Implications of incidental finding of testicular microlithiasis in paediatric patients

ObjectiveTo improve understanding of the implications of testicular microlithiasis (TM) in paediatric patients diagnosed incidentally on scrotal ultrasonography (US).Patients and methods31 boys aged 4–14 years diagnosed with TM based on US between February 2000 and September 2007 were retrospectively reviewed. Demographic data, indications for US, associated inguino-scrotal pathologies and follow-up data were collated.ResultsA total of 59 testes were evaluated. Fifty-four had TM at US. The most common indication for US was scrotal swelling (n = 17). Twenty patients (65%) had at least one associated inguino-scrotal pathology related to patent processus vaginalis, with cryptorchidism being the most frequently observed (39%). On follow up (mean 39.6 months), 6 patients documented decrease or resolution of TM, while 2 showed increase in TM density. No testicular malignancy was observed during follow up.ConclusionsTM is commonly diagnosed incidentally on US in paediatric patients. A literature review revealed few case reports on its association with testicular malignancy and a prevalence of 4.2% among asymptomatic boys. The spontaneous resolution of TM supports degeneration of seminiferous tubules as the possible cause and further questions its malignant implication. An appropriate surveillance scheme would require involvement of a well-informed patient and parent with good compliance on testicular self-examination.     

Ultrasound demonstration of testicular microlithiasis in pediatric patients: is there an association with testicular germ cell tumors?

Background

There is suggestion that testicular microlithiasis predicts risk of testicular malignancy, especially testicular germ cell tumors. This association remains uncertain.

Objective

We retrospectively reviewed testicular germ cell tumor occurrence in patients with testicular microlithiasis to assess this association and determined the prevalence of testicular microlithiasis in symptomatic boys.

Materials and methods

This study was IRB and HIPAA compliant. Two-thousand six-hundred twenty-five testicular US exams performed on 2,266 children (younger than 19 years of age) in our institution from 2000 through 2011 were reviewed for presence of testicular microlithiasis and masses. Testicular microlithiasis was defined as presence of five or more testicular microcalcifications on a single US image. Incidence of testicular germ cell tumors was calculated in a group of patients with testicular microlithiasis and in a control group without testicular microlithiasis. Relative risk, odds ratio, 90% and 95%CI were calculated.

Results

Eighty-seven patients out of 2,266 had testicular microlithiasis. One child was found to have both testicular germ cell tumor and testicular microlithiasis. In 2,179 children without testicular microlithiasis, 8 had testicular germ cell tumors. Incidence of testicular microlithiasis was 3.8%. Incidence of testicular germ cell tumors in testicular microlithiasis patients was 1.2%, and 0.38% in non-testicular microlithiasis patients. Relative risk of testicular germ cell tumors in testicular microlithiasis patients vs. non-testicular microlithiasis patients was 3.13 (90%CI: 0.55–17.76; 95%CI: 0.40–24.76), odds ratio 3.16 (90%CI: 0.55–18.32; 95%CI: 0.39–25.5).

Conclusion

There is no association between testicular microlithiasis and testicular germ cell tumors. We had hoped to do a meta-analysis, but only two studies had a sufficient case control group of non-testicular microlithiasis patients.     

Impacto de una maniobra educativa sobre el conocimiento y actitud de la autoexploración testicular

IntroductionThere is evidence that the percentage of adolescents that practice testicular self-examination is low.ObjectiveTo assess the short-term and long-term (6 months) impact in male adolescents of an educational intervention on the knowledge of testicular self-examination and attitude toward it.MethodsWe conducted a quasi-experimental pre-test post-test study in male adolescents. A questionnaire was validated to assess knowledge on testicular self-examination and attitudes towards it (awareness, intentions, and behaviour). The educational intervention was group-based and consisted in an instructional talk with the aid of diagrams and brochures. The questionnaire was administered before and after the intervention. A follow-up was scheduled 6 months later, and the talk was delivered again, with administration of the questionnaire before and after.ResultsThe study included 139 adolescents with a median age of 14 years. We found an improvement in knowledge (18.3% vs. 78.9%; P = .02) and attitude (5.6% vs. 53.5%; P = .02) after the initial intervention. At the 6-month follow-up (n = 98), there was no change in knowledge (87.0% vs. 93.0%; P = .671), but attitude improved after the second intervention (58.0% vs. 78.0%; P = .009).ConclusionAn educational intervention on testicular self-examination improved the proportion of adolescents with an adequate attitude (5.6% vs. 53.5%) and adequate knowledge (18.3% vs. 78.9%). The repetition of the intervention at 6 months increased the proportion of adolescents with an adequate attitude (53.5% vs. 86.4%).     

