Embryology and malformations of the male genital organs. Healing in boys - norm and deviations Development of male and female type

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Embrygenesis

Internal and external genital organs are formed in men in the embryonic period, in the pubertal - their development and improvement on the 18-20 years continues.

In the future, for 25-30 years, the normal functioning of the sex glands is maintained, replacing the gradual extinction of their function and reverse development.

Human half is determined primarily by a set of genital chromosomes (chromosomal floor), on which the formation and construction of sex glands depend on the hormonal floor, which, in turn, determines the structure of the genitals. From the last fact, the education of the individual, mental and civilian flooring is dependent.

The intrauterine development of the genital organs occurs in accordance with the genetic (chromosomal) floor of the embryo. Chromosomal set causes directional sexual evolution and adult individual. The human sex cell (men's or female) contains 23 chromosomes (haploid set). Genetic, or chromosomal, the floor is determined at the time of fertilization and depends on which chromosomal material receives an egg, which is normal there is 22 autosomes and a sexual X-chromosome, when it is fused with a sperm containing 22 autosomes and a sexual X-or Y-chromosome. .

When merging the egg cell with a spermatozooma carrying x-chromosome, a female genotype is formed - 46 (XX), the primary flooring of the embryo will be laid on the female type (ovaries). When the egg fertilization of the egg cell sperm containing the sexual y-chromosome, the primary flooring of the embryo will develop on the male type (testicles). Normal male genotype, therefore, is determined by a set consisting of 44 autosomal and 2 germ chromosomes X and Y.

The structure of the germ defines the gonadal floor.

The ovaries in the embryonic period are functionally inactive, and differentiation on the female type goes passively, without requiring control from the side of the sex glands. The embryo egg is very early becomes an active endocrine organ. Under the influence of androgens produced by embryonic testicles, the development of the internal and external genital organs on the male type is developed. The seed-eyed tubules, egg appenditions, seed bubbles, prostate gland are formed and developing; The scrotum, penis, urethra, is formed, the gradual lowering of the testicles in the scrotum occurs.

In the absence of androgens, violations of their development or insensitivity of peripheral receptors to them in, the process of embryogenesis The external genitals can be formed on the female type or various anomaly develops. From the moment of birth, the floor is determined by the structure of the external genital organs, after which it is fixed with psycho-efficient sexualization on the first 18-30 months of the child's life and is supported throughout the last life.

7. Fire differentiation scheme: a - male embryo after 11 weeks; b - 6-week embryo; B - female embryo after 11 weeks; 1 - prostate gland; 2 - cooper glands; 3 - urethra; 4 - egg; 5 - Egg appendage; 6 - seed bubbles; 7 - Volkers channel; 8 - Primary Past "Waive Iron; 9 - Wolf Body; 10 - Muller Channel; 11 - Spent Mullers Channel; 12 - Vagina; 13 - ovary; 14 - Garterners, 15 - uterine tube; 16-uterus.

In the period, the gender maturation of the testicles actively produce testosterone, which contributes to the emergence of secondary sexual signs, and approve the male hormonal floor. By this time, civilian floors are made, characterized by external signs of breakdown, clothing, manner, social behavior, sexual entry orientation.

The development of the germ.

The genitals are closely connected, with blades and are formed from the primary bud of the embryo - Mesonphros. Due to the growth of multilayer epithelial cover covering mesonphros, an embryonic roller epithelial germ forms is formed. It penetrates the depth of mesonphros, forming the primary sex, consisting of the primary genital cells - Hungal. (sperm predecessors), connective tissue cells that will secrete sex hormones, as well as undifferentiated cells playing a trophic and reference role.

From the 7th week, the fabric structures of the primary field of the fetus begin to differentiate into men's (testicles) or female (ovaries) sex glands. With the development of eggs from the 8th week, the primary sexual seasy is actively growing and turn into seed tubules with the formation of lumen in them.

In the lumen of the seed tubules there are sex cells - spermatogonium, which are formed from Gonocytes and in the future will begin the beginning of spermatogenesis. Spermatogonium is located on sustoocytes carrying out a trophic function. Mesonphros's connective tissue reservoirs are formed by intermediate cells capable of producing men's sex hormones for a certain period of embryogenesis. The development of primary gerbus in the testicles is completed by the 60th day of the intrauterine development of the fetus.

