Cryptorchidism in children
Introduction
Introduction to pediatric cryptorchidism Cryptorchidism, also known as testicular failure or testicular insufficiency, refers to testicular failure to descend from the lumbar ventral scrotum in accordance with normal developmental procedures. The incidence of cryptorchidism gradually decreases during growth and development. The prevalence of premature infants is about 30%, 4% for newborns, 0.66% for 1 year old, and 0.3% for adults, indicating that testicular decline is a gradual process. Testicles can still continue to decline after birth. However, generally after 6 months, the chances of further decline are significantly reduced. basic knowledge The proportion of sickness: 0.01% Susceptible people: children Mode of infection: non-infectious Complications: testicular injury male infertility
Cause
Etiology of pediatric cryptorchidism
Endocrine disorders (30%):
Clinical studies have shown that hypothalamic-pituitary-testicular axis imbalance leads to lower than normal testosterone levels in cryptorchidism, testicular decline is closely related to testosterone levels, testosterone-dihydrotestosterone binds to receptor proteins on the surface of spermatic cord and scrotum, promoting testis Decreased, if endocrine disorders, testicular decline received inhibition, causing the disease.
Insufficient MIS (25%):
MIS is the secondary renal tube inhibitor. In the early stage of the embryo, the fetus has both the secondary renal tube and the middle kidney tube. As the male gonad develops into the testis, the testicular stromal cells secrete testosterone, support the secretion of the secondary renal tubular inhibitor (MIS), and inhibit the deputy kidney. Tube development, if the MIS is insufficient, the secondary kidney tube can remain or not degenerate at all, causing obstacles to the decline of testicles.
Dysplasia (5%):
The cryptorchidism cerebral processes mostly end up above the pubic tuberosity or scrotum, while dysplasia leads to residual lead and the fascia covers the scrotum entrance, which prevents the testicles from falling.
Pathogenesis
The cryptorchidism testis often has varying degrees of hypoplasia, the volume is significantly smaller than the healthy side, the texture is soft, and sometimes the epididymis and vas deferens are malformed, the incidence rate is 36% to 79%. The histopathology of cryptorchidism is mainly characterized by germ cell development. The obstacles, followed by the decrease in the number of mesenchymal cells, the mean diameter of the seminiferous tubules of cryptorchidism is smaller than normal, the collagen tissue around the seminiferous tubules proliferate, and the histopathological changes of cryptorchidism become more obvious with age. Many studies believe that the histopathological changes of testis after 2 years old will be difficult to recover, so the operation should be completed before the age of 2, the adult cryptorchidism, the seminiferous tubule degeneration, almost no normal sperm, pathology The degree of change is also related to the location of the cryptorchidism. The higher the position, the more serious the pathological damage; the closer to the scrotum, the less pathological damage.
Prevention
Pediatric cryptorchidism prevention
The risk of malignant transformation of the testis in the abdominal cavity is 6 times greater than that of other parts. The older the testis is, the greater the risk of malignant transformation. Therefore, the testis should be fixed early and it is easy to check.
Complication
Pediatric cryptorchidism complications Complications testicular injury male infertility
1. Fertility decline or infertility: The pathology of cryptorchidism is mainly the developmental disorder of germ cells, thus affecting fertility. In general, the fertility of bilateral cryptorchidism is significantly reduced, but if the position of cryptorchidism is lower, it is expected to stay. Partial fertility, unilateral cryptorchid fertility, such as the testicular and epididymis that fell into the scrotum on the contralateral side, the development is not significant.
2. Insomnia of the sheath: the sheath of the cryptorchidism is basically closed, and there is a sacral intrusion in the intestine, which can be incarcerated. The sheath should be ligated at the same time.
3. Testicular injury: Because the testicle is in the inguinal canal or near the pubic tubercle, it is superficial and susceptible to direct damage from external forces.
4. Cryptorchidism: The rate of reversal of the testis is 20 to 50 times higher than that of the testis in the scrotum. The cryptorchidism is usually a painful mass in the inguinal region, which is similar to the incarcerated inguinal hernia, but no obvious gastrointestinal symptoms. The right ventral cryptorchidism is reversed, and its symptoms and signs are similar to acute appendicitis. Therefore, in the acute abdomen of children, attention should be paid to the examination of the testis in the scrotum.
