cryptorchidism
Introduction
Introduction to cryptorchidism Cryptorchidism refers to the failure of one or both testes to descend from the lumbar retroperitoneum to the ipsilateral scrotum, also known as testicular insufficiency. It is one of the most common congenital diseases of the male reproductive system in children. basic knowledge The proportion of illness: 1% Susceptible people: male Mode of infection: non-infectious Complications: infertility, inguinal hernia, testicular tumor
Cause
Cryptorchidism
Endocrine factors (20%):
Some scholars have determined that cryptorchidism may be a pre-pubertal hypothalamic-pituitary-gonadal axis imbalance, and luteinizing hormone (LH)-lining cell axis is insufficiently secreted, leading to a decrease in plasma testosterone due to testicular decline. It is closely related to testosterone levels. Some scholars have determined that testosterone levels in cryptorchidism are normal. It is mainly caused by 5-reductase deficiency, which causes dihydrotestosterone production disorder, or target organ androgen receptor deficiency or receptor gene mutation. Testosterone binds to target cell receptor proteins. Some pituitary gonadotropin and androgen disorder diseases such as Kallmann syndrome (LH-RH deficiency), no brain malformation pituitary hypoplasia and many other cryptorchidism, also indicate that pituitary gonadotropin and androgen and testicular decline Certainly, some people have recently found anti-gonadotrophin antibody in the blood of cryptorchidism patients, suggesting that cryptorchidism may be a pituitary autoimmune disease.
Anatomical factors (25%):
Mainly: 1 testicular lead band absent: during testicular decline, testicular lead with traction, the main branch of the end of the lead is attached to the bottom of the scrotum, and the testicles are pulled into the scrotum with traction. 2 sheath-like process is not closed. 3 dysplasia of the groin: the inner ring is too small or there is mechanical obstruction at the entrance to the scrotum. 4 spermatic vessels or vas deferens are too short.
Testicular developmental defects (15%):
In some cases, there are defects in the testis itself. For example, the testicles shrink after intrauterine torsion. Only the spermatic vessels and the vas deferens stump, the testis and epididymis are separated, and the epididymis is absent, which affects the testicular decline.
Causes
Because the mechanism of normal decline of testis in the fetal period is still unclear, the etiology of cryptorchidism is also widely described.
Pathogenesis
Cryptorchidism often has varying degrees of testicular hypoplasia, the volume is significantly smaller than the healthy side, the texture is soft, most patients with epididymis, vas deferens dysplasia, the incidence is about 19% to 90%, about 1% to 3% hidden In the test of the testis, the testicles are absent, and only the testes, epididymal remnants and/or spermatic vessels and vas deferens are seen.
The histopathological features of cryptorchidism are germ cell developmental disorders, and the number of interstitial cells is reduced. The changes are more obvious with age. The degeneration of adult cryptorchidism is significant, and almost no normal sperm can be seen. It is also related to the location of the cryptorchidism. The lower the position, the closer to the scrotum, the less pathological damage, and the more serious the pathological damage.
Histopathological signs of cryptorchidism:
1 The child still has germ cells after 1 year of age;
2Ad type of spermatogonia is reduced, and the development process of germ cells in normal testicular seminiferous tubules is: germ cell Ad spermatogonia Ap type spermatogonia B-type spermatogonia primary spermatocyte secondary Spermatogonial cells sperm cells sperm, normal children 60 to 90 days after birth, LH and FSH in the blood have a tidal secretion, stimulate the proliferation of stromal cells, and secrete a large amount of testosterone, forming a testosterone peak wave to promote the development of germ cells into Ad type In spermatogonial cells, this process is completed approximately 3 to 4 months after birth. Because of the frustration of LH and FSH in 60 to 90 days after cryptorchidism, the number of interstitial cells is reduced, the amount of testosterone is decreased, and testosterone cannot be formed. Peak waves, which cause the transformation of germ cells into Ad-type spermatogonia.
According to the position of the testicles, the cryptorchidism is clinically divided into:
1 high cryptorchidism: refers to the testis located in the abdominal cavity or near the inner ring of the groin, accounting for about 14% to 15% of cryptorchidism.
2 low cryptorchidism: refers to the testis located in the inguinal or outer ring.
There are also four types of cryptorchidism:
1 intra-abdominal testis: testis is located above the inner ring.
2 Inguinal canal testis: The testis is located between the inner and outer rings.
3 ectopic testis: the testicular deviation from the abdominal cavity to the normal descending path of the scrotum.
4 retraction testicles: testicles can be pushed or pulled into the scrotum, loosened and then retracted to the groin.
