Scrotal Swelling

Scrotal Swellings
Dr Ramlan Nasution SpU

Div. of Urology, Dept.of Surgery
Medical Faculty,
University of Sumatera Utara
University of Muhammadiyah
Sumatera Utara
Common Causes of Scrotal Swellings
Hydrocele
Epididymal Cyst
Varicocele
Testicular torsion
Epididymo-orchitis
Testicular Tumour
Hydrocele
Fluid collections within the tunica vaginalis
of the scrotum or along spermaticcord.
Persistent developmental connections along
the spermatic cord or Imbalance of fluid
product versus absorption.
Little risk of clinical consequence.
Pathogenesis
The fluid collects because of an imbalance
between production and absorption.
The tunica vaginalis normally produces around
0.5ml of fluid a day.
Pathophysiology
Proc. Vaginalis is a diverticulum of the
peritoneal cavity.
It descends with the testis into the
scrotum (28th gestational week).
Common Causes
Congenital Patent processus vaginalis (PPV)
Acquired Idiopathic
Tumour
Trauma
Infection
History & Examination
History: A painless swelling in the scrotum.
Onset may be gradual or sudden.
Examination: A scrotal swelling which you can get above

The testis cannot be palpated separate to the
swelling
The lump transilluminates
Investigation
Because one of the causes of a hydrocele is
testicular tumour, it is important to arrange a
scrotal ultrasound to rule out this as an
underlying pathology
Treatments
Conservative management if the hydrocele is
small and causing little in the way of symptoms
Aspiration +/- injection of a sclerosing agent
Surgery: Ligation of PPV in children
Jaboulay
Lords
Both the Jaboulay and the Lords procedure involve
incising the tunica vaginalis to allow the hydrocele
fluid to be absorbed by the scrotal lymphatics.
B/W procedure
Teknik Jaboulays bottleneck
Differentials
Orchitis
Testicular torsion
Indirect inguinal hernia
Traumatic injury to the testical
Varicocoele
Definition
A varicocoele is a dilatation of the veins of the
pampiniform plexus
Symptoms & Signs
Symptoms: Scrotal swelling
Far more common on left than on right
Dragging / aching sensation in the groin /
scrotum
Signs: Scrotal swelling which you can get above

Swelling feels like a Bag of worms
Significance of Varicocoele
A left sided-varicocoele may arise as a result of
obstruction to venous drainage caused by a renal
tumour
Therefore all patients with a varicocoele should

undergo imaging (usually ultrasound) of their
kidneys
Methods of Treatment
The two main methods are:
1 Surgical ligation
2 Embolisation under X-Ray control
Epididymo-Orchitis
Definition
An inflammation of the tissues of the
epididymis and testis
Symptoms & Signs
Symptoms: Painful scrotal swelling
Signs: A scrotal swelling which you can get above

and which is
- hot
- tender
- erythematous
Treatment
An appropriate broad-spectrum antibiotic is
used, such as ciprofloxacin.
Ciprofloxacin
This is a fluoroquinolone antibiotic
It acts by inhibiting an enzyme called DNA gyrase in

reproducing bacteria. This is one of the enzymes
responsible for unwinding DNA during replication
ACUTE SCROTUM
A child or adolescent with acute scrotal
pain, tenderness, or swelling should be
looked on as an emergency situation
requiring prompt evaluation, differential
diagnosis, and potentially immediate
surgical exploration.
Torsion of Testis
The disease process whereby there is
cessation of blood flow to the testicle
because of an occlusion of arterial blood
supply due to twisting of the spermatic cord
Lead to testicular loss unless there is timely
intervention. Irreversible ischemic injury to
the testicular parenchyma may begin as
soon as 4 hours after initial onset.
Epidemiology
Annual incidence of 1 in 4000 amongst
those under 25 years old male.
Adolescents with acute scrotal pain have a
50-60% chance of having a twisted testis,
but 25-35% in children.
Fig 1. Incidence of common causes for acute scrotal
problems in infants and children.
Davenport. BMJ. 1996:435-437