It has been established that the fruit egg is allocated by Androvenation, Androsteron and other androgenic nature steroids. The allocation of testosterone is more pronounced on the 9th and 15th week. Already at the 10th week of development, testosterone levels in the fetal testicles of a person 4 times higher than in the ovaries. At the 13-15th week of embryonic development, the testosterone content in the testicles exceeds it in the ovary of 1000 times. Further formation of internal and external genital organs depends on testosterone products.

Development of internal genital organs.

With the development of the pelvic kidney, the highest vertebrates primary kidney loses its purpose of the excretory body. At the end of the 2nd month of the intrauterine development, the output channel of the primary kidney is split into 2 duct: DUCTUS MESONEPHRICUS (CUTBER) I DUCTUS PARAMESONEPLIRICUS (Mullers duct - Fig. 7). From Ducti Mesonphrici, seed-eyed paths are developing, the ducti ParameSonphrici formulates a fallopian tube. Men's sex harmonies highlighted by embryonic testicles contribute to the separation of the Ducti Mesonphrici Development. In addition, the testicles secretly have some other factors of non-steroidal nature, under the influence of which the regress and atrophy of Muller channels occur. The upper Ducti Mesonphrici (after the reverse development of the primary kidney) is connected to the seed tube of eggs and form the seed-hanging tubules, a network of eggs, an appendage channel of eggs.

8. Differentiation scheme of external genital organs of the fetus (left - girl, right - boy), a - 2-3 months; B-B - 3-4 months; Mr - at the moment of birth; 1 - sex fold; 2 - anus; 3 - sex roller; 4 - sex gap; 5 - sex bumps; 6-urethral Sklvitch; 7 - scrotum roller; 8 - urethral gap; 9 - sexual process; 10 - the fold of the inner sexual lip; 11 - roller of outdoor sexual lips; 12 - Vulvar chip; 13 - seam scrotum; 14 - scrotum; 15 - urethral seam; 16 - penis; 17 - Small sexual lip; 18 - entrance to the vagina; 19 - a hole of the urethra; 20 - a large sexual lip; 21 - Clit.

The middle part of the Ducti Mesonphrici is converted into the seed-winning duct. The bottom department of the Ducti Mesonphrici (adjacent to the urinary sinus) ampuloid expands, forms a protrusion from which the seed bubble is formed. The lowest part of the Ducti MesonPlirici, which opens in the urogenital sine, turns into a seed-thrust duct. The pelvic part of the urogenital sine is transformed into the prostate and membrane part of the urethra and gives the prostate root, rotating into the surrounding mesenchym in the form of solid heavy. Museum and connecting elements of the gland are developing from mesenchym.

Sumpers in the prostate gland appear after birth, by the period of puberty. DUCTUS PARAMESONEPLIRICUS In the development of a male body disappear, only the XX rudiments remain: the upper part is the eagle process and the lowest part, from which the male uterus is formed - the blind appendage of the prostate part of the urethra of the seed tuberculk.

The development of outdoor genital organs.

The external genital organs are formed in both sexes from the flooring and the cloacade gap. The total cloaca still in the early stages of the development of the embryo is divided from above the partition on 2 departments: the rear (rear pass) and the front (urinary slot in which Wolf and Muller's ducts come out). The urinary bubble and urethra are formed, as well as ureterals and renal pelvis. At the neutral stage, the external genital organs are represented by a gender bump of the urogenital gap and two pairs of folds covering it (Fig. 8).

Internal is called sexual folds, external - sex rollers, from 4 months of embryonic life, the differentiation of external genital organs begins. The male embryo under the action of the field of androgens allocated by the egg, the sexy tuber grows, and the head develops out of it, and later - the cavernous bodies of the penis.

Sexual folds, surrounding the urinary hole, are prior to the lower part of the sexual tubercle, form a urethral groove. The edges of the genital folds, fucked along the urethral groove, form the urethra, around which the seven-powered body of the urethra is formed from the mesenchym.

Sex rollers in men, connecting throughout the entire length, form the skin of the scrotum. For the time of birth of the fetus, testicles are lowered. Chromosomal disorders (quantitative, structural, gene mutations), embryotoxic effects of endogenous and exogenous nature can lead to the development of anomalies of internal and external genital organs. Eggs development anomalies include position anomalies, as well as quantitative and structural.

