Cryptorchidism: Symptoms, Causes, Diagnosis, Treatment and Prevention
By cryptorchidism is understood an innate anomaly in which the birth of a boy and during the first 3 months of life one or both testicles do not occupy their normal position in the scrotum.This pathology of development is more typical for premature babies - they are fixed in 30% of cases.Among the babies who were born on time and with normal weight, cryptorchidism is noted many times less often - on average, in only 3.5% of cases.Table of contents: Pathogenesis Classification
Note: placement of the seminal gland in the scrotum, i.e., outside the abdominal cavity - is the most important thermoregulatory factor.Normal development of the testis and the subsequent formation of male sex cells is almost impossible at the body temperature normal for us.The difference between the temperature in the inguinal canal and scrotum can reach 3 ° C.One of the oldest methods of male contraception is a hot bath( bath).Even a slight heating testicle significantly reduces the likelihood of conception.
During the first 6 months after birth, 75% of boys with this congenital abnormality testicle themselves occupy a normal anatomical position in the scrotum.Most specialists associate this "self-healing" with a physiological increase in the testosterone level in a child.By the beginning of the second year of life, only 1% of children have an anomaly.At later stages of development, the probability of omission of these organs of the reproductive system without the intervention of a doctor is close to zero.
During fetal development, the testes are first placed retroperitoneally( next to the kidneys), and later - intraperitoneally, displacing the scrotum closer to the end of pregnancy.
Factors determining the movement of the testis to the scrotum:
- Extension of the organ in the desired direction by the Hunter draft;
- difference in the rate of development of the testis and cord;
- motility of the lower GI tract;
- increased intra-abdominal pressure;
- development of the appendage of the testis.
Note: undescension of the right testis is fixed in 50%, left - in 20%, and both - in 30% of diagnosed cases of cryptorchidism.
The process of moving testicles through the channel is largely affected by hormones.These include male luteinizing hormone, synthesized by the baby's pituitary gland, as well as his mother's gonadotropic hormones.Their deficiency is a frequent cause of cryptorchidism.To prevent the testicle from taking its place can also be mechanical factors.
Important: very often( up to 95%) undescended testicles combined with congenital inguinal hernia.
Cryptorchidism is one-sided and bilateral.
It is accepted to distinguish 2 main varieties of this pathology - retention and ectopia.Retention is also called true cryptorchidism.
The two main types of retention :
With intraperitoneal retention, the testes do not occupy a normal anatomical position, but "stop" without entering the canal.With inguinal retention, testicles pass into the canal and are on one of its levels, not descending into the scrotum.
- membered pubic;
- crossed scrotal;
Ectopia is formed due to the pathology of the development of the ligament-conductor, which in this case is attached not inside the scrotum, but at a different point.As a consequence, the cord directs the testis to the side, which causes an anomaly of the position of the organ.
With superficial ectopy the testis is located under the skin above one of the abdominal muscles.
Femoral ectopy involves the placement of a testicle in the region of the inner surface of the thigh.
With pubic pubic ectopic, testicles lie on the pubic bone above the penis.
In the development of crossed scrotal ectopia, both testicles pass one inguinal canal, eventually sinking to the right or left part of the scrotum.
Perineal ectopia is a type of anomaly in which the testis moves to the perineal zone.
Important: , even after a successful operation for ectopia of the testicle, most patients subsequently suffer from infertility.
Note: in rare cases with diagnosed cryptorchidism, testis and its appendage are connected by traction, but are located at a certain distance from each other.
Some boys experience a high cremaster reflex.It is characterized by the fact that the cremaster muscle can pull the testicle from the scrotum in the opposite direction, that is, into the inguinal canal.Such a phenomenon can be noted, for example, with strong psychoemotional stress or hypothermia.This phenomenon is most often observed in 6-7 years.This deviation is not dangerous and does not require medical intervention;You can manually reduce the testicle to the scrotum.When taking a warm shower or bath, the testes occupy a normal position.
Causes of development of cryptorchidism
Among the factors leading to the development of pathology, there are:
For endocrine reasons, the specialists refer to:
- hormonal imbalance in the future mother( including disorders of the thyroid and pituitary;
- , impaired functional activity of the testes in the unborn child.)
Mechanical factors are:
- shortening of the spermatic cord;
- short blood vessels;
- narrowing of the inguinal canal;
- intraperitoneal adhesions;
- underdeveloped testicles ligament.
Among the genetic factors, the leading factors are:
- hereditary anomalies in the development of the anterior abdominal wall
- Down Syndrome
- mutation of the GTD gene
Important: in preterm neonates of males born with a weight less than 910G, cryptorchidism is noted in 100% of cases.
