Abnormal Genital Development Research Articles

The laboratory in the multidisciplinary diagnosis of differences or disorders of sex development (DSD): III) Biochemical and genetic markers in the 46,XYIV) Proposals for the differential diagnosis of DSD.

46,XY differences/disorders of sex development (DSD) involve an abnormal gonadal and/or genital (external and/or internal) development caused by lack or incomplete intrauterine virilization, with or without the presence of Müllerian ducts remnants. Useful biochemical markers for differential diagnosis of 46,XY DSD include hypothalamic-pituitary-gonadal hormones such as luteinizing and follicle-stimulating hormones (LH and FSH; in baseline or after LHRH stimulation conditions), the anti-Müllerian hormone (AMH), inhibin B, insulin-like 3 (INSL3), adrenal and gonadal steroid hormones (including cortisol, aldosterone, testosterone and their precursors, dihydrotestosterone and estradiol) and the pituitary ACTH hormone. Steroid hormones are measured at baseline or after stimulation with ACTH (adrenal hormones) and/or with HCG (gonadal hormones). Different patterns of hormone profiles depend on the etiology and the severity of the underlying disorder and the age of the patient at diagnosis. Molecular diagnosis includes detection of gene dosage or copy number variations, analysis of candidate genes or high-throughput DNA sequencing of panels of candidate genes or the whole exome or genome. Differential diagnosis of 46,XX or 46,XY DSD requires a multidisciplinary approach, including patient history and clinical, morphological, imaging, biochemical and genetic data. We propose a diagnostic algorithm suitable for a newborn with DSD that focuses mainly on biochemical and genetic data.

Estrogens and development of the mouse and human external genitalia

The Jost hypothesis states that androgens are necessary for normal development of the male external genitalia. In this review, we explore the complementary hypothesis that estrogens can elicit abnormal development of male external genitalia. Herein, we review available data in both humans and mice on the deleterious effects of estrogen on external genitalia development, especially during the “window of susceptibility” to exogenous estrogens.The male and female developing external genitalia in both the human and mouse express ESR1 and ESR2, along with the androgen receptor (AR). Human clinical data suggests that exogenous estrogens can adversely affect normal penile and urethral development, resulting in hypospadias. Experimental mouse data also strongly supports the idea that exogenous estrogens cause penile and urethral defects. Despite key differences, estrogen-induced hypospadias in the mouse displays certain morphogenetic homologies to human hypospadias, including disruption of urethral fusion and preputial abnormalities. Timing of estrogenic exposure, or the “window of susceptibility,” is an important consideration when examining malformations of the external genitalia in both humans and mice. In addition to a review of normal human and mouse external genital development, this article aims to review the present data on the role of estrogens in normal and abnormal development of the mouse and human internal and external genitalia. Based on the current literature for both species, we conclude that estrogen-dependent processes may play a role in abnormal genital development.

AMA Acts on Treatment of Children at Border, Gun Violence, Pediatric Decision Making

AMA Acts on Treatment of Children at Border, Gun Violence, Pediatric Decision Making

A novel FGD1 mutation in a family with Aarskog-Scott syndrome and predominant features of congenital joint contractures.

Mutations in FGD1 cause Aarskog–Scott syndrome (AAS), an X-linked condition characterized by abnormal facial, skeletal, and genital development due to abnormal embryonic morphogenesis and skeletal formation. Here we report a novel FGD1 mutation in a family with atypical features of AAS, specifically bilateral upper and lower limb congenital joint contractures and cardiac abnormalities. The male proband and his affected maternal uncle are hemizygous for the novel FGD1 mutation p.Arg921X. This variant is the most carboxy-terminal FGD1 mutation identified in a family with AAS and is predicted to truncate the FGD1 protein at the second to last amino acid of the carboxy-terminal pleckstrin homology (PH) domain. Our study emphasizes the importance of the 3′ peptide sequence in the structure and/or function of the FGD1 protein and further demonstrates the need to screen patients with X-linked congenital joint contractures for FGD1 mutations.