Vices of the Development of Eggs Anomalies of the Eggs (Cryptorchism)

The testicles in the process of embryogenesis are laid together with primary kidney, and by the end of the 3rd month they migrate into the iliac region. When displaced, the testicle goes into the abdominal cavity, moving in front of him the peritoneum, which forms 2 folds. The cranial fold of the peritoneum covers the vessels and nerves that feed the testicle. Caudal fold forms a vaginal abnurbation process and covers the back guide leaflet, which consists mainly of smooth muscle fibers. By the end of the 7th month, the egg comes up to the inner ring of the inguinal canal, where the guide is penetrated.

Active role in the movement of eggs in the scrotum is played by the contractile ability of the guarantee, the stress of the abdominal muscles, an increase in intra-abdominal pressure. On the 8th month, the testicle passes the groin canal, while the magnitude of the vaginal abnormal process is widely communicated with the abdominal cavity. On the 9th month, the egg falls into the scrotum. Gateway is reduced, turning into a bundle connecting the caudal pole of eggs with a bottom of the scrotum. The vaginal abnurbation proceedings are committed in the proximal department, and the abdominal cavity is eliminated from the inter-brace sinus of the egg.

The absence of one or both testicles in the scrotum is called cryptorchism (from Greek. Hrupto; - hidden and orxis - egg). Cryptorchism is determined in 10-20% of newborns, in 2-3% of one-year-old children, in 1% in the pubertal period and only 0.2-0.3% of adult men. Such statistics are due to the fact that the unfinished omission of eggs in newborns in most observations is liquidated in the first weeks of non-utilized development. Up to 1 year, independent omission of the egg is noted yet in 70% of children with cryptorchism. In the future, the possibility of independent displacement of the testicles in the scrotum exists before the period of puberty.

Etiology and pathogenesis.

The delay in the migration of the egg in the scrotum may be due to endocrine disorders, mechanical causes, dysgenesis of the germ, hereditary genetic moments and a combination of these factors. In the emergence of cryptorchism, and an important role is assigned to the endocrine factor. Hormonal Dnskorrelations in pregnant women, violation of the incredor function of the testicles, thyroid gland, the pituitary of the embryo is able to cause a delay in the displacement of the testicles in the scrotum. These reasons are important in bilateral crilticism.

With a unilateral delay in the egg, the mechanical factors play a certain role, among which the narrow of the inguinal channel is detected during the operation; lack of tunnel in the scrotum; shortening of the seed rope, vaginal abnurbation process, vessels feeding the testicle; underdevelopment of the guide ligament; Pyritoneal fights in the field of the inner opening of the inguinal canal, etc. The listed changes may arise due to the suffering diseases, injuries during pregnancy, but can wear both secondary character on the background of hormonal disorders in the intrauterine period of development of the fetus.

Bilateral abdominal cryptorchism is often combined with disgenesis of testicles. Histological studies in almost half of observations are established primary hypoplasia, unoppopped testicles. Therefore, part of the patients, despite the early reduction in the scrotum, the testicles remain defective. It is likely that the magnificently embodiment in the embryonic period of the Egg predisposes to the development of cryptorchism due to the violation of the incredorial function. In favor of disgenesis, the testicles testifies to a large number of anomalies of the appendage and a seed-handed duct, which are detected by scratching.

In some cases, the unreasure of the testicles has a hereditary genetic nature. Family cryptorchism is observed in men of several generations. Doctors who treat cryptorchism should pay attention to the study of families of patients of boys.

Classification.

To date, there is no generally accepted classification of cryptorchism. The most complies with the correct interpretation of the terminology of this disease Classification S.L. Gorelik, Yu.D.Mirles (1968). We use our classification of cryptorchism and consider it convenient for use in practical work.
Cryptorchism can be one-sided and bilateral. 4 species of cryptorchism are distinguished: due to retention, ectopia, as well as false and acquired.

9. Options of the nizhet of the Egg (Scheme). 1.4 - the usual descent of the testicle; 2 - egg delay in the abdominal cavity; 3 - Egg Delay in the Patch Channel; 5-8 - Ectopia Eggs, deviation from the usual path to the scrotum; 7 - Penal Ectopia; 8 - femoral ectopia.

Cryptorchism due to retention (delay) of eggs.

Retention may be abdominal, gentle and combined. With abdominal retention, one or both eggs can be located in a lumbar or iliac region; With groin - in the inkhan channel. In the combined retention, the testicle on one side is found in the inguinal channel, and on the other hand, it is in the abdominal cavity (Fig. 9).

Cryptorchism caused by ectopia (an unusual location of the lowered eggs).