Testicular microlithiasis in children: sonographic features and clinical implications

BACKGROUND: The natural history of incidentally discovered testicular microlithiasis in children has not been well defined. Although a benign condition, this entity has been found to be associated with testicular malignancies. OBJECTIVE: To determine the spectrum of sonographic findings and clinical implications in children with testicular microlithiasis. MATERIALS AND METHODS: During a 3.5-year period, 850 scrotal examinations with grey-scale US detected testicular microlithiasis in 16 boys (1.9%), age range 6-18 years. The US records of these patients were retrospectively analysed for distribution and pattern of this finding. The presence of intratesticular pathology was determined and the medical records and pathological reports were reviewed. In five patients, US re-evaluation up to 6 years could be performed. RESULTS: Typical punctate hyperechoic foci were found bilaterally in all cases except five, which showed only unilateral foci. Additional pathology was depicted in four patients (chorioncarcinoma n=1; a cystic lesion in a patient with a large-cell calcifying Sertoli-cell tumour, n=1; diffuse structural alterations after orchidopexy, n=2). No testicular tumour developed during clinical follow-up. CONCLUSIONS: The association with benign and malignant testicular tumours, as described in adults, also seems valid in the paediatric age group. Therefore, children with testicular microlithiasis should have clinical and US long-term follow-up.     

Testicular microlithiasis in siblings: clinical implications

Testicular microlithiasis is a relatively uncommon condition in children. It is characterized by the presence of microcalcifications within the testicular parenchyma. Although it is a benign finding, underlying diseases and other conditions must be ruled out because testicular microlithiasis has been found in association with both benign and malignant lesions in the testes and other tissues. We present two brothers with testicular microlithiasis, and highlight the prevalence, natural history, associated malignant conditions and follow-up recommendations of children diagnosed with testicular microlithiasis.     

A non-endocrine cause of testicular enlargement mimicking precocious puberty: testicular microlithiasis

Untimely bilateral testicular enlargement greater than 3 ml is suggestive of precocious puberty, in which an underlying organic disease is more common in boys than in girls. We describe a 7 1/2 year-old boy presenting with testicular enlargement due to testicular microlithiasis. Following hormonal tests, diagnosis was based on ultrasonographic findings. Three years follow-up of the patient revealed normal pubertal progress and no malignant evolution. Testicular microlithiasis is a rare cause of testicular enlargement and pediatricians should take this disease into account in the differential diagnosis of suspected precocious puberty.     

How should we monitor boys with testicular microlithiasis?

Testicular microlithiasis (TM), a rare condition characterized by calcification within the seminiferous tubules, is associated with benign and malignant disorders of the testis. We review current practices of following up pediatric patients diagnosed TM incidentally on scrotal ultrasonography (US). We analyzed retrospectively patient characteristics, family history, indications for US, pathological features, US findings, outcome, and follow-up. At our institution, 2875 scrotal US examinations were performed on 2477 children with various scrotal complaints from 2008 to 2015. Testicular microlithiasis was detected in 81 patients (i.e., an incidence of 3.27%). Every 6 months, each patient underwent a clinical and ultrasonographic evaluation as well as serum tumor markers determination to detect a potential malignancy. Seventy-eight patients who had undergone scrotal US at least twice were included in this study. We evaluated the US studies for the type of TM (diffuse and focal) and change in follow-up studies. Testicular microlithiasis was typically diffuse (n = 56, 71.8%) and bilateral (n = 45, 57.7%), and it was detected the most frequently in the 9–11-year age group (27 patients, 34.6%). The most common comorbid conditions included undescended testes (31 patients, 39.7%) and hydrocele (11 patients, 14.1%). We found that serum tumor markers were within normal limits both at diagnosis and upon follow-up. No testicular tumors or new abnormal symptoms developed during the clinical follow-up. There is no convincing evidence that TM alone is premalignant in a pediatric population. In terms of follow-up, we advise regular self-examinations and annual US in the absence of risk factors.     