Anatomy
Extravaginal Intravaginal
torsion torsion
Testicular Torsion
Initially obstructs
venous return
Equalization of venous and

arterial pressures
As soon as
4 hours!!
Compromised arterial flow
TESTICULAR ISCHEMIA
PRESENTATION
Classic manifestation: Sudden onset of

unilateral persistent scrotal pain but in some
instances the onset appears to be more
gradual, and in some boys the degree of
pain is minimized
presentation
Acute onset ipsilateral testicular pain in 89%.
34% associated groin, abdominal or thigh pain,
which could be earliest and predominant symptom.
Urinary symptoms in 5% and vomiting in 39%.
36% have previous testicular pain or swelling.
Injury in 4%, recent exercise in 7%, bicycle riding
in 3% and 11% were woken form sleep with the
pain.
Anderson J. et al. Br J Surg. 1988:988-92

PRESENTATION
Inspection: asymmetric position of the
testicles with the torsed testicle occupying a
high position in the scrotum (high-riding
testicle)
PRESENTATION
Absence of cremasteric reflex. Positive
reflex is testicular retraction when upper
inner thigh is stroked
PRESENTATION
Normal testicle must be palpated first (it
should be in vertical position)
Next the spermatic cord of the affected
testis is palpated. Torsion: painful and
swollen
Finally, the affected testis is palpated
Fever and erythema of the overlying scrotal
skin are late signs, with low salvage rates.
Lack of relief of pain with caudal scrotal
support (Prehns sign).It was not reliable in
children.
Epididymitis/ Incarcerated
Orchitis Hernia
Differentia
l
Diagnosis
Torsion of
Varicocele Idiopathic
Appendix Testis Scrotal Edema
PRESENTATION
Scrotal ultrasound with color Doppler is
widely used (sensitivity 88.9% and specificity
98.8%), although some institutions use
technicium-99m radionuclide scanning to look
for blood flow to testicle (sensitivity 90% and
specificity 89%)
PRESENTATION
If imaging modality cannot be obtained in a
timely manner and the index of suspicion is
high intraoperative exploration is
mandatory
TREATMENT
Surgical identical for intravaginal and
extravaginal torsion
If testis appears nonviable initially
placed in warm gauze pad appropriate
color and turgor may return, in which case
orchidopexy should be performed;
otherwise orchiectomy is recommended
Rates of testicular salvage by time from start of symptoms.
Davenport, M. BMJ 1996;312:435-437
Copyright 1996 BMJ Publishing Group Ltd.

Attempt manual detorsion- outward
open the book . Some may be twisted 360,
720 or 1440 degrees
Torsion typically occurs in a medial
direction, manual detorsion should be
attempted initially by rotation the testis
outward toward the thigh.
TREATMENT
Viable testicle orchidopexy with creation
of a three-point nonabsorbable suture
fixation. Some authors also advocate
placement of the testicle in to a subdartos
pouch to fix the testicle by tissue as well as
by suture
TREATMENT
A median raphe scrotal incision may be
used to explore both sides, or a transverse
incision following the skin creases may be
placed in each hemiscrotum
The separate incisions are more appropriate
for dartos pouch placement of the testes
The affected side should be examined first
TREATMENT
The cord should be detorsed to reestablish
blood flow to the testis
A necrotic testis should be removed by
dividing the cord into 2 or 3 segments and
doubly ligating each segments with silk
suture
If the testis is to be preserved, it should be
placed in the dartos pouch with suture
fixation
TREATMENT
When torsion of the spermatic cord is
found, exploration of the contralateral
hemiscrotum must be carried out
In almost all cases a bell-clapper deformity
is found
The contralateral testis must be fixed to
prevent subsequent torsion
Even if a patient had a previous
orchidopexy, they may (rarely) develop
TREATMENT
Contralateral orchidopexy is often
performed (controversy)
Manual detorsion has been reported
CONCLUSION
The most important point:

keeping torsion in the top of the
differential diagnosis when
evaluating a scrotal emergency
Cryptorchidism
One of the most common male
developmental abnormalities
27,000 orchidopexies annually in USA
89% of untreated males with bilateral
cryptorchidism develop azospermia
Lifetime risk of neoplasia 2-3%
4 fold higher than average risk
Issues
Definitions & epidemiology
Normal testicular development and descent
Causes of cryptorchidism
Consequences
Azospermia
Increased risk for neoplasia
Treatment
Medical/hormonal
Surgical
Definitions
Cryptorchid: testis neither resides nor can be
manipulated into the scrotum
Ectopic: aberrant course
Retractile: can be manipulated into scrotum where
it remains without tension
Gliding: can be manipulated into upper scrotum
but retracts when released
Ascended: previously descended, then ascends
spontaneously
Epidemiology
Frequency 3.4 % in term boys
By 1 yo, incidence 0.8%
Is the incidence of
cryptorchidism increasing?
Literature controversial
Cryptorchidism, hypospadias, micropenis
Decreasing semen quality
Increasing testicular cancer
Increasing demand for assisted reproduction
Impact of environmental xenoestrogens
Herbicides, pesticides, PCBs, polystyrenes
Environmental antiandrogens
Linuron, vinclozolin, ppDDE, polyaromatic
hydrocarbons
Risk Factors
Hjerkvist 1989
IUGR, prematurity
Incidence in premies 30%
First-or second-born
Perinatal asphyxia
C-section
Toxemia of pregnancy
Congenital subluxation of hip
Seasonal (especially winter)
Issues
Consequences
Azospermia
Treatment
Medical/hormonal
Surgical
Is the incidence of
hydrocarbons
Risk Factors
Hjerkvist 1989
IUGR, prematurity
Perinatal asphyxia
C-section
Is the incidence of
hydrocarbons
Is the incidence of
hydrocarbons
Risk Factors
Hjerkvist 1989
IUGR, prematurity
Perinatal asphyxia
C-section
Is the incidence of
hydrocarbons
Risk Factors
Hjerkvist 1989
IUGR, prematurity
Perinatal asphyxia
C-section
Issues
Consequences
Azospermia
Treatment
Medical/hormonal
Surgical
Is the incidence of
hydrocarbons
Is the incidence of
hydrocarbons
Issues
Consequences
Azospermia
Treatment
Medical/hormonal
Surgical
Risk Factors
Hjerkvist 1989
IUGR, prematurity
Perinatal asphyxia
C-section
Risk Factors
Hjerkvist 1989
IUGR, prematurity
Perinatal asphyxia
C-section
Risk Factors
Hjerkvist 1989
IUGR, prematurity
Perinatal asphyxia
C-section
Hormonal treatment for
subfertility of cryptorchidism
Huff 2001
8/12 (67%) showed improvement in total germ
cell counts in one or both testes
No significant change if patients
Had no germ cells initially
Were older at treatment
8/18 (44%) undescended testes improved
5/6 (83%) contralateral descended testes improved
Naferelin induced improvement in 75% of patients
Testicular development
6 wk primordial germ cells migrate to
genital ridge
7 wk testicular differentiation
8 wk testis hormonally active
Sertolis secrete MIF
10-11 wk Leydig cells secrete T
10-15 wk external genital differentiation
Testicular descent
5-8 wk processus vaginalis
Gubernaculum attaches to lower epididymis
12 wk transabdominal descent to internal
inguinal ring
26-28 wk gubernaculum swells to form
inguinal canal, testis descends into scrotum
Insulin-3 (INSL3) effects gubernacular
growth
INSL3
Member of the insulin/relaxin superfamily
Highly expressed in Leydig cells
In mice, targeted INSL3 deletion associated
with bilateral cryptorchidism, abnl
gubernaculum development
INSL3
Tomboc 2001
DNA analysis of 145 cryptorchid males, 36 controls
Found 2 mutations (2/145, 1.4%), several
polymorphisms
Baker 2002
DNA from 118 cryptorchid boys, 48 controls
Several polymorphisms
No specific mutations
Important in descent but mutations an uncommon
cause of cryptorchidism
Germ cell maturation
8 wk: gonocytes (fetal stem cells)
15 wk: spermatogonia
3 mo of age: adult dark spermatogonia
(adult stem cells) appear and remain
Neonatal surge in LH, FSH, T
4 yo: primary spermatocytes
Puberty: spermatogenesis
Issues
Consequences
Azospermia
Treatment
Medical/hormonal
Surgical
Hypothalamus Low/absent GnRH
Kallmanns
GnRH
Pituitary Prader Willi
Hypopituitarism
FSH LH Dysgenesis/anorchia
Sertoli Leydig Germ cells
Testosterone biosynthetic problems
MIF Testosterone MIF deficiency/persistent Mullerian ducts
5 reductase 5 reductase deficiency

