Cryptorchidism, also known as undressed or incomplete testicle descent, refers to the failure of the testicles to descend from the lumbar peritoneum to the scrotum according to the normal development process, cryptorchidism is divided into unilateral and bilateral, bilateral cryptorchidism accounts for 1/3, the right cryptorchidism accounts for 70%, and the testicle originates from the urogenital crest on both sides next to the midline of the posterior abdomen of the embryo, which is equivalent to the 12th thoracic vertebra. Testicular descent begins in the 7th month of the embryo.
Before the start of the descent, the testicles and testicular lead and the inguinal canal are enlarged, the blood vessels of the spermatic cord are increased and elongated and varicose, and the activity of the testicles is also increased, which is conducive to the decline, so the decline of the testicles has a certain relationship with its development, and if the development of the testicles is stopped or delayed, it will affect its decline. The testicles protrude outward through the inner ring, inguinal canal, and outer ring, follow the external protrusions of the peritoneal sheath process, and then follow the testicular lead to the tail scrotum branch and enter the bottom of the scrotum.
If the testicles descend to the inner, inner, or outer ring of the inguinal canal, varying degrees of hypothesis occur. If the testicles do not descend to the bottom of the scrotum and other branches along the caudal end of the testicular band descend to the perineum, pubic bone, or femur, they become ectopic testicles. The testicles descend to the scrotum are often left first and then right.
In 2019, our department admitted a male child, after 2 years of treatment, the patient's testicles completely declined, and now the diagnosis and treatment process of the case is summarized as follows for the benefit of readers.
Author: Li Yuying, Ma Mingfu, Ma Weijuan, Ah Tingren
This article is published by the author with the authorization of Medical Pulse, please do not reprint it without authorization
Case situation
Present medical history
The child, male, 15 years old, was found to have bilateral cryptorchidism during foreskin surgery in March 2019, performed bilateral orchystitis immobilization at the Urology Department of our hospital, and was discontinued after hormonal supplementation in August 2019, March 2020 and July 2020, respectively, each course of treatment was 3 months, a total of 3 courses of treatment, and was reviewed in August 2021.
Past history
The child was in good health and had been vaccinated against the statutory vaccine.
Personal history
Full-term delivery
Family history
The parents are in good health, have an older brother, suffering from left cryptorchidism, and a twin brother, suffering from right cryptorchidism, and in the same year they all performed corresponding side testicular fixation in our hospital.
August 2019 HCG excitement experiment
Specialist examination
Auxiliary examination: in August 2019, March 2020, July 2020, and August 2021, no obvious abnormalities were seen in blood, urine, stool routine, coagulation, liver and kidney function, electrolytes, and blood lipids;
There were no abnormalities in the eight items of Jia Gong;
No obvious abnormalities were seen on chest x-ray, electrocardiogram, and abdominal ultrasound;
Pituitary MRI: suggests a pituitary microadenoma possible; re-examination of pituitary MRI is similar.
Karyotype of the chromosome: XY
No abnormalities were found in cortisol rhythms
diagnosis
After cryptorchidism
Growth retardation
treat
Chorionicin for injection, 2000iu, 2 times / week, im
Testosterone undecanoate gum pills, 40 mg, 1 time / day, po
Case analysis and discussion
pathogen
(1) Mechanical factors, the cord-like lead that introduces the testicles into the scrotum is abnormal or absent, and the testicles cannot be lowered from their original position to the scrotum (unilateral cryptorchidism);
(2) Endocrine factors, testicular hypoplasia, insensitivity to hormones, loss of decreased dynamic effect (unilateral or bilateral cryptorchidism), maternal lack of sufficient amount of gonadotropin, affecting the production of testosterone, and then affecting the dynamic effect of hormones (bilateral cryptorchidism).
classify
(1) Retractable testicles, the testicular colicidal muscle is too active, the testicles can be retracted to the position above the scrotum, but the testicles can be pushed into the scrotum during night rest and examination. There is no need to treat the position and size of the testicles after puberty, and the fertility is the same as normal people.
(2) True cryptorchidism, there are high cryptorchidism in the abdomen, cryptorchidism in the groin, high cryptorchidism in the scrotum, and sliding cryptorchidism.
(3) Ectopic testicles
(4) No testicular deformity
Clinical manifestations
One or both sides of the scrotum are empty, and testicular tissue is often palpable in the groin area and above the scrotum. Often with hydrocele or oblique inguinal hernia.
complication
Infertility, malignancy, reversal, trauma, psychological disorders, etc.
Adjunctive testing
(1) B ultrasound examination is a commonly used occult testicular positioning examination method that cannot be clinically touched by the testicles.
(2) Chorionic gonadotropin stimulation test is used for clinical examination, often can not touch the testicles, abdominal high testicles or the lack of testicles of the differential diagnosis.
(3) Laparoscopy In laparoscopy, the testicles located in the abdomen or the inner ring of the groin can be found along the spermatic vessels.
Physical examination is the first step in the clinical diagnosis, the patient has a flat scrotum, poor development, asymmetry. On palpation, the patient side has empty scrotum and no testicles.
