Insufficiency of testicular descent
Introduction
Introduction to testicular insufficiency Testicular insufficiency refers to a testicular decline disorder that stays on the way to the decline process and fails to enter the scrotum. Clinically, it is also known as cryptorchidism. Cryptorchidism is a congenital disease. The occurrence of cryptorchidism is related to hormone levels, testicular replacement and spermatic cord length. The cryptorchidism occurs mostly on one side, and the incidence of bilateral cryptorchidism is about 10-25%. The cryptorchidism is often accompanied by inguinal hernia. The cryptorchidism staying in the abdominal cavity or groin area, because the temperature is higher than the scrotum, the testicles are in this environment for a long time, dysplasia, degeneration of the seminiferous tubules, causing spermatogenic dysfunction. For a long time, when the young occult cryptorchidism will become a testicular tumor, the cryptorchidism should be treated early and returned to the scrotum to avoid complications. basic knowledge The proportion of illness: 0.03% Susceptible people: male Mode of infection: non-infectious Complications: infertility testicular torsion testicular tumor
Cause
Testicular insufficiency etiology
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
Testicular insufficiency prevention
The boy's parents should carefully check the child's scrotum. Generally, the testicles of peanut size can be molded on both sides of the scrotum. If there is a sense of physical sense when the scrotum is empty, you can't touch the testicles, or only one, you should go to the hospital immediately. At present, it is believed that cryptorchidism can be performed after 2 years of age, and no more than 10 years old at the latest, otherwise it may affect the function of sperm.
Once the child is found to be cryptorchidism, he must immediately go to a regular hospital for specialist treatment, including medication and surgery, but no matter what kind of treatment, it must be carried out within two years of the child, because over 2 years old, the testicular tissue of the child is There will be pathological changes. Professor Cao told reporters a painful example: a 7-year-old great physical examination found bilateral cryptorchidism. Although the doctor performed a cryptorchidism procedure for him in time, the cryptorchidism was found too late. The testicles stay in the abdominal cavity for too long, and the testis has undergone pathological changes, which means that the fertility function of the stick has been lost.
Complication
Testicular insufficiency complications Complications infertility testicular torsion testicular tumor
Complications of cryptorchidism:
Cryptorchidism and infertility, cryptorchidism due to histopathological changes, no normal spermatogenic function, the higher the position of cryptorchidism, the longer the position above the scrotum, the greater the damage of the testicular seminiferous tubule, Mengel After observation with ordinary microscope and electron microscope, the testis of cryptorchidism patients had pathological changes of seminiferous tubules and interstitial cells and obvious spermatogenic damage before the age of 2, Hecker examined normal adult and unilateral cryptorchidism testis The sperm concentration after fixation is significantly higher than the latter, indicating that unilateral cryptorchidism patients have bilateral cryptorchidism, bilateral cryptorchidism patients are untreated, infertility can reach 100%, such as early treatment of fertility Up to 40%, and the fertility of unilateral cryptorchidism can reach 60% after early treatment. The treatment of patients before the age of 2 can improve the development of spermatogonia, increase the number of spermatogonia and later spermatogenesis, unilateral Patients with bilateral cryptorchidism are still less than normal after adulthood despite early treatment.
Cryptorchidism and testicular torsion, due to dysplasia between the testes and ligaments of cryptorchidism, it is prone to testicular torsion. After puberty, there is more chance of increased testicular volume. Rigter reports that 64% of adult cryptorchidism is Due to malignant changes in the testes, and even changes in testicular weight and testicular gravity axis, the principle of treatment is testicular fixation or orchiectomy when needed.
Cryptorchidism and malignant transformation:
Cryptorchidism patients have a high incidence of malignant transformation after puberty. The incidence of malignant transformation of cryptorchidism is 25 to 48 times that of normal people (Whiter and Welvar). About 10% of testicular tumors occur in cryptorchidism due to cryptorchidism. The histology is abnormal, so early surgery can not prevent malignant transformation of cryptorchidism. In patients with unilateral cryptorchidism, the testicular histology of the contralateral scrotum has been abnormal, so there is also a high malignant change. Rate, Johnson found that one in five patients with malignant cryptorchidism in the unilateral cryptorchidism occurred in the testis on the side of the non-cryptorchidism, while in patients with bilateral cryptorchidism, if one side had malignant changes, the other side of the testicle There is a 15% chance of a malignant change.
The location of cryptorchidism has a significant relationship with malignant transformation. The incidence of malignant changes in the cryptorchidism in the abdomen is four times that of the cryptorchidism in the inguinal region, while bilateral cryptorchidism in the abdomen, such as malignant transformation on one side and 30% chance on the other testis. Malignant changes have also occurred.
Skakkebaek found that carcinoma in situ in a cryptorchidism biopsy caused a new understanding of malignant cryptorchidism, with a prevalence of 30%.
In short, in order to observe the changes of cryptorchidism and early detection of malignant transformation, early testicular fixation should be performed, especially the intra-abdominal cryptorchidism should be moved into the scrotum at an early stage. If it cannot be moved into the scrotum, orchiectomy should be performed. After malignant transformation of cryptorchidism, Most of them are seminoma, and should be done in time for radical resection of the testicle and post-peritoneal radiation therapy.