dihydrotestosterone
Androgen resistance
Androgen receptor
Post-receptor effects
Abnormal gonadotropins in
cryptorchid infants and boys
Insufficient T response to hCG in 36.5%
(Forest 1979)
Blunting of LH and FSH surge at 3 mo
(Gendrel 1980)
Leydig cell hypoplasia in some
undescended testes (Hadziselimovic 1986)
Defective onset of meiosis at
4-5 yo?
Normally see increase in urinary LH and
increased prominence of Leydig cells,
Appearance of primary spermatocytes
In cryptorchid males,
Low urinary LH & FSH
Impaired T response to hCG
May indicate deficiency of HP-gonadal axis as
a cause of defective meiosis
Issues
Consequences
Azospermia
Treatment
Medical/hormonal
Surgical
Impact on Fertility
At bx, # spermatogonia/tubule prognostic for
subsequent fertility potential
Bx without germ cells 33-100% risk of infertility
Possible causes of subfertility
Reduction in total # germ cells (already present in 1st
year of life)
Defect in one or more steps in germ cell maturation
Defective transformation of gonocytes into Ad spermatogonia
(Hadziselimovic 1986)
Delayed disappearance of gonocytes
Incidence of Azospermia
Azospermia in normal population 0.4-0.5%
Unilateral Bilateral
Untreated 13.6% 88.6%

(10/73) (31/35)
Medically 13.3% 32.0%
treated (28/210) (46/142)
Surgically 13.3% 46.4%
treated (126/942) (224/484)
Hadziselimovic 2001
Chronological development of germ cells (#/cross
section)
5
4
germ cells/txs
3 UDT
2 CDT
1
0
3-7 8-12 13-18 19-25 29-60 <120
n=15 n=15 n=12 n=15 n=13 n=10
age (mo)
Hadziselimovic 2001
Number Ad spermatogonia/tubular cross-section from 0-9 yo
0,18
0,16
0,14
0,12
Ad/T
0,1 UDT
0,08 CDT
0,06
0,04
0,02
0
0,3 0,9 1,5 2,5 3,5 4,5 5,5 6,5 7,5 8,5
Year
Hadziselimovic 2001
6 180
160
5
140
4 120
100
< 6 mo < 6 mo
3 80
6-24 mo 6-24 mo
60
2
40
1 20
0
0 Age
Age
Ad No Ad
# germ cells/tubular cross-section spermatogonia spermatogonia
Sperm/ejaculate (1x106)
Normal in 1st 6 mo, greatly decreased
Between 6-24 mo If Ad spermatogonia present at orchidopexy,
Tended to have normal sperm count as adults
Hadziselimovic 2001
Abnormal germ cell deveopment
Huff 2001
767 boys with unilateral cryptorchidism

Bilateral bx and orchidopexy between 0-9
yo
238 < 1 yo at orchidopexy
Transformation of gonocytes into Ad
spermatogonia
529 2-9 yo at orchidopexy
Onset of meiosis
4,5
4
3,5
3
germ 2,5
cells/tubule 2 UDT
1,5 CDT
1
0,5
0
1 3 5 7 9 11
month
Total germ cell counts significantly higher in undescended testes, p=0.024

Huff 2001
0,45
0,4
0,35
0,3
gonocytes/ 0,25
tubule 0,2 UDT
0,15 CDT
0,1
0,05
0
1 3 5 7 9 11
month
Total gonocyte counts significantly higher in undescended testes, p<00005

Huff 2001
Adult dark spermatogonia
0,25
0,2
0,15
UDT
0,1
CDT
0,05
0
1 3 5 7 9 11
month
Total adult dark spermatogonia counts significantly lower in undescended testes,
p<00005, Huff 2001
Boys < 1 yo
Gonocytes failed to disappear
Adult dark spermatogonia failed to appear
Indicates defect in germ cell maturation and
failure to establish an adequate adult stem
cell pool
Boys 2-9 yo
In undescended testes
Primary spermatocyte counts lower (p<0.0005)
failed to appear in undescended testes
Appeared in only 19% of contralat descended testes
Total germ cell counts lower (p<0.0005)
Adult dark spermatogonia lower (p<0.0005)
Indicates defect in onset of meiosis
Which normally occurs at 4-5 yo
Similar, less severe changes in contralateral
descended testes
Abnormal Epididymal Growth
de Miguel 2001
Decrease in differentiation of each segment