0-June: Observe and wait
June to 1 year of age: hormone therapy, HCG human chorionic gonadotropin, GnRH gonadotropin-releasing hormone.
1-2 years: (laparoscopic) orchyosysty.
Puberty: surgical treatment, orchiectomy.
Discussion and summary
The male reproductive system regulates male sex differentiation, secondary sex characteristic changes, and hormonal changes in puberty, ultimately leading to sperm production and fertility. Under the action of pituitary hormones (luteinizing hormone LH and follicle-stimulating hormone FSH), testosterone is secreted by testosterone, while germ cells are nourished by testostol cells, which separate, differentiate and mature into sperm. During embryonic development, testosterone and dihydrotestosterone induce virilization in renal canal development and external genitalia. During puberty, the testicles promote body growth and secondary sexual characteristic development. In adulthood, the testicles are important for spermatogenesis, stimulation of libido, and maintenance of normal sexual function.
The sedimentation of the testicles through the groin is partially controlled by insulin-like factor 3 (INSL3) secreted by interstitial cells, which works through the Great receptor (a G protein-coupled receptor that affects the decline of the testicles). Sertoli cells produce a Mullerian inhibitor (MIS), which degrades the structure of the Mullerian duct, including the fallopian tubes, uterus, and vaginal parts.
Normal male pubertal development:
Men's Youth Incident
For the child, considering that the child's secondary sexual characteristics are not developed, after bilateral testicular descent fixation surgery, gonadotropin and testosterone are used to help the normal development of the testicles, and the development of testosterone levels and secondary sexual characteristics is observed. Due to the decrease in the potency after long-term injection of gonadotropin and the side effects of the drug, each hormone supplement treatment is 3 months, each course of treatment is 3 months, a total of 3 courses of treatment. Intramuscular injection of 1500-2000 IUhCG 3 times a week is a common starting dose, testosterone levels need to be measured 48-72 hours after hCG injection and 6-8 weeks after treatment, and the hCG dose is adjusted in time to control testosterone levels within the appropriate normal range.
After reviewing the relevant literature, androgen therapy does not affect the subsequent response to hCG treatment, and considers that the patient's secondary sexual characteristics are absent, and the secondary sexual characteristics of the treatment of hCG alone are slow, so androgen therapy is given at the same time as HCG therapy. Androgen therapy can restore testosterone levels and correct signs associated with androgen deficiency. Testosterone replacement therapy improves libido and sexual life; increases energy, muscle mass, and bone density; and patients feel better about their physical condition. Testosterone is well absorbed orally, but the first degradation is quick when passed through the liver, and testosterone undecanoate is a octadecenic acid that, when taken orally, is preferentially absorbed through the lymphatic system into the systemic circulation, avoiding the degradation of the liver's first-pass effect.
Efficacy evaluation
After the treatment of the child with injectable chorionic hormone (2000iu 2 times / week im) and testosterone undecanoate (40mg 1 time / day po), the bilateral testicles completely decreased, the skin mucosa thickened, the muscle tissue was strengthened; the larynx was obviously raised with laryngeal knots, and gradually changed from a child's voice to a deep voice; the facial and limb hairs increased, the pubic hair and armpit hair developed, the hair of the lower limbs increased; the development of the mammary glands was normal; the hormone level was normal, and the height, weight, and testicular volume reached normal levels. Male secondary sexual characteristics develop normally.
At present, it is reported in the literature at home and abroad that after testicular fixation, there are more simple applications of hCG, and the combined application of hCG and androgens is less reported, and the current effect of the child is exact, the effect is ideal, no obvious side effects are found during and after treatment, and it is expected to establish normal fertility.
Expert Profiles
Professor Ma Mingfu
Chief physician
Director of the Department of Endocrinology, Fifth People's Hospital of Qinghai Province
Member of the Diabetes Prevention and Control Committee of the Chinese Preventive Medicine Association
Member of the Diabetes Professional Committee of the Chinese Medical Education Association
Member of the Diabetic Foot Expert Committee of the Chinese Association of Integrative Traditional and Western Medicine
Chairman of the Diabetes Prevention and Control Professional Committee of Qinghai Preventive Medicine Association
Vice Chairman of the Endocrinology and Metabolism Physician Branch of Qinghai Medical Doctor Association
Vice Chairman of the Endocrinology Society of Qinghai Medical Association
Director of the National Standardized Metabolic Disease Management Center (The Fifth People's Hospital of Qinghai Province).
Kunlun Elite Plateau Famous Doctor
Expert member of Qinghai Provincial Health Science Popularization Expert Database
Member of diabetes branch of Qinghai Association of Traditional Chinese Medicine
Expert member of Xining Intangible Cultural Heritage Expert Committee
First author
Li Yuying Attending Physician
Member of Diabetes Branch of Qinghai Medical Association
Secretary/Member of diabetes prevention and control professional committee of Qinghai Preventive Medicine Association
Member of the Youth Committee of the Endocrinology Society Branch of Qinghai Medical Association
Submission Email: [email protected]