Male genital abnormalities in intrauterine growth restriction

Previous studies have shown a correlation between hypospadias and intrauterine growth restriction (IUGR), suggesting an association between placental insufficiency and abnormal genital development. This study sought to analyze the association of IUGR and genital abnormalities apparent on fetal magnetic resonance imaging (MRI). This retrospective study included 22 MRI scans of 20 male fetuses between 20 and 35 weeks of gestation presenting with IUGR. On MRI, penile length and testicular descent were evaluated. Student's t-testing and analysis of covariance were used to compare MRI penile length measurements with published normative data obtained from fetal ultrasonography (US) and MRI. McNemar testing was used to evaluate testicular descent in IUGR, compared with reported fetal MRI normative data. The penile length in IUGR fetuses was shorter than in normal fetuses (p<0.001). Furthermore, six of 20 fetuses presented with a micropenis (2.5 SD below the mean value for age). Undescended testes were significantly more frequent in IUGR fetuses than in normal fetuses (p=0.004). Our data confirm that abnormal fetal growth may be associated with penile shortening and, potentially, also undescended testes.

Penoscrotal Transposition: A Case Report

Penoscrotal transposition (PST) is an extremely rare congenital malformation, usually associated with a wide variety of other anomalies. We describe an exceptional case of a newborn with PST, but normal upper urinary tract and no other associated malformations. An unbooked newborn male delivered at term with no reported antenatal complications. There was no evidence of mother being exposed to teratogens during pregnancy. On physical examination, an abnormal appearance of the external genitalia could be seen. There was a complete rotation of the external genitalia with cryptorchidism. Penis with chordee was noted (Fig. 1). Urinalysis, renal and vesical sonography, and voiding cystourethrography showed no other urological abnormalities. There were no associated cardiological or gastrointestinal anomalies. Fig. 1 Complete penoscrotal transposition PST is a very uncommon heterogeneous condition in which the scrotum is positioned superior and anterior to the penis. Less than 20 cases of extreme degree of PST with normal scrotum have been reported in the literature [1]. PST results from abnormal genital tubercle development around the 6th week of gestation. It is associated with delay in the midline fusion of the urethral folds. Although the occurrence of most reported cases of PST has been sporadic, other congenital anomalies such as hypospadias, chordee, and renal agenesis or dysplasia could be found in approximately 90% of patients [2]. Gastrointestinal abnormalities, predominantly imperforate anus, were found in 30% of cases [3]. PST may present with a broad spectrum of abnormalities ranging from simple shawl scrotum (doughnut scrotum) to very complex extreme transposition with cardiac, gastrointestinal, craniofacial, central nervous system, genital, and urological malformations [4]. Growth deficiency and mental retardation have also been noticed in 60% of patients [5]. Differential diagnosis must include pseudohermaphroditism, penoscrotal hypospadias, micropenis, intrauterine penile amputation, and especially penile agenesis with a midline skin tag anterior to the anus. Complete penoscrotal transpositions have been rarely reported in the Indian literature [6]. Surgery in more complex cases of PST is technically challenging. It is usually performed between 12–18 months. The size of the phallus and its potential to develop at puberty into a sexually satisfactory penis are of paramount relevance when surgery is planned. In order to assess this situation, a surgeon must carefully palpate the corporal bodies to determine their bulk and sometimes perform a testosterone test to demonstrate erections. Extreme penoscrotal transposition with severe hypospadias and chordee is difficult to differentiate from penile agenesis with a midline skin tag anterior to the anus (with penile atrophic body buried in the perineum). In both cases the penile reconstruction and repositioning are often unsatisfactory, and female gender reassignment, while ethically controversial, may be a prudent therapeutic in selected cases.

A novel mutation in the aristaless domain of the ARX gene leads to Ohtahara syndrome, global developmental delay, and ambiguous genitalia in males and neuropsychiatric disorders in females