Prevention
Cryptorchidism prevention
Pay attention to healthy eating and rest on time in daily life.
Complication
Cryptorchidism Complications infertility inguinal hernia testicular tumor
1. Decreased fertility or infertility: The main pathological change of cryptorchidism is the developmental disorder of germ cells, which can lead to decreased fertility or infertility.
Lipshultz (1976) reported a group of unilateral cryptorchidism patients treated before puberty, about 62% of adults have fertility after adulthood, and only 40% to 46% of those without surgery have fertility, even before prepubertal treatment, semen The low density (2.68×104/ml) indicates that cryptorchidism can affect the fertility of the healthy testis. Hecker performed bilateral testicular biopsy on 125 patients with unilateral cryptorchidism, and only 40% of healthy testicles had normal mature sperm. It is suggested that there may be autoantibodies, but it has not been confirmed that the unilateral cryptorchid fertility is inversely related to the age of surgery, that is, the older the operation, the lower the postoperative fertility, and the adult after 1 to 2 years of age The fertility rate is 87.5%, 57% of the patients in the 3 to 4 years old, and only 14% after the delay to 13 years old. In addition, the unilateral cryptorchid fertility is also affected by the development and maturity of the healthy testis and epididymis. For example, the attachment of the epididymis to the testicles will hinder the passage of mature sperm and cause infertility.
The fertility of patients with bilateral cryptorchidism is significantly decreased, such as the higher testicular position, due to serious pathological damage, serious disorders of germ cell development can cause infertility, but if the location of cryptorchidism is low, after appropriate treatment, it is expected to retain some fertility .
2. Congenital inguinal hernia: About 65% of cryptorchidism is accompanied by congenital inguinal hernia, which is the sheath that is not closed between the peritoneal cavity and the testicular sheath lumen, and the intestinal fistula descends into the scrotum. Internally, almost all the capsular ducts between the peritoneal cavity and the sheath of the cryptorchidism are not closed. When the sheath-like orifice is narrow, no sputum is formed. Some children have large sputum in the months after birth, which can be oppressed. The spermatic blood vessels make the cryptorchidism further atrophy, and some of them have oblique incarceration and strangulation. These must be treated as soon as possible. Under normal circumstances, the children should be treated with a small sinus and cryptorchidism.
3. Cryptorchidism reversal: Wallenstein counts 150 patients with testicular torsion, 90 (60%) are cryptorchidism patients, and the chance of reversal of the testis is 21 to 53 times that of the testis in the scrotum. The cause and mechanism of the disease are unknown. May be related to testicular lead or cremaster muscle attachment abnormalities.
4. cryptorchidism: Because the cryptorchidism is often located in the inguinal canal or near the pubic tubercle, the position is superficial and fixed, and it is vulnerable to external violence. As the age increases, the range of activity of the cryptorchidism increases, and the traumatic opportunity also follows. Increased, the testis is prone to fibrosis after the injury, accelerate its atrophy.
5. cryptorchidism malignant: cryptorchidism patients with testicular tumors, 20 to 40 times larger than normal testis, high cryptorchidism, especially intra-abdominal cryptorchidism, the incidence of malignant transformation is about 4 to 6 times higher than the lower cryptorchidism The intra-abdominal cryptorchidism has a testicular tumor rate of 22.7%. The Campbell's statistics have a malignant rate of 48.5%, while the cryptorchidism in the inguinal or external ring is only 6.8%. According to clinical observation, the surgeon cannot prevent the tumor after 10 years old. Occurrence, surgery can significantly reduce the incidence of tumors before the age of 10, surgery can prevent the occurrence of tumors before the age of 3, it is generally believed that testicular fixation can not prevent the occurrence of malignant transformation, even if early surgery, will not reverse this malignant tendency, However, the testicles that fall to the scrotum are easily found early after they become malignant.
The age of onset of cryptorchidism is more than 30 years old. The cause of the disease is related to local temperature, blood supply disorder, endocrine dysfunction, etc. Sohval observes undifferentiated seminiferous tubules and scrotum in cryptorchidism. The changes of seminoma in the inner testis are similar. It is believed that the congenital defect in cryptorchidism is the cause of malignant transformation. Batata et al. counted 137 cases of cryptorchidism with malignant transformation, 93 cases had testicular fixation, and 44 cases There was no operation. The age of the operation group was 12 years old. The average age of the tumor was 32 years old. The average interval was 20 years. The average age of the untreated group was also 32 years old. It should be observed at least 20 years after the correction of cryptorchidism.