Clinical presentation of McCune-Albright syndrome in males

The aims of this study were: (a) to survey gender prevalence and clinical findings at diagnosis in a series of patients who manifested at the time of this study the classical triad of McCune-Albright syndrome (MAS); (b) to investigate whether clinical presentation of MAS in boys may be different from that in girls; (c) to confirm whether boys with MAS may show a peculiar picture of testicular microlithiasis (TM) by testicular ultrasonography (US). Twenty-six patients (10 boys) with the classical clinical manifestations of MAS were recruited for the present study from the database of the Italian Multicenter Study Group on MAS. Age at diagnosis of MAS was significantly lower in girls than in boys (p < 0.025). Whilst there was no difference in the prevalence of skin and bone fibrous dysplasia for the two groups, a significantly higher prevalence of peripheral precocious puberty (PPP) was found in girls (chi2 = 6.5, p < 0.025). Moreover, PPP onset was earlier in females than in males (2.8 +/- 2.3 vs. 6.9 +/- 2.7 years, p < 0.005). In one boy, aged 2.9 years, the first clinical manifestation of MAS was monolateral testicular enlargement in the context of a picture of classical PPP. US scanning of the testes, at the time of the present study, showed bilateral hyperechogeneic multiple spots, compatible with diagnosis of TM, in 6/10 boys. CONCLUSIONS: (a) MAS is slightly more frequent in females. (b) PPP in MAS is significantly more frequent and earlier in girls. (c) PPP in boys with MAS is generally associated with bilateral testicular enlargement, but monolateral macroorchidism may also be seen. (d) TM may be another marker for MAS in males.     

Familial testicular torsion: A meta analysis suggests inheritance

ObjectiveFamilial occurrence of testicular torsion has been infrequently reported. To date, no systematic analysis has been published. We systematically analyzed the literature to elucidate the epidemiology, presentation, management, and whether the observed prevalence of testicular torsion in families is consistent with absence of inheritance and is randomly distributed.Patients and methodsWe searched electronic databases using keywords “testicular torsion”, “spermatic cord torsion”, “familial torsion” and “sibling torsion”. Reports with genetically related first degree relatives were included in the analysis. Levene's nonparametric test was used to compare the variance of the age of presentation within families to that between different families to differentiate between familial predisposition and chance events.ResultsUp to 10% of patients with testicular torsion have an affected first degree relative. We were able to reject the null hypothesis that the observed prevalence of testicular torsion is due to chance (p < 0.001). Family history is missed in at least 27% of affected families. There is a high incidence of bilateral testicular torsion in families (37%) and probands (17%) and a high concordance rate for bilaterality among monozygous twins.ConclusionsCurrent evidence from clinical and animal studies suggests the presence of a genetically determined component in familiar testicular torsion. Increased awareness may lead to earlier clinical presentation and higher testicular salvage rates.     

Is surgical exploration necessary in bilateral anorchia?

ObjectiveTo review the current management of boys with bilateral anorchia and assess whether surgical exploration is necessary when endocrine investigation indicates absent testicular function.Patients and methodsThe medical records of 11 boys being managed for bilateral anorchia were reviewed in relation to clinical presentation, pituitary-gonadal function, surgical and histological findings.ResultsAll boys had absence of testicular function based on undetectable levels of serum anti-Müllerian hormone, elevated basal or peak follicle-stimulating hormone and luteinising hormone levels and no testosterone response to human chorionic gonadotrophin stimulation. All boys underwent abdominal exploration, ten of whom showed no macroscopic signs of testis tissue, confirmed histologically in seven. Histology was not available in the remaining three boys. Abnormally small intra-abdominal testes were found bilaterally in one boy. These were sited in the scrotum at orchidopexy but had subsequently atrophied. Endocrine tests confirmed absent testicular function.ConclusionBased on the high degree of concordance between the surgical and histological findings and the results of the endocrine tests, it is suggested that surgery is unnecessary in bilateral anorchia when endocrine tests confirm the absence of functioning testicular tissue.     

