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Phase 2: Reproduction, Nephrology and Urology > Lecture 7: Cryptorchidism > Flashcards

Lecture 7: Cryptorchidism Flashcards

1
Q

Genetic sex is fixed at fertilisation by which gamete?

A

Male gamete

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2
Q

the human embryo is bipotential until what stage?

A

40 days gestation (7 weeks)

Bipotential: no sexual differences

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3
Q

What genes are essential in the development of the testes?

A

SRY

SOX9

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4
Q

Which chromosome contains SRY?

A

Y chromosome

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5
Q

Presence of SRY will result in which sexual differentiation?

A

Male differentation

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6
Q

Leydig cells produce testosterone. What must happen to this testosterone in order for the male external genitalia to develop?

A

Testosterone must be converted into dihydrotestosterone (DHT)

DHT is more potent- stimulates the development of the male external genitalia

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7
Q

The Sertoli cells produce which hormone during development that suppressed the Mullerian duct?

A

Anti-Mullerian hormone

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8
Q

The fetal Leydig cell population disappears after week 17-18 when will the adult Leydig cell appear?

A

Appear in puberty

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9
Q

Describe the layers of the scrotum?

A

mnemonic: Some Damn Englishman Called It The Testes

S: Skin

D: Dartos muscle

E: External spermatic fascia

C: Cremasteric muscle

I: Internal spermatic fascia

T: Tunica vaginalis

T: Tunica albuginea

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10
Q

The gonads and the kidney develop from with germ layer?

A

Mesoderm

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11
Q

At day 21, the mesoderm has differentiated into 3 parts:

Paraxial mesoderm, Intermediate mesoderm and lateral plate mesoderm.

Which one of these will go on and become the kidneys and gonads?

A

Intermediate mesoderm

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12
Q

What is the difference between seminiferous cords and tubules?

A

Seminiferous cords refers to them prior to puberty, when no lumen is present.

Seminferous tubules refers to them after puberty when a lumen has formed allowing the sperm to pass.

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13
Q

Which tunica of the scrotum is there a fluid filled cavity?

A

Between the visceral and parietal layers of the tunica vaginalis

Fluid filled space filled with peritoneal fluid

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14
Q

Describe a hydrocele?

A
  • Result of an acculumation of fluid in the peritoneal cavity of the tunica vaginalis of the scrotum.
  • Clinically, it appears as a painless swelling in the scrotum
  • Often found in newborn boys
  • Hard to palpate the testes.
  • Diagnosed by Transillumination test, this involves holding a light behind the scrotum. If the light shines through the mass is cystic. If the light is blocked by the mass then the mass is solid. In hydrocele, the light should shine through.
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15
Q

The testis develop as an intra-abdominal organ. It descends to the scrotum for what reason?

A

As normal body temperature is harmful to spermatogenesis: the testis requires a temperature 2oC lower than body temperature

Scrotum lies outside the body- therefore lower body temperature

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16
Q

When does the testicular descend begin in development?

A

It begins in the 10th week of gestation

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17
Q

What hormone is necessary for testicular descent?

A

Testosterone, produced by the embryo Leydig cells

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18
Q

Testicular descent is a two-stage process. What are the names of each stage?

A

Stage 1: Transabdominal stage (8 to 15 weeks)

Stage 2: Transinguinal phase (25 to 35 weeks)

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19
Q

Brief description of what occurs in the stage 1 of testicular descent (transabdominal stage)?

A
  • Involves contraction and thickening of the gubernacular ligament and degeneration of the craniosuspensory ligament.
  • Mediated by the testis themselves as they secrete factors e.g. insulin-like 3
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20
Q

Brief description of what occurs in the stage 2 of testicular descent (transinguinal stage)?

A
  • Controlled by androgens e.g. testosterone.
  • The gubernaculums shortens and migrates
  • The testis usually arrives in the scrotum a few weeks before birth, sliding down behind the processus vaginalis
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21
Q

Name the borders of the inguinal canal?

A

mnemonic is MALT.