ARX, the aristaless-related homeobox gene, is implicated in cerebral, testicular, and pancreatic development. ARX mutations are associated with various forms of epilepsy, developmental delay, and ambiguous genitalia in humans. A mouse model that recapitulates X-linked lissencephaly with ambiguous genitalia (XLAG) is far from elucidating the substrate for phenotypes that different ARX mutations cause. Moreover, despite phenotypic pleomorphism associated with X-linked dominant ARX mutations, heterozygous female carriers have not been thoroughly studied. Reviewing records of patients with ARX mutations, infantile epilepsies, and psychomotor retardation, we analyzed a family harboring a novel ARX mutation with different phenotypes in males and females, including Ohtahara syndrome. Children's Hospital Boston patient records were retrospectively screened for patients with infantile epileptic encephalopathies who underwent ARX sequencing based on clinical suspicion. Identified families were analyzed for genetic and neuropsychiatric phenomena. The proband was a male with Ohtahara syndrome, ambiguous genitalia, psychomotor delay, and central nervous system dysgenesis due to a novel ARX mutation in exon 5, causing a frameshift in the aristaless domain. Heterozygous females demonstrated neurocognitive/psychiatric phenomena including learning difficulties, anxiety, depression, and schizophrenia. This is the first reported case of Ohtahara syndrome with abnormal genital and psychomotor development in the setting of this novel ARX mutation in exon 5. Based on the unique phenotype of the proband and on the presence of heterozygous females with neurocognitive/psychiatric ailments, this study describes the potential roles for ARX mutations in epilepsy and neuropsychiatric disease, underscoring the importance of ARX in interneuron development, cerebral electrical activity, cognition, and behavior.

Ambiguous genitalia: an overview of 17 years' experience

Aim The newborn with abnormal genital development presents a difficult diagnostic and treatment challenge for the pediatric surgeon providing care. The purpose of this study was to evaluate the results of surgical treatment for children with ambiguous genitalia. Patients and Methods The records of 85 children managed surgically for ambiguous genitalia in our unit from 1988 to 2005 were reviewed retrospectively. Age at surgery, operative procedures, sex of rearing, and outcome were recorded. Results The intersex committee's decision concerning sex assignment was female for 62 children (75%) and male for 23 children (25%). The etiologies of children reared as female were congenital adrenal hyperplasia (n = 37), male pseudohermaphroditism (n = 12), mixed gonadal dysgenesis (n = 6), true hermaphroditism (n = 4), and Mayer-Rokitansky syndrome (n = 3). Fifteen children with male pseudohermaphroditism, 5 children with congenital adrenal hyperplasia, and 3 children with true hermaphroditism were reared as male. The mean age at surgery was 4.4 years and follow-up period averaged 7 years. Eighteen (29%) patients with feminization procedures and 8 (34%) of 23 patients with masculinization procedures experienced complications and required redo operations. Vaginal stenosis was the most common complication. Conclusion The surgical management of ambiguous genitalia has always been difficult, and it must be performed by skilled pediatric surgeon. Genital surgery in infancy needs to be reassessed in the light of literature findings revealing poor outcome. In patients who underwent feminizing genitoplasty, vaginal reconstruction should be delayed until adolescence to achieve better cosmetic and functional results.

Intrinsic androgen-dependent gene expression patterns revealed by comparison of genital fibroblasts from normal males and individuals with complete and partial androgen insensitivity syndrome

BackgroundTo better understand the molecular programs of normal and abnormal genital development, clear-cut definition of androgen-dependent gene expression patterns, without the influence of genotype (46, XX vs. 46, XY), is warranted. Previously, we have identified global gene expression profiles in genital-derived fibroblasts that differ between 46, XY males and 46, XY females with complete androgen insensitivity syndrome (CAIS) due to inactivating mutations of the androgen receptor (AR). While these differences could be due to cell autonomous changes in gene expression induced by androgen programming, recent work suggests they could also be influenced by the location from which the fibroblasts were harvested (topology). To minimize the influence of topology, we compared gene expression patterns of fibroblasts derived from identical urogenital anlagen: the scrotum in normally virilized 46, XY males and the labia majora from completely feminized 46, XY individuals with CAIS.Results612 transcripts representing 440 unique genes differed significantly in expression levels between scrotum and CAIS labia majora, suggesting the effects of androgen programming. While some genes coincided with those we had identified previously (TBX3, IGFBP5, EGFR, CSPG2), a significant number did not, implying that topology had influenced gene expression in our previous experiments. Supervised clustering of gene expression data derived from a large set of fibroblast cultures from individuals with partial AIS revealed that the new, topology controlled data set better classified the specimens.ConclusionInactivating mutations of the AR, in themselves, appear to induce lasting changes in gene expression in cultured fibroblasts, independent of topology and genotype. Genes identified are likely to be relevant candidates to decipher androgen-dependent normal and abnormal genital development.