Age-related prevalence and features of migraine headache in Hungarian schoolchildren and adolescents

BackgroundDifferences occur in certain features of childhood and adult migraine, such as the duration and location. However, few studies have been reported of the changes in other symptoms during childhood.AimsThe aims of this study were to establish the prevalence of migraine headache in children in Hungary, and to investigate the changes in prevalence of migraine and migraine symptoms in a wide paediatric age range.MethodsWe conducted a school-based study with the use of a questionnaire.Results7361 7–18-year-old students participated. The 1-year prevalence of migraine was 12.5% (9.2% in boys and 15.4% in girls). With the criterion of a headache duration of 4 h for 15–18-year-olds and of 1 h below the age of 15, the overall prevalence decreased to 9.1%. The prevalence of migraine increased steadily from young childhood to late adolescence in both boys and girls. The frequency and duration of headache increased, whereas vomiting and nausea became less prevalent with advancing age in both genders. The prevalence of uni/bilaterality, photophobia and phonophobia increased only in girls, while that of a pulsating character did so only in boys.ConclusionsThe migraine characteristics displayed by the studied population proved similar to those experienced in other countries. The duration of headache applied in the diagnosis of migraine exerts a great impact on the prevalence data. The features of migraine change with advancing age, a situation demanding consideration in studies on migraine in children of different ages.     

Prepubertal testicular tumors: frequently overlooked

ObjectivePrepubertal testicular tumors are fundamentally distinct from their adult counterparts. We reviewed our 10-year, two-institution experience with respect to diagnosis and treatment.Material and methodsA retrospective review was performed of all testicular tumors diagnosed between 1996 and 2006 in males younger than 14 years. We analyzed clinical characteristics, diagnostic procedures, treatment methods, histopathologic findings and outcome.ResultsOf 15 primary testicular tumors, eight (53%) were germ-cell tumors (three teratomas, two yolk sac tumors, one seminoma, one embryonic carcinoma and one choriocarcinoma), four (27%) tumor-like lesions (epidermoid cysts), two (13%) gonadal stromal tumors (a Leydig and a Sertoli cell tumor), and one (7%) gonadoblastoma with gonadal dysgenesis. All boys were presented with a painless scrotal mass and four (27%) of them with elevated tumor markers. Ten cases (66%) were misdiagnosed by urologists preoperatively and presented for treatment of congenital or acquired scrotal disorders. Twelve children (80%) were treated with radical orchiectomy and three (20%) with a testis-sparing procedure. At a mean 4-year follow-up no patient has presented with recurrent tumor in the residual or contralateral testicle. Postoperative physical examination and scrotal ultrasound were obtained in 14 patients at a median follow-up of 48.2 months, and there was no evidence of tumor progression. One boy with a choriocarcinoma (stage IV) died due to distant metastases.ConclusionsBenign teratoma and epidermoid cysts were the most common prepubertal testicular tumors. Any suspicion of a testicular tumor warrants an inguinal approach to prevent scrotal violation of the tumor. Our limited experience with testis-sparing procedures supports the current trends that organ-confined surgery should be performed for benign lesions such as teratoma, Leydig cell tumor and epidermoid cysts based on frozen biopsy findings.     

Acute scrotum — Etiology and management

Objective: Acute scrotal pain is a common urological emergency. Urgent exploration is the standard means of management, since no investigation can confidently exclude torsion of testis from the differential diagnosis.Methods: A review of all boys presenting with acute scrotal pain who underwent emergency scrotal exploration between January 1983 and March 2003 was performed.Results: 195 boys were included in this study. They were divided into 3 groups: group 1–73 with epididymo-orchitis, group 2–63 with torsion of testicular appendages and group 3–57 with spermatic cord torsion. The patients in group 2 were older than group 1, also patients in group 1 were older than group 3. During neonatal period the most common pathology was spermatic cord torsion, whereas in prepubertal period torsion of appendages was more common. In all boys, mean duration of pain at presentation was 2.11 days. Epididymo-orchitis was diagnosed in 37% of patients, with torsion of the appendages being the next most common entity. Testicular torsion was diagnosed in 29% of patients. In the group with testicular torsion salvage rate of testis was 37% because of late admission. The perioperative morbidity and mortality was not seen in any of the groups.Conclusion: We believe that any boy with acute scrotal pain and any suspicion of testicular torsion in physical examination must be applied routine surgical exploration.     

