Kriptorkhizm – the congenital anomaly which is characterized by absence at the time of the birth at the boy of one or both testicles in a scrotum that is caused by a delay of their lowering on the inguinal channel from zabryushinny space. Kriptorkhizm is shown by asymmetry of a scrotum, lack of a small egg in it at a palpation, the aching groin or stomach pains. Diagnostics at a kriptorkhizm includes performing ultrasonography of bodies of a scrotum, MRT, stsintigrafiya of testicles, angiography of a belly aorta and venografiya of a yaichkovy vein. The main way of treatment of a kriptorkhizm – quick: bringing down of the neostarted-up small egg and its fixing to a scrotum.
In children's urology not omission of testicles or a kriptorkhizm is the most frequent congenital anomaly which is found at 4% of the full-term and 10 — 20% of premature newborn boys. Within the first 6 months of life 75% of the children born with a kriptorkhizm have an independent omission of testicles probably in connection with gradual increase in level of testosterone. By the end of the 1st year of life the kriptorkhizm remains only at 1% of boys. Further in the absence of a medical grant the probability of independent omission of testicles in a scrotum is improbable.
Untimely surgical treatment of a kriptorkhizm increases probability of development in the future of male infertility and cancer of a small egg.
Bookmark and formation of testicles (testicles) at a fruit occurs in an abdominal cavity. In the last trimester of pregnancy there is an omission of testicles in a scrotum on the inguinal channel. It is considered that timely independent bringing down of testicles is defined by a number of mechanisms – the intra belly pressure, local level of testosterone, a condition of the directing linking of a small egg and its attachment to a scrotum. After the boy's birth further normal development of testicles is possible only at their stay in a scrotum where temperature is 2-3 °C lower, than in an abdominal cavity. Such distinction of temperatures is a necessary condition of a normal spermatogenesis. Usually neostarted up small egg has the smaller sizes, than lowered in time.
The reasons of a delay of omission of a small egg and development of a kriptorkhizm are definitely not known. As possible prerequisites the endocrine, mechanical and genetic factors promoting this anomaly are considered.
Refer presence of a hormonal imbalance at the pregnant woman to endocrine mechanisms of development of a kriptorkhizm (in particular, diabetes 1, 2 types or gestational, dysfunctions of a hypophysis, a thyroid gland) or testicles at an embryo. These states are capable to slow down timely omission of testicles in a scrotum and to cause development of a bilateral kriptorkhizm.
The narrowness or impassability of the inguinal channel, shortening of yaichkovy vessels or a seed kanatik, an underdevelopment of the copular device of testicles, vnutribryushinny unions, etc. are distinguished from the mechanical factors causing a kriptorkhizm.
In some cases the kriptorkhizm is associated with GTD gene mutation (306190, Hr21), a Down syndrome, pre-natal defects of development of a forward belly wall.
Significantly premature birth and prematurity of a fruit increase probability of a kriptorkhizm. Kriptorkhizm comes to light at all premature boys weighing less than 910 g and at 17% with body weight more than 2040.
Classification of a kriptorkhizm
Distinguish a kriptorkhizm false and true. At a false kriptorkhizm (the migrating small egg) under the influence of the muscular tension or cold the small egg can be displaced to the pakhovy canal or an abdominal cavity. The false kriptorkhizm meets in 25-50% of cases of all observations. Symmetry and normal development of a scrotum is characteristic of it; migration of a small egg to the area of an abdominal ring or the lower third of the inguinal channel; a possibility of free bringing down of a small egg in a scrotum at a palpation or its independent omission under the influence of heat or in the weakened quiet condition of the child.
Migration of a small egg is option of physiological norm and is explained by the small diameter of a small egg in comparison with diameter of an external abdominal ring. Therefore at reduction of the corresponding muscles the small egg is easily tightened to an inguinal fold. The false kriptorkhizm does not demand treatment and disappears independently at pubertatny age.
Speak about a true kriptorkhizm at impossibility of manual bringing down of a small egg in a scrotum. In this case the small egg most often settles down in the field of an abdominal ring (40%), in the inguinal channel (20%), an abdominal cavity (10%). At not omission of one of testicles speak about a unilateral true kriptorkhizm; in case of a delay of omission of both – about bilateral anomaly. The bilateral true kriptorkhizm is often combined with a gipogonadizm, gipotalamo-hypophysial insufficiency (gipopituitarizm), inguinal hernia.
It is necessary to distinguish such state as a small egg ektopiya from a true kriptorkhizm. In case of an ektopiya a small egg, having passed the pakhovy channel, gets not to a scrotum, and to a crotch, the medial surface of a hip, a forward belly wall, it is rare – on the dorsalny surface of a penis. At a small egg ektopiya even after treatment most of patients are infertile.