Steroid Receptors and Mammalian Penile Development: An Unexpected Role for Progesterone Receptor?

We investigated the role of steroid receptors in normal and abnormal genital tubercle development in males and females. We hypothesized that progesterone receptor expression might be involved in abnormal development in both sexes. We examined the effects of medroxyprogesterone acetate on steroid receptor mRNA expression and assessed the involvement of androgen receptor in the action of medroxyprogesterone acetate on genital tubercle development using androgen receptor deficient (Tfm) mice. Quantitative reverse transcriptase polymerase chain reaction and morphological results demonstrated a pattern of virilized females and feminized males in medroxyprogesterone acetate exposed embryos. Progesterone receptor was the only steroid receptor examined that did not differ between medroxyprogesterone acetate treated males and vehicle treated females. At the morphological level in utero exposure to medroxyprogesterone acetate from gestational days 12 to 17 feminized male genital tubercles, producing a more proximal urethral opening. Female fetuses exposed for the same period exhibited virilized genitalia, with a more distal urethral opening. We also exposed Tfm mice to medroxyprogesterone acetate to assess the role of androgen receptor in the activity of medroxyprogesterone acetate. These medroxyprogesterone acetate exposed mice did not differ morphologically from vehicle treated Tfm mice, indicating that medroxyprogesterone acetate requires androgen receptor to elicit genital tubercle abnormalities. The increase of progesterone receptor mRNA expression in males and the decrease in females as a result of exposure to medroxyprogesterone acetate, which also causes urethral abnormalities in both sexes, suggests a previously unidentified role for progesterone receptor, possibly interacting with androgen receptor, in anomalous genital tubercle development.

Female genital mutilation of a karyotypic male presenting as a female with delayed puberty

BackgroundFemale genital mutilation (FGM) is commonly practiced mainly in a belt reaching from East to West Africa north of the equator. The practice is known across socio-economic classes and among different ethnic, religious, and cultural groups. Few studies have been appropriately designed to measure the health effects of FGM. However, the outcome of FGM on intersex individuals has never been discussed before.Case presentationThe patient first presented as a female with delayed puberty. Hormonal analysis revealed a normal serum prolactin level of 215 Mu/L, a low FSH of 0.5 Mu/L, and a low LH of 1.1 Mu/L. Type IV FGM (Pharaonic circumcision) had been performed during childhood. Chromosomal analysis showed a 46, XY karyotype and ultrasonography verified a soft tissue structure in the position of the prostate.ConclusionFGM pose a threat to the diagnosis and management of children with abnormal genital development in the Sudan and similar societies.

Endocrine abnormalities in boys with hypospadias.

The multifactorial etiology of hypospadias is becoming more clearly defined with ongoing investigation. Endogenous endocrine abnormalities identified so far include testosterone biosynthesis defects, 5alpha-reductase type 2 mutations, and androgen receptor mutations (the rarest cause, even in cases of severe hypospadias). Other significant risk factors include IVF (because of progesterone administration or endocrine abnormalities associated with infertility) and environmental agents that can potentially cause testicular dysgenesis, disrupt the male androgen axis, and disturb normal male genital embryology (Table 6). [table; see text] It also seems that the incidence of hypospadias is increasing, both in the United States and in Europe--which may be due to better medical care for those with genital abnormalities and/or infertility problems, as well as environmental endocrine disruptors. Hypospadias is a physical manifestation that may be a consequence of numerous physiological aberrations, and our ability to understand and to potentially prevent this congenital malformation will require a significant amount of additional work. Our challenge for the future remains to identify the various etiologies, provide prenatal counseling for affected families with a history of hypospadias, and minimize or eliminate exposure to environmental agents that may contribute to this problem. Perhaps one day we will be able to offer prenatal therapy to prevent hypospadias when the risk for this birth defect seems high. How might this be possible? Consider the modern management of a family with a child born with the adrenogenital syndrome, another endocrine derangement that can cause abnormal genital development. In this situation, dexamethasone can be administered to the mother in subsequent pregnancies to prevent fetal virilization until the sex of the fetus can be determined or adrenal enzyme mutations can be excluded. Perhaps in the future a similar approach will be taken for those families with strong risk factors for hypospadias.