Symptom
Testicular hypoplasia Symptoms Common symptoms Testicular tenderness Testicular hypoplasia Testicles One large and one testicular nodules
If the cryptorchidism is located in the inguinal canal and the intra-abdominal or the testicular is absent, the testiculars often fail to detect the testicles. The cryptorchidism that Levitt does not measure in clinical examinations accounts for about 20% of all cryptorchidism. For these patients, HCG stimulation is often used first. The test, that is, injection of HCG1500IU, once every other day, a total of 3 times, check the serum testosterone level before and after injection, if the serum testosterone level increased after injection, indicating the presence of functional testicular tissue, if the serum testosterone level after injection does not change, often indicates There is no functional testicular tissue present.
For clinically undetectable cryptorchidism, special diagnostic methods are often needed for cryptorchidism. B-mode ultrasound is the most commonly used method. This type of examination is non-invasive and can check patients for hydronephrosis. Urinary system lesions such as malformations and stones have a relatively high diagnostic rate for cryptorchidism in the inguinal canal, but the diagnostic rate for intra-abdominal cryptorchidism is not high enough. Selective spermatic vein angiography is a widely used method. The location of the cryptorchidism or the lack of testicular can be diagnosed from the end of the spermatic vein after injection of the contrast agent, but often the venous valve affects the development of the spermatic vein, and it is difficult for children under 2 years of age to operate. Tomography (CTScan) and magnetic resonance imaging (MRI) have also been used in the diagnosis of cryptorchidism in the abdomen in recent years. They have high accuracy. Wolverson reports that 20 patients have CT examinations with an accuracy rate of 96%; Fritzche reports 12 A total of 15 cryptorchidism confirmed 14 cryptorchidism by MRI and 1 case of misdiagnosis. The disadvantage of these two tests is that it is difficult and expensive to check in young children.
Laparoscopy has been widely used in the diagnosis and treatment of cryptorchidism in the abdomen in recent years. Laparoscopy is widely used in patients of all ages and children under 1 year of age. The operation method is simple and the time is short, and the diagnosis rate can reach 88%. To 100%, the location of the cryptorchidism or the absence of the testis can be determined. In the laparoscopic examination, the testicular blood vessels can often be found along the anatomical location of the testicular vessels in the retroperitoneum. The testicular vessels located in the abdomen or the inner ring of the groin can be found along the spermatic vessels. If the blind end of the blood vessel is seen along the blood vessel, it can be determined that the testicular is absent. If the blind end has a nodule that should be removed and sent for pathological examination, Diamond concludes that there are three results in the clinically undetectable cryptorchidism in laparoscopy:
1 Seeing the blind end of the spermatic vessels and the vas deferens above the inner ring of the inguinal region, lacking testicles;
2 normal spermatic cord enters the inguinal canal;
3 intra-abdominal testicles, the latter are required for surgical exploration, if the vasectomy is only seen into the inguinal canal and no spermatic vessels are seen, laparotomy should be performed. If high ventral cryptorchidism is observed during the examination, it is very long. The vas deferens can be used for the first stage of staged testicular fixation, that is, separation, clamping and cutting the spermatic vessels, leaving the second stage of testicular fixation, if the testicular development is not normal, it is suitable for stage testicular fixation. Laparoscopy should be performed for orchiectomy.
Examine
Examination of testicular insufficiency
Patients with cryptorchidism often have scrotal emptiness and no testicles for treatment. There are also patients who have been treated with the main complaints, or because of bilateral cryptorchidism and infertility after marriage. The diagnosis is generally not difficult, but for The identification of cryptorchidism and testicular deficiencies in the testicles should not be considered, as the latter does not require surgery.
If the patient's chromosome is XY, serum follicle stimulating hormone (FSH) is elevated, serum testosterone (T) is decreased, and testosterone levels do not respond to chorionic gonadotropin (HCG) stimulation, it is absent from both testes. No need for surgical exploration for unilateral testicular dysplasia is difficult to confirm before surgery, hormone test is normal, gonad venography, laparoscopy, B-ultrasound, CT scan may be helpful for diagnosis, if necessary, surgical exploration is still needed.
Diagnosis
Diagnosis and differentiation of testicular insufficiency
diagnosis
Diagnosis is generally not difficult, but the identification of cryptorchidism and testicular deficiencies that do not touch the testicles should be considered, because the latter does not require surgery.
Differential diagnosis
"Shrinking yang", also known as "shrinking yin", also known as "yang contraction" or "yin contraction", refers to male vaginal scrotum, scrotum, testicular sudden retraction, often accompanied by less abdominal pain as the main clinical manifestations A disease, and impotence refers to a condition in which the yin cannot be erect, or the erection is not hard to perform sexual intercourse. The scrotum must be stimulated with cold, the scrotum contracts, but the pubic sin does not contract, and there is no systemic symptoms and less abdominal pain. The physiological phenomenon is differentiated and differentiated from cryptorchidism.