  • Roof is formed by Muscles (internal oblique and transversus abdominis)
  • Anterior wall is derived from Aponeuroses (internal and external oblique aponeuroses)
  • Floor is formed from Ligaments (inguinal and lacunar ligament).
  • Posterior wall is dervied from 2xTs (transverse fascia and conjoint tendon)
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22
Q

The testes develop high on the embryo’s ___ abdominal wall

A

Posterior

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23
Q

The testes travel through which canal before reaching the scrotum

A

Inguinal canal

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24
Q

Tunica albuginea is a fibrous capsule which extends inwards forming ____ that divide each testis into lobules

A

Septa

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25
Q

Sertoli cells produce which hormone?

A

Inhibin, when levels of spermatozoa are too high

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26
Q

Adult leydig cells produce which hormone?

A

Testosterone

27
Q

Name the 3 arteries that travel via the spermatic cord?

A
  1. Testicular artery
  2. Ductus artery
  3. Cremaster artery
28
Q

What are the functions of the pampiniform plexus?

A
  • Venous drainage for the testes.
  • A role in the temperature regulation of the testes
29
Q

How does the pampiniform plexus work as a cooling agent for the testes?

A

Acts as a countercurrent heat exchanger, cooling blood in adjacent arteries

Provide an effective mechanism for cooling arterial blood entering the testicle and transferring its heat to the venous blood leaving the testicle

30
Q

At what volume of the testes indicates puberty is starting?

A

4ml

31
Q

Describe orchidometer ?

A

A string of beads that indicate the volume of the testis.

Used as an indicator if puberty has begun.

32
Q

What is the average volume for the testes, in an adult male?

A

Average adult volume of 18 mL

33
Q

How do you differentiate between an indirect and direct inguinal hernias?

A

Indirect – where the peritoneal sac enters the inguinal canal through the deep inguinal ring.

Direct – where the peritoneal sac enters the inguinal canal though the posterior wall of the inguinal canal.

34
Q

Describe the rings of the inguinal canal?

A

These are the two openings to the inguinal canal

  • deep (internal) ring
    • ​entry point to the inguinal canal
  • superficial (external) ring
    • ​exit point to the inguinal canal
35
Q

If the underlying cause of the testicular dysgenesis is due to a decrease in Leydig cell function. What are the possible outcomes?

A

Hypospadias- opening of the urethra is on the underside of the penis instead of at the tip

Cryptorchidism- one or both of the testes fail to descend from the abdomen into the scrotum

36
Q

If the underlying cause of the testicular dysgenesis is due to a decrease in Sertoli cell function. What are the possible outcomes?

A

Infertility

Testicular cancer

i.e. may not be detectable until reproductive age

37
Q

Cryptorchidism is also known as impalpable or undescended testes.

What is the difference between impalpable and undescended

A

Undescended: still able to palpate them so means they are mildly undescended

Impalpable: indicates the testes are severely undescended- more of a serious condition.

The higher in the body the testes are, the more they are getting cooked- worse an outcome

38
Q

What are the two types of Cryptorchidism?

A

Unilateral

Bilateral

39
Q

What is the difference between unilateral and bilateral Cryptorchidism?

A

Unilateral: only one testes is undescended

Bilateral: both testes are undescended

40
Q

Out of these four Cryptorchidism which one has the worset out?

A) Unilateral unpalpable cryptorchidism

B) Bilateral unpalpable cryptorchidism

C) Unilateral undescended cryptorchidism

D) Bilateral undescended cryptorchidism

A

B) Bilateral unpalpable cryptorchidism

Clinical emergency

41
Q

What are some of the long term consequences of Cryptorchidism?

A
  • Risk of testicular cancer
  • Fertility- may effect testicular function
42
Q

When are the testes usually checked to make sure they are descended?

A

Baby check that is carried out soon after birth

43
Q

What are the 4 clinical classification for the position of the testes (in reference to cryptorchism)

A
  1. Abdominal (Severe case)
  2. Inguinal
  3. Prescrotal (mild)
  4. Scortal (normal)
44
Q

With cryptorchidism, it is recommended to operate to physically descend the testes under 1 year. Why wait this long?

