I. Abnormalities in cells of the testis, efferent ducts, and epididymis in juvenile and adult mice with beta-hexosaminidase A and B deficiency

Beta-hexosaminidase (Hex) is a lysosomal enzyme that exists as two major isoenzymes: Hex A (subunit structure, alphabeta) and Hex B (betabeta). The presence of Hex in the testis and epididymis suggests important roles for the enzyme and its substrates in male fertility and reproductive functions. Disruption of the Hexb gene encoding the beta-subunit of Hex has led to the generation of a mouse model of human Sandhoff disease that survives to adulthood, enabling us to analyze the effects of Hex A and Hex B deficiency on epithelial cellular morphology of the male reproductive tract. At 1 and 3 months of age, the testes, efferent ducts, and epididymides of Hex-deficient (Hexb -/-) and wild-type (Hexb +/+) mice were perfuse fixed and analyzed by routine light and electron microscopy (LM and EM, respectively) as well as with immunocytochemistry employing antibodies to lysosomal proteins. In the testis, the morphological appearance and topographical arrangement of the cell types of the seminiferous epithelium of Hexb -/- mice were similar to those of wild-type animals at both ages. Both Sertoli and germ cells appeared to be unaffected. However, at both ages, myoid cells and macrophages showed an increased number of lysosomes in their cytoplasm as compared with the number seen in controls. The epithelial cells of the efferent ducts also showed an accumulation of lysosomes that increased with age as compared with controls. Principal cells of the entire epididymis revealed an increase in the size and number of lysosomes at 1 month of age as compared with those of controls, and by 3 months, these lysosomes often filled the supranuclear and basal regions of the cells. Narrow cells of the distal initial segment and intermediate zone, normally slender cells showing several lysosomes, became greatly enlarged and entirely filled with lysosomes in Hexb -/- mice. Clear cells of the caput, corpus, and cauda regions also showed a progressive increase in the size and number of lysosomes with age as compared with controls; the clear cells of the mutant mice were often enlarged and at times bulged into the lumen. Some basal cells of each epididymal region in Hexb -/- mice were similar to controls at 1 and 3 months, showing few lysosomes, while others showed an accumulation of lysosomes. Lysosomes of all affected epithelial cells were of varying sizes, but many large ones were present, apparently resulting from lysosomal fusion. Although pale stained, their identification as lysosomes was confirmed by EM immunocytochemistry with anti-cathepsin D and anti-Hex A antibodies. Predominantly in the proximal initial segment, large, pale cellular aggregates were noted in the LM analysis at the base of the epithelium, which by EM analysis were identified as belonging to two different cell types, narrow cells and halo cells. Taken together, these data reveal an increase in the size and number of lysosomes in all epithelial cell types lining the efferent ducts and entire epididymis as well as in myoid cells and macrophages of the testis. In the light of data showing epididymal defects restricted predominantly to the initial segment in Hexa -/- (Hex A-deficient) mice, our data on the Hexb -/- mice demonstrate a major role for Hex that can be fulfilled by either Hex A or Hex B in the epididymis.     

Postnatal development and regulation of beta-hexosaminidase in epithelial cells of the rat epididymis

beta-Hexosaminidase (Hex) catalyzes the hydrolysis of terminal sugar residues from a number of substrates such as GM2 gangliosides, glycoproteins, glycolipids, and glycosaminoglycans. As an enzyme present in lysosomes of epithelial cells of the adult rat epididymis, it serves to degrade substances endocytosed from the epididymal lumen. In this way, it modifies and creates a luminal environment where sperm can undergo their maturational modifications. In this study, the postnatal developmental pattern of expression of Hex was examined in animals from days 7-56. In addition, the role of testicular factors on Hex expression in the different cell types and regions of the epididymis of adult rats was examined in orchidectomized and efferent duct-ligated rats. Both parameters were examined on Bouin-fixed epididymides in conjunction with light microscope immunocytochemistry. At postnatal day 7, the epithelium of the entire epididymis was unreactive for anti-Hex antibody. By day 21, narrow and clear cells of their respective regions became reactive, whereas basal cells became reactive only by day 29. Principal cells displayed only an occasional reactive lysosome at day 21, several by day 29, and numerous reactive lysosomes by day 39, comparable to the region-specific distribution noted for 90-day-old animals, and at an age when high androgen levels are attained. Thus, postnatal onset of Hex expression varies according to the different cell types of the epididymis, suggesting different regulatory factors. This finding was confirmed from studies employing adult orchidectomized and efferent duct-ligated adult rats. Indeed, in all experimental animals, Hex immunostaining in narrow, clear, and basal cells was intense and comparable to control animals. In contrast, there was a notable absence of lysosomal staining in principal cells at all time points after orchidectomy, which was restored, however, following testosterone replacement. No effect on Hex expression was observed in efferent duct-ligated animals. Taken together, the data suggest that Hex expression in lysosomes of principal cells is regulated by testosterone or one of its metabolites. However, the expression of Hex being independent of testicular factors in narrow, clear, and basal cells of adult animals, but occurring at different time points during postnatal development, suggests that different regulatory factors are responsible for onset of Hex expression in these cell types during development.     