Decreased size of efferent and epididymal ducts
Decreased epithelial height, muscular wall height,
& lumen of epididymis
Cryptorchid epididymis grows more slowly during
transition to puberty, smaller in adult males
Suggests a primary congenital defect of testis
Implies surgical descent would not completely
reverse these changes
Increased risk of neoplasia
Cortes 2001: 1638 testicular samples from
1335 patients (23% bilateral, 77%
unilateral)
Mean age @ surgery 11.7 yo (0.1-18.9 yr)
1 invasive germ cell tumor
6 carcinoma in situ
1 Sertoli cell tumor
Neoplasia & cryptorchidism
3 neoplasms in intra-abdominal testes
4 neoplasms in boys with abnormal external
genitalia
2 neoplasms in boys with known abnormal
karyotype
Risk of neoplasia 5% with intraabdominal
testes, abnormal external genitalia or
abnormal karyotype (Cortes 2001)
Issues
Consequences
Azospermia
Treatments
Medical/hormonal
Surgical
Treatments
Hormonal
hCG
GnRH
hMG
Combined (hCG & GnRH)
Surgical
Hormonal Therapy
hCG since 1930
GnRH since 1974 (IM) and 1975
(intranasal) (Europe)
Variable rates of success
hCG 0-55%
GnRH 9-78%
Confounding Variables in Data
Inclusion/exclusion of retractile testes
Variable ages of treatment
Randomized or not
Different dose regimens and durations
Original testicular position not documented
in all studies
Small patient numbers
hCG vs GnRH: multicenter trial
330 boys (?ages)
Randomized to
hCG 100 IU/kg IM twice weekly x 3 wk
GnRH 200 ug intranasal TID x 28 d
Placebo intranasal TID x 28 d
Success if both testes located at bottom of
scrotum after treatment
Changes in position in boys with bilateral cryptorchidism after
treatment. Christiansen 1992
Placebo GnRH hCG
Not palp 12 8 8
6 1 2 2 1
Inguinal 86 70 70
5 69 1 1 4 46 8 2 2 31
Suprascrotal 6 21 11
14 1 3 2 5 4 6 6
High scrotal 12 15 7
1 3 1 5 4 6 1 15 5 2
Scrotal
1 2 3 5 1 12 4 7 3 17 6 5
Rates of descent of the undescented testes following treatment.
Christiansen 1992.
25
20
15
% Bilateral
10 Unilateral
0
Placebo GnRH hCG
Bilateral: p=0.0016
Unilateral: p=0.013
A review & meta-analysis of
hormonal treatment of
cryptorchidism (Pyorala 1995)
Reports from 1958-1990, in English
Primary treatment with GnRH or hCG
Excluded articles not documenting final
testicular position
Durations of treatment
GnRH 1 day 4 wk
hCG 1 wk 12 mo
Review & meta-analysis
33 studies including 3282 boys, 4524 undescended
testes
RCTs (n=11) included 872 boys, 1174
undescended testes
Meta-analysis only on RCTs that compared GnRH
vs placebo (n=9 trials)
Risk ratio for descent after GnRH 3.21 (1.83-5.64)
(p<0.001)
4 trials excluded retractile testes, risk ratio 2.57 (1.39-
4.74) (p<0.01)
Mean success rate (%) for treatment in combined RCTs comparing
hGC and GnRH with placebo. Pyorala 1995
25
20
15 Placebo
% hCG
10 GnRH
# Trials 9 2 11
Testes 472 148 554

Mean success rate (%) for treatment in RCTs exluding retractile testes, comparing
hGC and GnRH with placebo. Pyorala 1995
20
18
16
14
12 Placebo
% 10 hCG
8 GnRH
6
4
2
0
# Trials 4 2 5
Testes 308 148 335

Mean success rates (%) by original location, includes both RCTs and
nonRCTs after GnRH and hCG. Pyorala 1995
60
50
40 Abdominal
Inguinal
% 30
Prescrotal
20 High srotal
10
# trials 17 21 14 4
# testes 907 1430 295 67

Mean success rates (%) of hormonal treatment (GnRH or hCG) in combined
RCTs in boys under 4 yo vs boys > 4 yo. Pyorala 1995 p=NS
25
20
15
% Placebo
10 Homone
0
<4yo >4yo
# trials 2 2 3 4
# testes 48 49 167 267

Long term outcomes
5/11 randomized GnRH trials
24% (13-35%) ascended/relapsed
Conclusions:
GnRH more effective than placebo
hCG seems effective, but not as much data
Combined GnRH and hCG
Giannopoulous 2001
2467 boys with 2962 cryptorchid or gliding

testes
GnRH nasal spray 1.2 ug QD x 4 wk
hCG 5 doses (by age) at 2 d intervals
59% in scrotum after combined rx
4 different regimes
Bertelloni 2001
155 boys 10-48 mo with unilateral inguinal