Ectopia There is a crotch, pubic, femoral, penal, transverse, etc. Extopia arises due to the deviation of the egg from the usual way to the scrotum. In this case, the testicle can be located on the pubic, perineum, the inner surface of the hip, at the base of the penis. With transverse ectopia, both eggs are in one of the half of the scrotum.

False cryptorchism (the so-called migratory testicle).

The egg can temporarily under the influence of a cold or physical exertion to migrate into the groin canal and even in the abdominal cavity. When heating and relaxed muscles, it returns to the scrotum. With false cryptorchism, the scrotum is always well developed, with severe folding and noticeable median seam, the groove ring is somewhat extended.

Acquired cryptorchism.

Most often after injury, the egg can go into the abdominal cavity or a groin canal. The migratory testicle is predisposed to this, in which the groin canal is quite wide. In other cases, the migration of eggs in the abdominal cavity contributes to his atrophy.

Diagnosis of cryptorchism is based on the analysis of complaints and examination of the patient. The main symptoms are underdevelopment, asymmetry of the scrotum, the disappearance of one or both eggs in the scrotum. Often patients complain about the laundering pain in the groin area or in the stomach. When cryptorchism, due to inguinal retention or ectopia, pain appear at an early age due to frequent injury, infringement, yachrobe. With the abdominal egg delay, pain, as a rule, is joined only in the period of puberty. It can be intensified during exercise, stool delay, sexual excitation.

Many patients have a combination of cryptorchism with groin hernia. Therefore, patients need to be inspected lying in a calm state and at the strain of the abdominal press. When stretching into the groin canal, a junk bag can be lowered together with the testicle that becomes available for research.

If in the inguinal channel to prove the testicle fails, then it should be carefully examined and put the places of possible ectopia. Only with the exclusion of unusual localization of the eggs can be suspected the presence of abdominal retention. In 5-10% of patients, especially in bilateral cryptorchism, there may be signs of endocrine insufficiency (eunuchoidal physique, obesity, underdevelopment of the penis, agriculture but the female type, gynecomastia).

However, these symptoms are more characteristic of the anorrhism. Some patients have a delay in sexual development. The abdominal bilateral delay of the testicles should be differentiated from the anorrhism, and one-sided - from monorhism, which is often quite difficult.

Currently, magnetic samples are successfully used, ultrasound scanning, as well as egg scintigraphy after administration of TC compounds. When scintigraphy, using a gamma chamber, it is possible to determine not only the localization and sizes of the egg, but also its functional state. Angiography can be given: the study of the abdominal aorta for the detection of the testicular artery, as well as the super-selective sensing of the inner testicular vein with the fulfillment of the occasional an uninterrupted egg. In doubtful cases, the operational audit of the groin area and the retroperitoneal space is shown.

With different types of cryptorchizman, the Egg, located in unusual conditions for him, has a number of adverse factors; Increased temperature, constant traumatization, nutritional disorders, as well as hyperstimulation by pituitary gland. These conditions lead to the development of atrophic processes in the testicular, to the violation of spermatogenesis and can cause its malignant rebirth. When cryptorchism may also be observed or twisted eggs.

The signs of these complications are the sudden appearance of pain in a relevant or ectopied testicular, swelling, in rare cases - an increase in body temperature. If a perception or infringement is suspected to prevent necrotic changes in the egg, urgent surgery is necessary.

Cryptorchism treatment may be conservative, operational and combined. Conservative treatment should be aimed at improving the functional state of the testicle and the correction of endocrine disorders that often accompany krnptorhism. Therapy can be carried out in all cases as preoperative preparation in patients with hormonal disorders, as well as take place in the postoperative period.

Treatment starts from 4-5 years of age. Vitamin preparations are widely used. Tocopherol acetate (vitamin E) regulates histobiochemical processes in glandulocytes and in the epithelium of the tubing tubules by stimulating the hypothalamic-pituitary system. Retinol (vitamin A) activates cell regeneration processes in the testicles, and also participates in the formation of nuclear spermatogenic epithelium structures. Vitamins C, P, B, improve the redox processes in tissues, are of great importance for the normal functioning of the endocrine glands of the central and peripheral nervous system.

I.F. Yunda (1981) recommends starting the treatment of true cryptorchism immediately after the birth of a child with the appointment of nursing mothers tocopherol acetate intramuscularly to 200-300 mg / day. Through the age of 1, the child is given tocopherol acetate in the 14-10 mg / day mixture in 2-3 receptions within 1 1 / 2-2 months. With a monthly break, the course of treatment is repeated 3-4 times a year: nursing mothers are prescribed multivitamins, it is important to be made full nutrition of the child. Food must contain a sufficient amount of proteins, fats and carbohydrates.