In rare cases, cryptorchidism may have an acquired character.The cause of reverse migration of the testis in some cases are injuries.
Clinical signs of cryptorchidism
Symptoms of cryptorchidism are:
- asymmetry of the scrotum;
- inability to detect testis on palpation;
- aching pain in the inguinal and / or abdominal area( not always).
The most likely complications of cryptorchidism
Against the background of testicular failure, very serious complications can develop:
- infringement of inguinal hernia( with subsequent necrosis of tissues);
- twisting of the spermatic cord and vessels;
- hydrocephalus of testis shells;
- infertility( the risk is highest for bilateral anomalies and late surgical treatment);
- development of malignant tumors of testicles( 10 times higher than in the absence of pathology).
Important: testicular cancer most often develops if surgery has not been performed and the intraperitoneal location of the testis has persisted.
If cryptorchidism is combined with an inguinal hernia, then there is a possibility of pinching the testicle with a loop of the intestine in the inguinal ring.This complication is accompanied by intense pain and a sharp violation( termination) of the blood supply.If an emergency surgery is not performed, necrosis of the testes and the intestinal tract develops.
Diagnosis of cryptorchidism
The diagnosis of cryptorchidism is straightforward.Visually and palpation is determined by the non-admission of one or both testicles in the scrotum.As a rule, in the inguinal region a swelling in the projection of the testis is determined.It is impossible to lower the testis manually into the scrotum.
Cryptorchidism is often accompanied by a more or less pronounced underdevelopment of the scrotum.
Important: if the test does not palpate or develop pathologies such as micropenia or hypospadias during the examination, the child may need additional advice from a geneticist and endocrinologist.This is necessary to eliminate the pathology of gender formation.
To clarify the diagnosis, determine the location of the testicle and the condition of regional blood vessels, the following methods of instrumental research are used:
- Tissue scintigraphy,
- Magnetic Resonance Imaging;
- vein of the testicular vein;
- angiography of the abdominal aorta.
In some cases, diagnostic laparoscopy may be required.
Treatment of cryptorchidism
Conservative treatment of this pathology involves hormonal therapy with the introduction of chorionic gonadotropin preparations.The probability of success is estimated at about 20%, with a fifth of the patients having relapses after the course is over.The lower the testes are originally located, the higher the probability of success of conservative treatment of cryptorchidism.
The universal hormone therapy scheme has not been developed.Usually, IM injections of gonadotropin are given twice a week.The duration of the course therapy is 4 weeks.Treatment begins when the boy reaches the age of six months.
Alternative drugs are synthetic analogs of the luteinizing hormone releasing hormone
The question of the need for neoadjuvant( pre-operative) and adjuvant( postoperative) hormone therapy is decided individually in each case.These methods are not considered standard.
Operative treatment of cryptorchidism
In case of ineffectiveness of conservative methods of influence resort to surgical treatment of cryptorchidism.
The objectives of the operation are:
- prevention of complications( primarily malignant tissue of the organ);
- preservation of the ability to reproduce;
- preservation of testicles functions( synthesis of hormones);
- removal of a cosmetic defect.
Note: in older age is a psychosexual motivation for surgical correction.
According to most experts, the best age for surgery for cryptorchidism is from 5-6 to 18 months of age.Early operative treatment minimizes the risk of development of oncologic damage to testicles, as well as violations of sperm formation and hormone production.
Egg lowering( orchipexy) is a planned surgical intervention, the main objectives of which are:
- traction of the spermatic cord;
- mobilization of the testis;
- the formation of a bed for the testicle in the cavity of the scrotum;
- the actual reduction and anchoring of the testis in the desired zone.
During the operation, it is important to avoid even minimal vascular tension.Properly conducted intervention subsequently enables the reintegrated reproductive organ to subsequently develop according to a perfectly normal pattern.
If palpation of the testicles is impossible, i.e. with too high an arrangement, laparoscopic intervention becomes the best choice for the treatment of cryptorchidism.
Important: if there is intraperitoneal placement of the testis on one side and the other testicle is normal, then in the older age it is recommended to remove the intraperitoneal testicle in order to avoid malignancy of the organ.
Boys with false cryptorchidism do not need treatment, but they have been shown to observe until they reach puberty.
The probability of complications with timely treatment is small, but it increases significantly if cryptorchidism is not eliminated before the age of 2 years.
With the impossibility of conception, up to 20% of men with unilateral pathologies face up to 80% - with bilateral.
Konev Alexander, physician-therapist