passing the inguinal canal, falls not in the scrotum, but in the perineum, the medial surface of the thigh, the anterior abdominal wall, rarely – on the dorsal surface of the penis. With ectopic testis, even after treatment, most patients are infertile.
True, false cryptorchidism and ectopia testis are congenital disorders. Rarely, cryptorchidism has acquired character. Thus, a wide inguinal ring or scrotal injury can cause the migration of an initially normally located testicle to the inguinal region or abdominal cavity.
Symptoms and complications of cryptorchism
The main manifestation of cryptorchidism is the absence of one or two testicles in the scrotum, which the urologist determines palpation. Thus the scrotum looks underdeveloped, flattened or asymmetric.
With cryptorchism, aching and pulling pains in the groin or abdomen can be noted. When the testicles are localized in the abdominal cavity, pains usually appear only in puberty and can be strengthened with muscle tension, straining, constipation, sexual arousal.
At a later age, cryptorchidism increases the risk of testicular cancer (seminoma), fertility disorders (reduced sperm count, semen quality and fertility). With bilateral cryptorchidism about 70% of men are impotent.
In addition, cryptorchism can cause the development of testicular (torsionspermatic cord), formed by the blood vessels, nerves and the vas deferens. In the case of a combination of cryptorchidism with inguinal hernia, it is not excluded that the testicle is infringed along with the intestinal loops in the inguinal ring. These conditions are accompanied by severe pain due to a violation of blood supply to the testicle and its death within the next few hours.
With the location of an undescended testis in the inguen, it can be pressured by the pubic bone, which in turn increases the risk of traumas of the sexual gland.
Diagnosis of cryptorchism
Cryptorchidism is revealed during examination and palpation of the scrotum. In the absence of the testicle, the scrotum on the corresponding side looks underdeveloped and flattened. With the abdominal retention, the testicle can not be palpated; in other cases, the testicle is found in the inguinal canal. With the inguinal position of the testicle, it is to some extent movable, shiftable, with false cryptorchidism easily shifted into the scrotum. In the case of true cryptorchism, it is not possible to reduce it to the scrotum. The absence of the testicle is confirmed by ultrasound of the scrotum organs.
If impossible to determine the location of a palpation testicle, ultrasound of the abdominal cavity and inguinal region, survey radiography of the abdominal cavity is performed. If the information is uninformative, it may be necessary to perform contrast MRI or CT, and in difficult cases – diagnostic laparoscopy to confirm abdominal retention of the testicle or establish monarchism or anarchism.
If palpatory and instrumental detection of both testicles is impossible, the male pseudohermaphroditism must be eliminated, for which genetic tests, testosterone, gonadotropic hormones are performed.
The treatment of cryptorchism
With false cryptorchism no treatment is required. Correction of true cryptorchism is carried out by urologic surgeons.
Drug therapy is performed by intramuscular injection of human CG or intranasal introduction of gonadorelin. As a result of conservative therapy, testicular ovulation can be achieved in 30-60% of patients. Hormonal pharmacotherapy of cryptorchidism is contraindicated in pubertal age, when there is an increase in the level of its own testosterone and gonadotropic hormones.
When the conservative therapy of cryptorchidism is unsuccessful, surgical tactics are recommended – orchiopexy (surgical removal of the testicle into the scrotum). During the operation, a testicular biopsy is required to exclude malignant processes and discenezia of the gonads. Surgical intervention is absolutely necessary in case of torsion, infringement of the testicle, inguinal hernia, ectopia of the testicle.
In detecting hypotrophy or necrosis of the gland, resection of the testicle or its removal is performed – orchiectomy. In the latter case, as well as in anorchia, a donor testicle or implantation of an artificial testicle is required for cosmetic correction of the defect.