- What is Cryptorchidism?
- Reasons of Cryptorchidism
- Cryptorchidism Classification
- Symptoms and Sequela of Cryptorchidism
- Diagnostics of Cryptorchidism
- Cryptorchidism Treatment
- Therapeutical Prognosis
What is Cryptorchidism?
Cryptorchidism is a congenital disorder related to the absence of one or two testicles in the scrotum of a new-born boy. This disorder is caused by the delay of the testicle descending along the abdominal canal from the retroperitoneal space. Cryptorchidism appears in the form of scrotum dissymmetry, absence of the testicle in the scrotum, and dull pains in the pelvic area or abdomen.
Cryptorchidism is one of the most frequently met abnormalities in paediatric urology. It is met in 4% mature new-borns and in 10-20% premature new-born boys. Within the first six months in 75% boys born with cryptorchidism the testicles get into the scrotum without any therapeutic interference. The possible reason is the gradual increase of testosterone level. By the end of the first year only 1% boys born with cryptorchidism remain suffering from the disorder. In future the possibility of the testes descent is very low.
The absence of the timely surgical treatment of cryptorchidism increases the threat of male infertility and testicle cancer.
Reasons of Cryptorchidism
The formation of testicles in the unborn child takes place in the abdomen. During the last trimester of pregnancy testicles descend to the scrotum through the abdominal canal. In-time testes descent is considered to be caused by several factors such as intra-abdominal pressure, local testosterone level, state of gubernaculum and its attachment to the scrotum. After the boy is born the further healthy development of testicles is possible only in case of their scrotum location as the scrotum temperature is 2-3 degrees C lower than that in the abdomen. Such a difference between temperatures is a vital condition for the healthy spermatogenesis. As a rule, undescended testis is smaller than the one descended in time.
The reasons of the testes descent delay and cryptorchidism development are not known with certainty. Endocrine, mechanical and genetic factors are considered to be possible preconditions of the given abnormality.
Endocrine mechanisms of the cryptorchidism development include hormone misbalance a pregnant woman may suffer (diabetes or gestational diabetes, pituitarism, thyroid dysfunction). The given health states are able to retard the in-time testes descent to the scrotum and to cause the double-side cryptorchidism development.
Mechanical factors influencing the cryptorchidism growth involve narrow or blocked abdominal canal, short testicular vessels or spermatic cord, hypoplasia of testicle ligaments, intra-abdominal adhesion of parts and so on.
In some cases cryptorchidism may be associated with the mutation of GTD gene (306190, Xp21), Down’s syndrome, prenatal defects of anterior abdominal wall growth.
The probability of cryptorchidism development increases in case of preterm delivery and premature fetus. Cryptorchidism is diagnosed in all the premature boys with the weight less than 910 gr and in 17% boys with the weight of more than 2040 gr.
Two types of cryptorchidism are defined: true and false. False cryptorchidism or migrating testicle refers to the ability of testicle to change its place and to shift to the abdominal canal or abdomen under the influence of muscle tension or cold.
False cryptorchidism is met in 25-50% cases. It is characterized by:
- Symmetry and healthy development of the scrotum,
- Testicle migration to the area of abdominal ring,
- Ability to get the testicle back to the scrotum by palpating without any problem,
- Testes descent under the influence of warmth or in case of calm state of a boy.
Testicle migration is a variant of normal physiological condition and can be explained by the smaller diameter of the testicle comparing to that of the external abdominal ring. That is why if the corresponding muscles are contracting the testicle easily goes up to the inguinal fold. False cryptorchidism does not require any treatment and disappears in the puberty.
One can talk about the true cryptorchidism if it is not possible to get the testicle down to the scrotum manually. In this case the testicle is more often located in the area of the abdominal ring (40%), in the abdominal canal (20%) or abdomen (10%). If one testicle cannot be descended one can talk about unilateral cryptorchidism. In case of two testes descent delay it is called a bilateral cryptorchidism. Bilateral true cryptorchidism is often combined with hypogonadotropism, hypopituitarism and inguinal hernia.
One should distinguish two states: cryptorchidism and ectopia testis. In case of ectopia while going through the abdominal canal the testicle comes to perineum, medial side of the thigh, anterior abdominal wall or dorsal surface of penis (which is seldom) rather than to the scrotum. Patients suffering from ectopia remain infertile even after the treatment.