The true, false kriptorkhizm and ektopiya of a small egg are congenital states. More rare, the kriptorkhizm has the acquired character. So, a wide abdominal ring or injuries of a scrotum can cause migration of initially normally located small egg to the inguinal area or an abdominal cavity.
Symptoms and complications of a kriptorkhizm
As the main manifestation of a kriptorkhizm serves lack of one or two testicles in a scrotum which the urologist defines palpatorno. At the same time the scrotum looks underdeveloped, flattened or asymmetric.
At a kriptorkhizm the aching and nagging pains in a groin or a stomach can be noted. At localization of a small egg in an abdominal cavity of pain, as a rule, appear only in a puberty and can amplify at a muscular tension, a natuzhivaniye, locks, sexual excitement.
At later age at a kriptorkhizm the risk of development of cancer of testicles (seminoma), fertility violation increases (reduction of quantity of spermatozoa on a spermogram, poor quality of sperm and its impregnating ability). At a bilateral kriptorkhizm about 70% of men are infertile.
Besides, the kriptorkhizm can cause development of a perekrut of a small egg, more precisely than the seed kanatik formed by blood vessels, nerves and a semyavynosyashchy channel. In case of a kriptorkhizm combination to inguinal hernia infringement of a small egg together with intestines loops in an abdominal ring is not excluded. These states are followed by sharp pains in view of violation of blood supply of a small egg and its death during several next few hours.
At an arrangement of the neostarted-up small egg in a groin, on it the lonny bone can press that, in turn, increases risk of injuries of gonad.
Diagnostics of a kriptorkhizm
Kriptorkhizm comes to light at survey and a palpation of a scrotum. In the absence of a small egg the scrotum on the relevant party looks underdeveloped and flattened. At a belly retention the small egg does not manage to be propalpirovat; in other cases the small egg is found in the inguinal channel. At an inguinal arrangement of a small egg it is to a certain extent mobile, displaced, at a false kriptorkhizm is easily displaced in a scrotum. In case of a true kriptorkhizm it is not possible to reduce it in a scrotum. Lack of a small egg is confirmed when performing ultrasonography of bodies of a scrotum.
At impossibility of palpatorny definition of finding of a small egg resort to performance of ultrasonography of an abdominal cavity and inguinal area, a survey X-ray analysis of an abdominal cavity. At not informational content of ultrasonography carrying out contrast MPT or KT, and in difficult cases - a diagnostic laparoscopy for confirmation of an abdominal retention of a small egg or establishment of monarchism or anarchism can be required.
At impossibility of palpatorny and tool identification of both testicles the exception of a men's pseudo-hermaphroditism is required for what genetic analyses, a research of testosterone, gonadotropny hormones are carried out.
Treatment of a kriptorkhizm
Start treatment of a kriptorkhizm on reaching the child of 9-month age, to this term counting on a possibility of spontaneous omission of a small egg in a scrotum. Medicamentous therapy is carried out by means of intramuscular introduction of human HG or intranazalny introduction of a gonadorelin. As a result of conservative therapy it is possible to reach omission of a small egg at 30-60% of patients. Hormonal medicamentous therapy of a kriptorkhizm is contraindicated at pubertatny age when increase in level of own testosterone and gonadotropny hormones is observed.
At unsuccessfulness of conservative therapy of a kriptorkhizm to age of 15-24 months surgical tactics – an orkhipeksiya is shown (surgical bringing down of a small egg in a scrotum). In the course of operation carrying out a biopsy of a small egg for an exception of malignant processes and dyskinesia of gonads is required. Surgical intervention is absolutely necessary in case of a perekrut, infringement of a small egg, inguinal hernia, a small egg ektopiya.
At detection of a hypotrophy or a necrosis of gland the resection of a small egg or its removal – an orkhiektomiya is carried out. In the latter case, and also at anarchism at more advanced age change of a donor small egg or implantation of an artificial small egg for cosmetic correction of defect is required.
The forecast at a kriptorkhizm
In case of early (up to 2 years) bringing down of a small egg or a unilateral kriptorkhizm the risk of the subsequent complications significantly decreases. Infertility develops further at 20% at patients with a unilateral kriptorkhizm and at 70-80% at patients with a bilateral kriptorkhizm.
In the absence of at least only thing, normally functioning small egg boys need treatment from the endocrinologist for normal sexual and physical maturing on men's type.
Further carrying out self-inspection of testicles for detection of possible tumoral processes is recommended to parents, and then and the teenager.