testis
1. hCG 500 IU/wk (<2yo), 1000 IU/wk
(>2yo)
2. hCG as in 1 + hMG 75 IU/wk x 6 wk
3. GnRH 1200 ug/d x 28 d
4. GnRH as in 3, + hCG 1500 IU/wk x 3 wk
Bertelloni 2001 cont.
Overall success rate 19.3% (30/155)
No significant differences between regimes
Relapse 23.3% (7/30)
No significant difference between regimes
When to treat?
Hamza 2001
As spontaneous testicular descent closely

related to postnatal LH and T surges,
In term boys, 4 mo
In premies, 6 mo
Impact of age on treatment
success
Job 1982: success with hCG twice as high
in 3-4 yo than in boys < 3 yo
Hagberg 1982: highest success with GnRH
in 2-5 yo
De Muinck Keizer-Schrama 1986: most
success with GnRH in 5-12 yo
Pyorala 1995: no significant differences < 4
yo vs > 4 yo
When to operate?
Lee 2002
Inverse correlation between age at surgery
and T
Inverse correlation between body wt and T
Direct correlation between T and sperm
density, motility, morphology
Indicates direct relationship between
spermiogenesis and T in cryptorchid men
No differences in mean free T, T, LH between pts
and controls
No differences in time to conception in fertile
cryptorchid men vs controls
Suggests that orchidopexy later in childhood assoc
with subclinically depressed Leydig cell function
May result in subotpimal hormonal milieu for
adult reproduction
Is further treatment after surgery
indicated?
Subfertility correlates with reduced total
germ cell counts
Defects in germ cell maturation associated
with blunting of normal surges LH/FSH
Prepubertal treatment with GnRH could
theoretically trigger normal germ cell
maturation & proliferation
Huff 2001
12 boys (7 mo 12 yo) with cryptorchidism

& poor prognosis for fertility (<0.21 germ
cells/tubule)
Treated with Naferelin 200 ug biweekly x 6
mo after orchidopexy
Biopsy 5 mo after Naferelin completed (2-
14 yo)
Improvement if 2nd bx > 1 category
Huff 2001
8/12 (67%) showed improvement in total germ
cell counts in one or both testes
No significant change if patients
Had no germ cells initially
Were older at treatment
8/18 (44%) undescended testes improved
5/6 (83%) contralateral descended testes improved
Naferelin induced improvement in 75% of patients
Erythropoietin and germ cells
Cortes 2001
2 boys (6 mo, 21 mo) with renal function
impairment
Epo 100 IU/kg SQ weekly x 3 mo before
orchidopexy for inguinal cryptorchidism
# spermatogonia unusually high (& normal)
compared to 698 controls
Possible mechanisms
Stimulation of T production
?direct on Leydig cells
Direct effect on germ cell proliferation and
antiapoptotic signalling by blocking p53-
gene mediated apoptosis (as seen in
erythropoiesis)
Clinical trial ongoing
Issues
Consequences
Azospermia
Treatment
Medical/hormonal
Surgical
THANK YOU

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What are the common causes of scrotal swellings discussed in the document?

What are the common causes of scrotal swellings discussed in the document?

What is hydrocele and what are its causes and characteristics?

What is hydrocele and what are its causes and characteristics?

Scrotal Swellings

Dr Ramlan Nasution SpU

Examination: A scrotal swelling which you can get above

Signs: Scrotal swelling which you can get above

Therefore all patients with a varicocoele should

The two main methods are:

Signs: A scrotal swelling which you can get above

This is a fluoroquinolone antibiotic

It acts by inhibiting an enzyme called DNA gyrase in

Davenport. BMJ. 1996:435-437

Equalization of venous and

Classic manifestation: Sudden onset of

Anderson J. et al. Br J Surg. 1988:988-92

Davenport, M. BMJ 1996;312:435-437

Copyright 1996 BMJ Publishing Group Ltd.

The most important point:

MIF Testosterone MIF deficiency/persistent Mullerian ducts

5 reductase 5 reductase deficiency

Untreated 13.6% 88.6%

767 boys with unilateral cryptorchidism

Total germ cell counts significantly higher in undescended testes, p=0.024

Total gonocyte counts significantly higher in undescended testes, p<00005

Decrease in differentiation of each segment

Placebo GnRH hCG

Testes 472 148 554

Testes 308 148 335

# testes 907 1430 295 67

# testes 48 49 167 267

2467 boys with 2962 cryptorchid or gliding

155 boys 10-48 mo with unilateral inguinal

As spontaneous testicular descent closely

12 boys (7 mo 12 yo) with cryptorchidism

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