Cloning and Characterization of an Alternatively Spliced Gene in Proximal Xq28 Deleted in Two Patients with Intersexual Genitalia and Myotubular Myopathy

We have identified a novel human gene that is entirely deleted in two boys with abnormal genital development and myotubular myopathy (MTM1). The gene,F18,is located in proximal Xq28, approximately 80 kb centromeric to the recently isolatedMTM1gene. Northern analysis of mRNA showed a ubiquitous pattern and suggested high levels of expression in skeletal muscle, brain, and heart. A transcript of 4.6 kb was detected in a range of tissues, and additional alternate forms of 3.8 and 2.6 kb were present in placenta and pancreas, respectively. The gene extends over 100 kb and is composed of at least seven exons, of which two are noncoding. Sequence analysis of a 4.6-kb cDNA contig revealed two overlapping open reading frames (ORFs) that encode putative proteins of 701 and 424 amino acids, respectively. Two alternative spliced transcripts affecting the large open reading frame were identified that, together with the Northern blot results, suggest that distinct proteins are derived from the gene. No significant homology to other known proteins was detected, but segments of the first ORF encode polyglutamine tracts and proline-rich domains, which are frequently observed in DNA-binding proteins. TheF18gene is a strong candidate for being implicated in the intersexual genitalia present in the twoMTM1-deleted patients. The gene also serves as a candidate for other disorders that map to proximal Xq28.

Deletions in Xq28 in two boys with myotubular myopathy and abnormal genital development define a new contiguous gene syndrome in a 430 kb region.

We have recently described a female patient with myotubular myopathy (MTM1) and an interstitial deletion at Xq28. Characterisation of the deletion allowed us to position the MTM1 gene to a 600 kb region between DXS304 and DXS497. In order to further restrict the region we screened for deletions in a set of 38 patients. We found two overlapping deletions in boys that in addition to MTM1 showed an unexpected abnormal genital development. As the latter phenotype is not found in the other non-deleted MTM1 patients, our observations are best explained by a contiguous gene syndrome. The deletions define a 430 kb region that contains the MTM1 gene and most likely a gene implicated in male sexual development. A high resolution physical map of this region is presented.

A new deletion of the 5α‐reductase type 2 gene in a Turkish family with 5α‐reductase deficiency

The molecular basis for male pseudohermaphroditism produced by the 5 alpha-reductase deficiency is becoming increasingly understood. We have performed biochemical and molecular analyses of the 5 alpha-reductase type 2 gene in a Turkish family with a 5 alpha-reductase deficiency. A 46,XY prepubertal Turkish patient with female phenotype showing clitoral hypertrophy, high plasma testosterone and dihydrotestosterone, and normally differentiated and developed testosterone-dependent internal genitalia. 5 alpha-Reductase activity, measured by the conversion of 3H-T into 5 alpha-reduced compounds, was determined from cultured genital skin fibroblasts by both intact monolayer assay and cell-free extracts at various pH values. The five exons of the 5 alpha-reductase type 2 gene were sequenced after enzymatic amplification (PCR) of the patient's genomic DNA. Labelled PCR of the consanguineous parents' DNA was submitted to electrophoresis on a sequencing gel. A marked decrease in the transformation of T into 5 alpha-reduced compounds by intact cells and a diminished 5 alpha-reductase activity at acidic pH by sonicated cell extracts strongly suggested a 5 alpha-reductase type 2 deficiency. Molecular analysis of the 5 alpha-reductase type-2 gene showed a trinucleotide deletion straddling codons 156 and 157, responsible for a methionine residue deletion at position 157 of the protein. The parents' DNA contained both normal and deleted alleles. This is the third deletion described in the 5 alpha-reductase type 2 gene. The deleted methionine 157 is conserved in both types 1 and 2 of human and rat 5 alpha-reductase, which suggests its crucial role in the functioning of the enzyme. This gene rearrangement was thus clearly responsible for the reduced 5 alpha-reductase activity and abnormal genital development in this patient.