Ultrasonographic late results after surgically treated cryptorchidism

Background. Because uncorrected cryptorchidism is accompanied by the high risk of later disturbed testicular function and cancer, early surgery in the second year of life is recommended. Objective. To evaluate testicular morphology, the sonomorphologic testicular long-term outcome and additional complications, as well as possible differences depending on varying ages at surgery. Materials and methods. Seventy-five previously maldescended testes in 68 boys were studied with US, 2–11 years after intrascrotal orchidopexy. Nineteen had been operated on in the first or second year of life, while the other 49 boys underwent surgery at a later age (up to 7 years). Each examination utilised conventional B-mode and colour Doppler (7-MHz linear ART probe, Acuson XP 128) to examine the scrotal and inguinal regions on both sides; testicular volume and perfusion were assessed. Ultrasound changes in testicular volume, architecture and Doppler flow rates were regarded as the most valid indirect indices of testicular damage. Histopathological correlation was not obtained, for ethical reasons, in any of the probands. Results. Thirty-five of the surgically fixed testes were normal with regard to position, volume, structure and perfusion. The other 40 (53 %) showed abnormalities of one or more of these parameters without any correlation with the patient's age at surgery or the time interval between surgery and US. Additional relevant findings, which were also found on the non-operated side, were: microlithiasis (n = 6), inguinally retained testis (n = 6), hydrocoele (n = 5), hydatid (n = 5) and varicocoele (n = 1). Conclusions. Ultrasound, including colour Doppler, enables an exact morphological analysis of the late results after surgically corrected cryptorchidism. The spectrum of findings does not show any correlation with the time of surgery. Thus, the value of even early surgery has to be questioned. Pre-existent primary damage (dysplasia) seems more important for long-term outcome of the testis. Additionally, US was of high value in demonstrating additional unexpected anomalies, the majority of which needed sonographic follow-up or even surgery. Received: 30 June 1999/Accepted: 12 August 1999     

Testicular microlithiasis: an unreported feature of McCune-Albright syndrome in males

OBJECTIVE: To ascertain the incidence of testicular microlithiasis (TM) in boys with McCune-Albright syndrome (MAS). STUDY DESIGN: Study population consisted of 8 boys with MAS whose medical records were reviewed with emphasis on their past genitourinary histories. All of the boys underwent a clinical and ultrasonographic (US) scanning of the scrotal and inguinal regions. US results in boys with MAS were compared with those obtained in two control populations consisting of 20 healthy subjects and 12 boys with idiopathic and untreated central precocious puberty (CPP). RESULTS: Clinical examination revealed urological abnormalities in no patients, whereas US showed a typical picture of TM in 5 of 8 boys. TM was observed in none of the subjects belonging to control populations (v=15.2 and 11.3, respectively; P <.001). CONCLUSIONS: In a series of 8 boys with MAS we demonstrated a high prevalence (62%) of TM that was associated with neither malignant nor nonmalignant conditions. This finding is unlikely to be only occasional, considering the very low prevalence of TM reported until now in healthy children and young adults and in our results in control populations. TM may be another marker for MAS.     

High prevalence of intratesticular varicocele in a post-orchidopexy cohort

PurposeIntratesticular varicocele (ITV) is an uncommon sonographic finding. A prevalence of up to 2% has been reported in men with testicular problems. In a cohort of men who had undergone prepubertal orchidopexy for acquired undescended testis, several cases of ITV were found. The aim of this study was to analyse the prevalence and clinical aspects of ITV in this cohort.MethodsIn a long-term follow-up study of position and growth of undescended testis after prepubertal orchidopexy, ultrasonography was used to identify men with ITV. Data on clinical presentation, testicular volume, and the location, size and Doppler aspects of intratesticular varicocele were collected and analysed.ResultsOf the 105 men, 9 were identified with ITV (8.6%). In all patients, the side of orchidopexy correlated with the side of the ITV, and all were left-sided. The testis with ITV had a smaller volume than the testis without ITV (p = 0.026).ConclusionsA remarkably high prevalence of ITV (8.6%) was found as well as a smaller volume of the testes with ITV in a cohort of men who had undergone prepubertal orchidopexy for acquired undescended testis.     