5. cryptorchidism malignant: cryptorchidism is 18 to 40 times higher than normal testis, high cryptorchidism, especially intra-abdominal cryptorchidism, the incidence of malignant transformation is 6 times higher than the lower cryptorchidism, testicular fixation before 6 years old Then the malignant changes are much lower than those after the age of 7 years. The age of onset of cryptorchidism is more than 30 years old.
Symptom
Symptoms of cryptorchidism in children Common symptoms Abdominal pain, pain, gastrointestinal symptoms, no testicles
Cryptorchidism can occur on one or both sides, more common on one side, unilateral cryptorchidism, the incidence on the right side is slightly higher than the left side, but even bilateral cryptorchidism, there is still a moderate amount of androgen production It can maintain the development of male secondary sexual characteristics, and rarely affects sexual behavior in adulthood. The cryptorchidism patients without complications generally have no symptoms. The main manifestations are flat scrotum on the affected side, left unilateral, and asymmetric scrotum on the right side. , bilateral cryptorchidism scrotum emptiness, depression, if the inguinal hernia is paralyzed, there is a mass on the affected side after the activity, accompanied by pain and discomfort, severe paroxysmal abdominal pain, vomiting, fever, if the cryptorchidism is reversed, such as The cryptorchidism is located in the inguinal canal or the outer ring. It is mainly characterized by a local painful mass. There is no normal testis in the affected scrotum. The gastrointestinal symptoms are mild. For example, the cryptorchidism is located in the abdomen. After the twist, the painful part is in the lower abdomen near the inner ring. At the same time, the right ventral 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, the testis should be height-free in the affected scrotum. Suspected intra-abdominal testicle Turn, according to the location of the testes, cryptorchidism clinically divided into:
1 high cryptorchidism, which refers to the testicle located in the abdominal cavity or near the inner ring of the groin, accounting for 14% to 15% of the cryptorchidism;
2 low cryptorchidism, where the testicle is located in the inguinal or outer ring.
There are also four types of cryptorchidism:
1 intra-abdominal testis, the testicle is located above the inner ring;
2 in the inguinal canal testis, the testicle is located between the inner ring and the outer ring;
3 ectopic testis, testicular deviation;
4 retract the testicles, the testicles can be pushed or pulled into the scrotum, loosened and then retracted to the groin.
Examine
Examination of pediatric cryptorchidism
Routine examination is generally normal, if necessary, chromosome examination to help identify, the risk of malignant transformation of testis in the abdominal cavity is 6 times larger than that of other parts. The older the testis is, the greater the risk of malignant transformation, so it should be done early. Testicular fixation, also easy to check, can be routinely performed ultrasound, CT and magnetic resonance examination, for the diagnosis of inaccessible testicles, unilateral laparoscopy can be used.
Diagnosis
Diagnosis and diagnosis of cryptorchidism in children
diagnosis
Diagnosis is not difficult, physical examination shows that the affected side of the scrotum is flat, bilateral scrotum development is poor, palpation, the child's scrotum is empty, no testicles, about 80% of cryptorchidism can be found in the inguinal canal area, the pressure has pain Feeling, activity is large, can not be pushed into the scrotum.
Differential diagnosis
It should be differentiated from testicular abscess, ectopic testis, retractive testis, etc. Pediatric cremaster muscle reflex is more active, subject to certain stimuli, such as cold or scare, cremaster contraction, which can be located in the scrotum The testicles are lifted to the proximal end of the scrotum and even into the inguinal canal. The clinical manifestations are quite similar to cryptorchidism, but these testes are easily pushed back into the scrotum and stay in the scrotum, not cryptorchidism, and some testicles are difficult to reach during palpation, but this It does not mean that these cryptorchidism are located in the abdomen. About 80% of the cryptorchidism that is not accessible can be found in the inguinal canal or near the inner ring during surgery. The remaining 20% are still not detected by surgical exploration. If the testicle is not found on one side, it is called single testis or unilateral testicular absent, the incidence rate is 3% to 5% of cryptorchidism exploration, and one of about 5,000 males is absent from unilateral testis; Lateral cryptorchidism, failed to find testis, known as no testicular deformity, only 1 in about 20,000 men, for the inaccessible cryptorchidism, there is no satisfactory method to judge the testis before surgery Presence or presence and location of cryptorchidism, ultrasound, CT and magnetic resonance examination Because of the influence of intestinal gas, it is often difficult to obtain satisfactory results. If the testis is not touched on both sides, the genital genital condition should be checked for chromosomes, and the HCG challenge test can be used to judge the presence or absence of the testis, but the surgical exploration is The only reliable way.