Male infertility with chromosomal abnormalities. II. XX-male syndrome

We report two cases of the XX-male syndrome, and review the literature. The first case was a 31-year-old married man, a welder, complaining of infertility. His height was 158 cm, weight 82 kg and distance of extended hand 155 cm. The external genitalia showed a normal male type, but bilateral small testes and gynecomastia were noticed. The second case was a 32-year-old married man, a shopkeeper, complaining of infertility. His height was 165 cm, weight 60 kg and distance of extended hand 167 cm. No gynecomastia was noted. The external genitalia showed a normal male type, but bilateral small testes were noticed. In each case, azoospermia was identified in semen analysis. Urethrography revealed the prostatic utricle in the second case. The testicular biopsy specimens revealed hyalinization of seminiferous tubules and proliferation of Leydig cells. X chromatin was positive in buccal smears, and Y chromatin negative in cultured lymphocytes. Chromosomal analysis showed 46, XX karyotype in the first case and 46, XXp+ in the second case. H-Y antigen was positive in each case. Basal serum levels of LH and FSH were moderately elevated and the serum testosterone level was low. Serum levels of PRL, TSH, estradiol, GH, T3 and T4 were normal. An impaired response by testicular Leydig cells to hCG was observed. The LH and FSH responses to LH-RH were almost normal. Clomiphene citrate administration resulted in a decrease in the serum testosterone and gonadotropins levels. These results indicate hypergonadotropic hypogonadism secondary to testicular failure in both XX-males. Twenty-six cases of the XX-male syndrome have been cited in the Japanese literature. The clinical features and etiology of this syndrome are discussed.     

Gamma-glutamyl transpeptidase activity in the epididymis during fetal and postnatal development in rats.

The histochemical and biochemical distributions of gamma-glutamyl transpeptidase (gamma-GT) were investigated in the epididymis of rats during fetal and postnatal development. In the epididymal homogenates, gamma-GT activity was detected on the fifth day after birth. A sharp increase was observed after 30 days of life in the caput homogenates. Moderate levels of the enzyme were found in the cauda epididymis. Gamma-GT is histochemically detected from the 15th day of gestation in Wolffian ducts and in 17- to 18-day-old fetuses in newly differentiated epididymal tubules. Enzyme activity, was associated with the plasma membranes (apical, lateral, and basal), was preponderant on the apical part of the epithelial cells. During the first 15 days of the postnatal life, the histochemical reaction intensities were identical from the caput to the cauda epididymidis. From the 18th day onwards, enzyme activity decreased in the corpus and in the cauda, while gamma-GT increased in the caput epididymidis, and a strong activity was found on the apical surface of epithelial cells. Weak or moderate gamma-GT activity of spermatozoa in the caput tubules, increasing steadily from caput to cauda epididymidis, suggests that gamma-GT may be related to the functional maturation of spermatozoa.     

Dysplasia of the testis and epididymis.

Various congenital malformations of the testis and the seminal pathways are illustrated by 10 cases. Though these malformations are often free from symptoms, an increasing number of them are now being discovered in connection with investigations of male infertility. In cases of azoospermia where testicular biopsies show complete spermatogenesis, surgical exploration is indicated. Some of these malformations may then be treated by surgery, with fairly good prospects of restored fertility.     

Major differences between the testis and epididymis in the induction of granulomas in response to extravasated germ cells. I. A light microscopical study in mice

A spermatic granuloma is a chronic inflammatory lesion which surrounds extravasated spermatozoa. Clinically, the lesion develops in the interstitial spaces of the epididymis and vas deferens, and only exceptionally in the testis itself. In the present study, murine testes and epididymides were injured using a needle and the histological appearances of these organs was then compared. Traumatic injury induced extravasation of germ cells in both testes and epididymides. A few days later, spermatic granulomas consistently formed in the epididymides, however, such lesions were not induced in the testes. To examine the possibility that epididymal spermatozoa have inherently greater ability to form spermatic granulomas than do testicular germ cells, isolated epididymal spermatozoa or testicular germ cells were locally injected into the testes and epididymides of recipient mice. Spermatic granulomas readily formed in the epididymides after local injection of either epididymal spermatozoa or testicular germ cells. In contrast, such lesions did not form in the testes even when epididymal spermatozoa were injected. Therefore, this study suggests that the microenvironment of the testicular interstitium, rather than the extravasated components from the ruptured seminiferous tubules, is the main factor determining the limited formation of spermatic granulomas in the testis.     

Histiocytoid hemangioma of the epididymis. A very unusual entity

The presence of vascular origin tumor in the epididymis and testicle, are today considered of low frequency. We report a case of histiocytoid (epithelioid) hemangioma of the epididymis. Its differential diagnosis with the adenomatoid tumor, is discussed.     

A new modification of rotationplasty in a patient with proximal femoral focal deficiency Pappas type II.