Testicular microlithiasis in patients with Down syndrome

OBJECTIVES: Testicular microlithiasis (TM) occurs with benign as well as with pathological conditions, such as testicular cancer. Since Down syndrome (DS) may be associated with increased frequency of testicular cancer, we determined the prevalence of TM in DS in patients from a DS clinic and evaluated the prevalence by age group. STUDY DESIGN: We compared results of research scrotal ultrasounds obtained from 1998 to 2001 from 92 Latino patients with DS (ages newborn to 29.7 years) and clinical ultrasounds obtained from 1998 to 2004 from 200 Latino patients without DS (ages newborn to 18.3 years). We also reviewed the medical records. RESULTS: The prevalence of TM in DS was 29%, significantly higher than the 7% found in patients without DS (P < .0001). Twenty of the 27 patients with DS and TM had no testicular pathology clinically or by history. The TM prevalence in the entire group of patients with and without DS increased with advancing age. CONCLUSIONS: We found a significantly increased prevalence of TM in DS. The clinical significance of TM needs to be investigated further.     

Testicular microlithiasis: The importance of self‐examination

Aim: To explore the issue of appropriate management of testicular microlithiasis. We report the third ever case of tumour arising from a testis previously known to have microlithiasis in childhood and review the literature to provide an evidence‐based approach to management of testicular microlithiasis. Methods: Case report and review of previous literature. Results and Conclusions: Although there is a strong association between testicular microlithiasis and testicular malignancy at diagnosis, there are only three reported cases of subsequent tumour development in childhood. Testicular microlithiasis is an increasingly recognised entity. There is insufficient evidence in the current literature to support any regime of clinical surveillance. Self‐examination is the most important factor in the early detection of testicular malignancy.     

Is there an optimal contralateral testicular cut-off size that predicts monorchism in boys with nonpalpable testicles?

ObjectiveTo identify a contralateral testicular cut-off size that would predict monorchism (intra-abdominal vanishing testis or inguinal/scrotal nubbin) in boys with unilateral nonpalpable testis (NPT).Materials and methodsBoys with cryptorchidism, treated by a single surgeon at a tertiary care center from 2009 to 2013, were grouped based on intra-operative findings: boys with a solitary gonad (monorchism group, M) and two control groups: intra-abdominal testis (IAT) and palpable undescended testis (pUDT). Immediately before the procedures, the contralateral descended testes were measured using callipers. Boys with NPT underwent diagnostic laparoscopy. Sensitivity, specificity, positive and negative predictive values, likelihood ratios and receiver operating characteristic (ROC) curves were calculated.ResultsOut of the 324 boys with cryptorchidism, 58 were found to have pUDT and 85 had NPT. Of these 85 boys with NPT, 50 had an IAT and 35 had monorchism. Mean ages at surgery for groups M, IAT and pUDT were similar (28.0, 31.3 and 30.4 months, respectively; P = 0.4). Mean length of the contralateral descended testes in groups M, IAT and pUDT was 24.3, 16.5 and 18.8 mm, respectively. Contralateral testicular cut-off lengths of 18, 19 and 20 mm had positive likelihood ratios (LR+) of 6.5, 7.4 and 10.1, respectively. The area under the ROC curve was 95% (95% CI: 91–100%).ConclusionA contralateral testicular cut-off length of 19–20 mm had the best accuracy in predicting monorchism in boys aged 11–30 months with unilateral NPT.     

An old technique for surgery of 'high' undescended testis revisited

IntroductionMost undescended testes resolve spontaneously in the first year of life. If the testis remains undescended by the second year, the most probable means of scrotal placement is orchiopexy. After the first successful operation for orchiopexy, many surgical modifications were described. This study presents our limited experience with Prentiss' maneuver in six boys with high undescended testes.Patients and methodsTwo left, two right and two bilateral testes, in six patients, were operated. Five patients were admitted with the complaint of unilaterally or bilaterally ‘empty scrotum’. The sixth patient previously had a right high undescended testis which had been placed in a high scrotal position. Following the standard steps of inguinal orchiopexy Prentiss' maneuver were performed and yielded adequate distance to place the testes mid scrotum.ResultsOn follow-up, Doppler ultrasound examination revealed normal sized testes with normal blood flow in all patients with dimensions correlated with age.ConclusionAlthough perhaps only useful in orchiopexy for high undescended testis, incision of the transversalis fascia preserves testicular blood flow by relieving tension on the testicular vessels.