A

May resolve spontaneously during the first months of life when endogenous testosterone briefly increases

45
Q

What are thought to be some risk factors for cryptorchidism?

A
  • Smaller birth weight (<2.5kg)
  • Born earlier- less time to complete the transinguinal stage of testes descent.
  • Maternal diabetes
  • Problems with the placenta
  • Environmental factors e.g. endocrine disruptors
46
Q

Name a condition that cryptorchidism is part of the underlying disease?

A

Noonan condition

chromosomal defect

Symptoms include heart defects and cryptochidism

47
Q

What happens if bilateral cryptorchidism was not treated?

A

Persistent bilateral cryptorchidism have azoospermia (no healthy sperm)

Infertility can occur

48
Q

What is the preferred treatment for bilateral cryptorchidism?

A

Earlier surgery (between 10 months and 4 years)

49
Q

Cryptorchidism can increase the risk of which conditions?

A

Low sperm quality- infertility

Higher risk for testicular cancer

50
Q

Which investigations will you conduct in bilateral unpalable cyrptorchidism?

A

These investigations are looking for the testes (the sex at the moment is uncertain)

  • Ultrasound
    • First line as if you cannot find the testes you can look for female structures
  • CT / MRI
  • Laparoscopy
51
Q

What are the treatments options for cryptorchidism?

A

Operation to bring the testes down.

52
Q

What is orchidopexy?

A

A surgery to move a testicle that has not descended or moved down to its proper place in the scrotum.

53
Q

What are the possible complications of orchidopexy?

A
  • Immediate complications
    • Haematoma (localised bleeding), pain, wound infection
  • Long term complications
    • Testicular atrophy (shrinkage of the testis), recurrent cryptorchidism
54
Q

What are the success rates of orchidopexy surgery?

A

Success rate 75-95%

55
Q

What is the possible treatment for cryptorchidism excluding orchidopexy surgery?

A

Hormonal treatments- 20% efficacy

  • hCG stimulation test
    • Stimulation of the Leydig cells- causes an increase in testosterone. If there is an increase to about double the baseline, it suggests testosterone is normal- if not synthesised testosterone may be used
  • LHRH test
    • Used to detect the gonadotrophin activity, FSH and LH.
56
Q

What is the epidemiology of hypospadias?

A

Most common congenital anomaly of the penis

1 in 300 births

57
Q

Define hypospadias?

A

Hypospadias is a birth defect (congenital condition) in which the opening of the urethra (urethral meatus) lies proximal to the tip and on the ventral aspect of the penis.

58
Q

What is the aetiology of hypospadias?

A

Usually develops sporadically and without an obvious underlying cause

59
Q

What are the range of severities for hypospadias?

A

Range from mild to severe.

Example of mild:

Glandular hypospadisa- when the urethral opening is found near the head of the penis

Example of severe:

Scrotal hypospadisa- when the urethral opening is found near/on the scortum.

60
Q

What are the possible treatments for hypospadias?

A

Some hypospadias abnormalities are so minor that no treatment is needed. However, in most cases it is treated with surgery. The aim of the surgery is to bring the urine meatus to the tip of the penis.

Involves stretching the urethra- occurs in stages.

Advise against circumcision as some of the foreskin may need to be used during the reassigment surgery.

61
Q

Describe Congenital adrenal hyperplasia?

A

Inherited condition caused by mutations of the genes that encode for CYP21A protein.

Prevents the conversion of androgens into cortisone and aldosterone.

Signs: low levels of cortisone and aldosterone.

62
Q

Describe 5 alpha reductase deficiency?

A

Inherited condition caused by mutations of the genes that encode for 5 alpha reductase protein.

Prevents the coversion from testosterone to dihydrotestosterone (DHT)

DHT is important in puberty and the development of the secondary male characteristics

63
Q

All newborn infants should receive a male or female sex assignment. What if sexual characteristics cannot be determined?

A
  • Surgical management
  • Sex steroid replacement
  • Psychosocial management

Phase 2: Reproduction, Nephrology and Urology (25 decks)

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