Neonates with Abnormal Genital Development Assigned the Female Sex: Parent Counseling

A team consisting of an endocrinologist, an urologist, a surgeon and a psychologist, all specialized in pediatrics, counselled eight pairs of parents of neonates with a 46XY karyogram and an external genital organ that was either completely female or hermaphrodite. These were children whose genotype was not in accordance with their phenotye. The authors discuss policy in regard to counseling and support of the parents from the time when the child's genital abnormality is first observed to its adulthood. The aim of the policy is to create the conditions required to achieve a good female gender identity for the child.

Physical and hormonal evaluation of transsexual patients: a longitudinal study.

The physical and hormonal characteristics of 60 male-to-female transsexuals and 30 female-to-male transsexuals were measured before or during treatment with commonly used forms and dosages of hormones. Only two patients (both female-to-male) had either a congenital defect in hormonal production or abnormal genital development. Patients were seen at 3- to 6-month intervals for an average of 18 months. The response to therapy was examined over time; physical parameters, hormonal concentrations, liver function tests, lipids, and glucose were measured. Three patients were changed from ethinyl estradiol to conjugated estrogen because of liver enzyme elevations. Ethinyl estradiol (0.1-0.5 mg/day) was equal to conjugated estrogen (7.5-10 mg/day) in its ability to suppress testosterone and gonadotropins and to promote breast growth. Maximum breast growth required 2 years of therapy. During treatment with testosterone, female-to-male transsexuals had a significant mild elevation of cholesterol and triglyceride. The female-to-male transsexuals receiving testosterone cypionate, 200 mg every 2 weeks, ceased to have menstrual periods and became progressively masculinized. A mean maximal clitoral length of 4.6 cm which achieved by 1 year of therapy. Based on the data generated by this study, we recommend as hormonal therapy 0.1-0.5 mg/day of ethinyl estradiol or 7.5-10 mg/day of conjugated estrogen for male-to-female transsexuals, and intramuscular testosterone cypionate, 200 mg every 2 weeks, for female-to-male transsexuals.

Short term hCG stimulation test in patients with various types of testicular insufficiency and abnormal genital development (author's transl)

Short term hCG stimulation test in patients with various types of testicular insufficiency and abnormal genital development (author's transl)

Constitutional statural overgrowth and increased lower body segment with normal sexual development in a family of four

I N THE newborn child measurement of trunk or upper body segment, taken from top of pubis to top of the)~ead, will be found to be greater than measurement of lower body segment, taken from pubis to heel, by as much as 5 inches. As time goes on, and as normal infant grows older, lower measurement gradually approaches upper measurement, unti l at about age of 10~ to 11 years, if he is still normal in development, lower measurement is almost equal to upper measurement. Finally, as child approaches age of 14 to 15 years~ and then thereafter into adulthood, lower measurement in male exceeds upper measurement by about one inch, and, in female, upper measurement exceeds the'lower by about one inch2 ~ Where there is abnormal genital development, such as with hypoplasia or cryptorchidism, there will be a derangement of these body measurements, especially, if abnormalities had their inception in early infancy. The extent of skeletal disproportion depends upon type and severity of endocrine disturbance, age of patient when distm'bance had its onset, and length of time it has been in existence. I have found that an increased lower body segment may be found in boys with gonadal insufficiency regardless of whether these boys present normal, accelerated, or depressed total linear height, whether patients present an adipose or nonadipose type of genital dystrophy, and whether origin of gonadal insufficiency is pituitary, pr imary gonadal, or thyroid. In cretin, where growth in general is interfered with severely and where linear growth specifically and most other developmentM processes are practically at a standstill, one may not find an increased lower body segment. TM b, Where gonadal insufficiency has existed since infancy in any of types of cases enumerated above, I have noted, after treating and studying many such endoeri~e cases over many years, that lower measurements are equal to upper measurements at about age of 6 or 7 years instead of at age of 10 89 or 11 years as in normal; and that, thereafter, lower measurements eventually surpass the upper measurements, not by an inch or so as in normal male, but by ~inches or even by as much as 7 inches or more. That is, skeletal disproportion is similar to that seen in eunuchism or eunuchoidism which has existed since early infancy--so-called eunuchoid skeletal proportions. Generally, eunuchoid proportions found in a patient indicate that a gonadal deficiency exists or had existed. In other words one usually assumes that two conditions accompany each other.

Endocrine Factors Concerned in Abnormal and Subnormal Genital Development

Endocrine Factors Concerned in Abnormal and Subnormal Genital Development