Symptom
Cryptorchidism symptoms Common symptoms androgen too low serum testosterone concentration low pain abdominal pain gastrointestinal symptoms no testis
Patients with cryptorchidism without complications generally have no symptoms, mainly manifested as flattened scrotum on the affected side, left side, left side scrotum asymmetry, bilateral cryptorchidism scrotum emptiness, depression, if the inguinal hernia is concurrent, the affected side There is a mass, accompanied by pain and discomfort. In severe cases, paroxysmal abdominal pain, vomiting, and fever may occur. If the cryptorchidism is reversed, such as cryptorchidism at the inguinal or external ring, the main manifestation is a local painful mass. There is no normal testis in the scrotum, and the gastrointestinal symptoms are mild. For example, the cryptorchidism is located in the abdomen. After the torsion, the pain is located in the lower abdomen near the inner ring. The right intra-abdominal cryptorchidism is similar to the symptoms and signs of acute appendicitis. The main difference is that the intra-abdominal cryptorchidism has a low tender point and is close to the inner ring. In addition, there is a high degree of suspicion of intra-abdominal testicular torsion when there is no testicle in the affected scrotum.
When examining the body, the testicle should first be examined at the patient's position. If the palpation is not satisfactory, the supine position should be taken again. The indoor should be avoided, and the stimulation of the cremaster reflex should be avoided, because these factors may induce the cremaster reflex. And testicular retraction, sometimes washing a warm water bath before the physical examination is more conducive to examination, about 20% of cryptorchidism can not be paralyzed during physical examination, which does not mean that these cryptorchidism are located in the abdominal cavity, can not be hidden About 80% of the testis can be found in the inguinal canal or near the inner ring. In the remaining 20%, the unilateral testicular deficiencies account for about 3% to 5%, and the bilateral testicular deficiencies account for about 0.6%. At the time of exploration, about 65% of the testicular dysfunction can find the spermatic cord and the vas deferens at the inner ring of the inguinal region. This requires intra-abdominal exploration to find the testicles, accounting for only 2% to 3% of all cryptorchidism.
Examine
Cryptorchidism
Patients with cryptorchidism that cannot be bilaterally treated should be tested for sex hormones before surgery. Serum testosterone, luteinizing hormone (LH) and follicle hormone FSH values should be measured before the test, and then HCG chorionic gonadotropin 1000-1500 U should be injected intramuscularly. The testosterone, LH and FSH values were reviewed once every other day for 3 times. If the testosterone value increased or did not respond to HCG, but LH and FSH did not increase, it indicated that at least one testicle should be present and should be surgically explored. LH and FSH have increased, and the testosterone value does not increase after injection of HCG, it can be diagnosed as a lack of bilateral testicular, requiring surgical exploration.
For cryptorchidism that cannot be removed, some special tests can be used to determine whether there are testicular and cryptorchidism, such as hernia sac, testicular artery, and venography. These examinations are complicated and have a low success rate. There are some side injuries and complications, the results are not easy to be clear, and it is rarely used. There is no damage examination. For example, B-ultrasound can accurately locate the cryptorchidism in the inguinal canal, and has no value in the diagnosis of cryptorchidism in the abdomen. , CT, MRI examination is expensive, poor specificity, can only be used as a reference. In recent years, laparoscopic surgery for undetectable cryptorchidism preoperative examination has achieved satisfactory results (see below for specific methods), another ideal The testicular localization method is to scan with a nuclear-labeled HCG radionuclide, using a nuclear-labeled HCG to accumulate a sufficient amount of HCG on the testicular LH/HCG receptor to display the testis in a gamma-scan scan.
Diagnosis
Cryptorchidism diagnosis
diagnosis
Diagnosis can be based on medical history, clinical symptoms, and laboratory tests.
Differential diagnosis
It should be differentiated from testicular abscess, ectopic testis, and retracted testis.
Retracted testes are more common in infants and young children due to excessive contraction of the cremaster muscle. As the age increases, testicular enlargement and cremaster muscles decrease, this phenomenon will gradually decrease, and the retracted testicles will be gently pushed down by hand. Squeeze, can be returned to the scrotum, after the loose hand testicles can stay in the scrotum for a period of time, the difference between the sliding testicles is that the latter is pushed into the scrotum, once the testicles are released back to the original position, is a cryptorchidism category.
The ectopic testicle can find the testicle above the pubic symphysis, the thigh or the perineum. When the normal testicle descends, in most cases, the scrotum branches along the end of the lead band enter the bottom of the scrotum, such as the testicle does not fall to the bottom of the scrotum. As the other branches along the end of the testis lead descend to the pubic symphysis, the thigh or the perineum, an ectopic testis is formed, accounting for approximately 1% of the cryptorchidism.