True or false cryptorchidism as well as ectopia testis are congenital states. However in some cases cryptorchidism can be an acquired condition. Wide abdominal ring or scrotum and injuries may cause migration of the healthy located testicle into the inguinal or abdominal area.
Symptoms and Sequela of Cryptorchidism
The major symptom of cryptorchidism is an absence of one or two testicles in the scrotum. The absence is usually defined by the urologist during palpation. The scrotum looks underdeveloped, asymmetric or flattened.
The patients suffering from cryptorchidism may experience dull and dragging pain in the abdomen or inguen. If the testicle is located in the abdomen pains appear only in puberty, as a rule. They may intensify during the muscle tension, at straining, constipation or when the young man is sexually excited.
Later cryptorchidism may lead to the testicle cancer (or seminoma), fertility disorders (decrease of the quantity of spermatozoids, low sperm quality and poor impregnating ability). Men with bilateral cryptorchidism are infertile in 70% cases.
Besides, cryptorchidism may cause the development of the inverted testis, more truly, the spermatic cord which is formatted by blood vessels, nerves and seminal duct. In case of the combination of cryptorchidism and inguinal hernia one cannot exclude the incarceration of the testicle together with intestine loops in the abdominal ring. The given state is often accompanied by sharp ache due to the deterioration of blood supply to the testicle and its death within several hours.
If the non-descended testicle is located in the inguen it may be pressed by the pubic bone. That may increase the risk of the sex gland injury.
Diagnostics of Cryptorchidism
Cryptorchidism can be diagnosed during the investigation and palpation of the scrotum. If the testicle is absent the scrotum looks underdeveloped and flattened at the corresponding side. In case of abdominal retention the testicle cannot be palpated. In other cases it can be found in the abdominal canal. If it is located in the abdominal canal the testicle is quite mobile and can be shifted. In case of false cryptorchidism it can be easily shifted to the scrotum. In case of true cryptorchidism it is impossible to get the testicle down to the scrotum. The absence of the testicle is usually proved by the ultrasound investigation.
If the location of the testicle cannot be found by palpation ultrasound investigation of abdomen and inguinal area is used. In case if the ultrasound investigation is useless one can apply plain radiography of the abdominal cavity, contrast-enhanced MRT or computed tomography. The most difficult cases require even diagnostic laparoscopy to prove the abdominal retention of the testicle or to reveal monorchidism or anorchidism.
If all the above-mentioned methods don’t work one should exclude the probability of the male false hermaphroditism. To do that certain medical analyses as well as testosterone level and gonadotropic hormones investigation are required.
False cryptorchidism does not need any treatment. The treatment of true cryptorchidism is provided by pediatric endocrinologists and urologic surgeons (andrologists).
The major treatment method is surgery that presupposes descending of the incorrectly located testicle with its further fixation in the scrotum. However, there are other methods that can be successfully applied depending upon the complexity of the case.
The treatment of cryptorchidism should be started when the boy is 9 months. Before that age there is a possibility for the testicle to descend to the scrotum spontaneously. Drug therapy is conducted with the help of intramuscular introduction of human chorionic gonadotropin or intranasal introduction of gonadorelin. As a result of the given conservative therapy, 30-60% patients can have their testicle descended. Hormone drug therapy is not administered in the puberty period when the increase of testosterone and gonadotropic hormone level takes place.
If the drug therapy is not successful doctors prescribe cryptorchidopexy by the age of 15-24 months. Cryptorchidopexy is a surgical descent of the testicle into the scrotum. During the surgery one should make testicle biopsy in order to exclude malignant alterations and dyskinesia of genital glands. Surgical interference is vitally important in case of the inverted testis, incarceration, inguinal hernia and ectopia testis.
If hypotrophy or gland necrosis is revealed resection or removal of the testicle (orchidectomy) is conducted. The latter case as well as anorchidism in adult age requires transplantation of the testicle or implantation of the artificial organ to correct the defect visually.
If the testicle descends to the scrotum quite early (up to 2 years) or the patient suffers from unilateral cryptorchidism the risk of further complications is quite low. Male infertility is experienced in 20% cases of unilateral cryptorchidism and in 70-80% cases of bilateral cryptorchidism.
If at least one healthy testicle is functioning boys need the therapy at endocrinologist’s in order to have physical development and sexual maturation according to the male pattern.
Further the teenager and his parents are recommended to conduct self-investigation of the testicles to prevent possible malignant processes.
Canada Pharmacy Research – www.mycanadianpharmacypro.com