Under reduced nutrition, it is treated with a non-creep, which refers to anabolic steroids, stimulates protein synthesis in the body, improves metabolic processes in the apparent germ glanes. With excess nutrition, obesity is recommended to use thyroidine, which increases tissue respiration, improves the metabolism in the body, activates the antitoxic function of the liver, the excretory ability of the kidneys, normalizes the functions of the thyroid and sex glands.

These drugs are prescribed depending on the age, individual characteristics and patient states. Thyroidine in tablets is recommended at 0.005 g at the age of 5, 0.05 g - aged 15 years 1-2 times a day for 15-25 days. Non-pellets are prescribed: from 3 mg 1 time per day at the age of 5 years, up to 5 mg 1-2 times a day at the age of 15 years (within 20-30 days).

The retented egg is distinguished by a reduced ability to develop testosterone, which is accompanied by hypoandrogenemia with a unilateral process. To stimulate the function of intersticitial cell cells, therapy is carried out by chorionic gonadotropin or its analogue containing predominantly LH. An increase in testosterone generation by intermediate cells can contribute to omitting the delayed eggs. Depending on the age, intramuscularly 250, 500 or 1000 units of chorionic gonadotropin (choriogonin) from 1 to 3 times a week are introduced, on the course of treatment 6-18 injections. MG Georgiev (1969) recommends introducing choriogonin at 500-700 cells 1 time per day for 3 days in the groin canal from the unstacked egg, which provides, besides the usual, local deprepese-lying effect.

With pronounced augenogenic insufficiency, the combined use of the necolila (non-blood) and choriogonin in doses corresponding to age are possible. During the period of puberty under explicit signs of hypogonadism, it is advisable to assign intramuscular injections of testosterone at 10-20 mg every other day (per course of 15-20 injections). After that, a choriogonin is treatment for 1000 union intramuscularly 3 times a week (on the course of 12 injections).

The main method of treatment of cryptorchism remains operational (Orkhnpexia). We believe CTR orchipexia it is advisable to spend aged 5th years, by the time of the child's receipt to school. An earlier operational treatment obviously does not make sense, since the vascular system and seed can be not formed at this age.

There are a large number of ways to reduce the testicles in the scrotum. But they all differ in the ultimately only methods of fixation.

The operation is carried out under anesthesia.

The incision is produced in the groin area, as with hangeal. After opening the front wall of the inguinal canal, the egg is found. The main method of reducing the egg to the scrotum is the mobilization of the seed rope (Fig. 10, a). At the same time, it is necessary to separate the unacceptable vaginal abnormal process (Fig. 10, b) from it. In the presence of hernia, the vaginal process turns into a hernia. In this case, it should be opened, then with the help of the prepacating in the transverse direction of the peritoneum covering the seed edge, and, removing it from the seed rope, is highlighted, flashing and tied up, the neck of the hernial sack.

After that, you follow the finger to penetrate into the inner ring of the inguinal canal, stupidly split it in the medial direction and separate the peritoneum from the seed rope. These manipulations in most cases contribute to the introduction of eggs to the scrotum should be critical of the recommendations of crossing the egg artery to lengthen the seed cord, as this can lead to egg atrophy due to diet. However, with a short vascular leg, autotransplantation of eggs in the scrotum using it for arterialization of its lower left-hand artery is possible. A less favorable egg transplant for iliac vessels.

In the appropriate half of the scrotum, spreading the fabrics, create the box for the egg. In adults, the testicle is often fixed in the scrotum with a thick silk ligature, stitching through the mobilized shells, derived through the bottom of the scrotum and attached by means of elastic rubber thrust to a special cuff, bowed to the upper third of the lower leg. The operation is completed by plastic in the inguinal channel according to the Martynov or Kimbarovsky method.

10. Mobilization of seed rope and eggs with a single block together with the vaginal abnurbation process (A); Mobilization of the seed rope is released by vaginal abnurbation and hernia bag (b).

In children, orchipexia can be performed in 2 stages by Torch - Herzen and modifications. After the mobilization of the family rope, the egg is carried out in the corresponding half of the scrotum. Through the incision in the day of the scrotum and the skin of the thigh, the testicle is supplied and laid to wide fascia, hips. Then above the egg stitch the edges of the cuts of the scrotum and the skin of the thigh. The leg is placed on the Beller bus.