The application of rotationplasty type B III (Winkelmann) for a patient with proximal femoral focal deficiency (PFFD) Pappas type II in a 5-year-old patient is described. The advantages for prosthetic management are discussed in comparison with other surgical options.     

A view of the development of intestinal suture. Part II. Principles and techniques

During the 19th century, the principles of suturing and operating upon the bowel were developed. Lembert published his technique, emphasizing the importance of the serosa in 1826. This brought about sudden transition from the ancient methods of intestinal surgery. Considerable controversy followed. Dieffenbach reported the first clinical success with this suture in 1836. Lister introduced aseptic sutures and the principles of antisepsis to the intestine which allowed the subsequent developments. The importance of the submucosa in anchoring a stitch, so that divided surfaces could stay opposed, was drawn to surgeons' attention by Gross and by Halsted. Mall described the histologic changes and pointed out that necrosis would occur if sutures were too close or too tight. More than 200 modifications were described by the beginning of the 20th century. During the 1950s, everting suture was compared with inverting anastomoses, and the safety of this method was realized.     

Fusional anomalies of the testis and epididymis.

Earlier, the cause of infertility in undescended testis (UT) had been widely accepted as a consequence of the higher temperature of the inguinal/abdominal region. Observations made in the past two decades, however, gave new evidences. The most important of these is that UT is often associated with the fusional anomalies (FA) of the testis and epididymis. FA is the consequence of pathological intrauterine hormonal processes and many authors believe FA to be the primary cause for infertility in UT. Since 80% of UT cases are of endocrine origin, it would be suspected that the very same factors are responsible for both UT and FA. FA and other anomalies of the epididymis often occur in testicular torsion (TT) as well. It is remarkable that infertility could follow the unilateral forms of UT and TT despite the presence of a "healthy" contralateral gonad. In both entities contralateral FA (probably associated with testicular dysgenesis) is suspected. These observations could influence the primary surgical treatment of patients with UT and TT, as well as the mode of further management of these cases.     

Role of inhibitor deficiency in urolithiasis. II. Deficiency grade-adjusted and intermittent augmentation therapy for magnesium and citrate deficiency.

63 patients with hypocitraturia (44.9% of the total) and 33 patients with hypomagnesiuria (24.8% of the total) received oral magnesium hydroxide and/or Na/K citrate in addition to other therapeutic agents if indicated and a common-sense diet. Hypocitraturic patients were categorized into 3 groups and received 27-81 mEq/day oral citrate according to the deficiency grade. Hypomagnesiuric patients also formed two groups according to the deficiency grade and received 500 and 1,000 mg/day magnesium hydroxide, respectively. Replacement was intermittant and was controlled every 3 months until reaching normal values. We evaluated 28 of 63 hypocitraturic and 15 of 33 hypomagnesiuric patients who had inhibitory deficiency as the sole causal factor of their urolithiasis. After a follow-up of 13.5 +/- 10.2 months, no patient in either group developed a new stone. Citrate and magnesium were increased significantly in the respective groups; calcium and oxalate excretion was lowered, and urine pH and volume increased significantly. A deficiency grade-adjusted and intermittant replacement therapy with Mg and citrate is very effective, has less side effects and ensures good patients compliance.     

Abnormalities of the vas deferens and epididymis in cryptorchid boys with congenital rubella.

Cryptorchidism was present in 12% of 316 boys with congenital rubella (CR) followed by The Roosevelt Hospital Rubella Project. Eight of these patients, age 4 through 16 yr, had a recent orchiopexy, 4 on the left, 2 on the right, and 2 bilaterally. The vasoepididymal system was absent or apparently obstructed in 60% of the 10 sides. The epididymis was abnormal in 6 instances and the vas deferens in 5. Sixty-one boys of the entire series had an intravenous pyelogram (IVP) that was significantly abnormal in 18%. The 8 patients described all had a normal IVP except for 2 who had a malrotated kidney on the involved side. In 5 of the 8, a known maternal rubella infection has occurred during the first 8 wk of gestation. As the rubella virus is known to interfere with cellular growth and tissue differentiation in early pregnancy, it apparently altered the developing testis and mesonephric duct system. Similar vasoepididymal abnormalities have been described previously in patients with uncomplicated cryptorchidism, inguinal hernia, kidney defects, cystic fibrosis and male sterility. Their presence should alert the clinician to perform an IVP and also consider a diagnosis of congenital rubella.     

A full-term fetus with holo-acranial anencephaly and other abnormalities.

A fetus with no head or neck was dissected in order to trace possible remnants of those structures. Many other abnormalities were also displayed. Mechanisms of anencephaly are discussed, especially those which probably caused this malformation.     

Appearance of specific proteins in rat epididymis during postnatal development

In the immature 30-day-old caput and cauda epididymides of the rat, only a single prealbumin protein was visible. Additional epididymis-specific proteins appeared in the caput on day 45, coinciding with the entry of testicular fluid containing first wave of spermatozoa. In the cauda epididymides, additional proteins appeared only on day 50. These results indicate that the functional differentiation of caput precedes that of the cauda epididymidis.