Patients discharge on the 10-12th day after surgery. The second stage of the operation is produced after 2-3 months. It consists in excision of the skin anastomosis and the sewing of small wounds on the thigh and the scrotum.

Operation in ectopia is quite simple due to the considerable length of the seed rope. The transverse ectopia of the treatment eggs does not require.

With bilateral retention, the issue is solved individually taking into account the complaints of the patient and preservation of one of the testicles. Preference should be given to separate rejection of the testicles. At the same time, we begin with less complex surgical intervention.

The forecast for cryptorchism due to the retention of the testicles is improving after surgical treatment. Infertility is cured in 80% operated on with one-sided and in 30% - with bilateral cryptorchism.

Anomalies of the number of testicles

The reason for the violation of the normal course of the embryogenesis of the genital glands may be chromosomal anomalies (structural or quantitative), disorders of the rotation of the sex glands in the early stages of embryonic development. Agility of severe infectious diseases, intoxication, alimentary dystrophy or hormonal shifts in pregnant women. Purely quantitative anomalies of testicles are extremely rare, in most cases they are combined with their structural changes.

Polyorchism.

The presence of more than 2 testicles is a rare anomaly. It described 36 cases of polyorhimism.

The adding egg may have its own appendages and seeding duct. Egg and appendages are usually underdeveloped. Palpation is not enough to confirm the presence of additional eggs, since the tumors of eggs, additional appendages, cysts and other intramochemical formations may be mistaken for an additional egg. Updated testicles can be located in the abdominal, cavity and subjected to degenerative changes. Considering the tendency of hypoplasiated testicles to malignant reincarnation, it shows the operational removal of an additional egg with the reduction of normal in the presence of cryptorchism.

Synorchidism.

Extremely rarely observed an intra-abdominal battle of the testicles, which prevents them with omitting into the scrotum. Hormonal disorders are not revealed, which distinguishes this pathological condition from the anorrhism and bilateral abdominal retention of the testicles. Diagnostics is based on Uz-scanning and operational revision of the retroperitoneal space.

Monorchism (one-sided anesthesia of eggs) is a congenital anomaly characterized by the presence of one egg.

This anomaly arises as a result of a violation of the embryonic bookmark of the primary kidney on the one hand, from which the flooring is formed, so monorchism is often combined with congenital aplasia of the kidney, the appendage of the appendage and the seed-eyed duct, is observed by the scrotium on the appropriate side. The presence of one normal eggs is not manifested by spermatogenesis disorders and endocrine disorders. If the only egg does not fall into the scrotum or is in a rudimentary state, there are signs of hypogonadism.

The diagnosis should be set with the help of angiography, scintigraphy of testicles or during the revision of the retroperitoneal space and abdominal cavity.

Treatment.

In the hypoplasia of the single egg, the replacement therapy androgens is shown, especially during puberty. Such therapy will contribute to the normal. The development of the genital organs.

Anorhisism (Gonadny Agensia) is an innate displacement of eggs in an individual with a karyotype of 46 xy.

Due to the fact that the testicles in the embryonic period do not secrete androgens, the genitals develop on the female type or have a rudimentary structure. Much less often, the external genital organs are developing on male, type. In this case, an elanchoidal physique is observed, the lack of appendages of eggs, seven-way ducts, prostate gland; Rudimentary scrotum.

The final diagnosis is made after the exclusion of bilateral abdominal retention of the testicles. To do this, radionuclide studies and scintigraphy of testicles may be made after the administration of TC compounds. After intravenous administration of the drug on the gamma chamber, the localization and nature of cryptorchism is determined. With anhorism of local accumulation of the drug will not be. You can test a sample with choriogonin for the presence of testicular androgens in the blood. In doubtful cases, the operational audit of the abdominal cavity and the retroperitoneal space is shown.

Treatment.

With anoregism, replacement therapy is carried out by sex hormones, depending on the structure of the external genital organs, and the patient's morphothip, therapy androgen drugs include the appointment of methyltesteterone, Andriol in tablets 3 times a day or testosterone of propionate in 50 mg (1 ml of 5% oil solution) intramuscularly daily. In the future, it is possible to apply the preparations of prolonged action: Sustanon-250, Omnodrene-250, test lat. All of them are introduced intramuscularly 1 ml 1 time in 2-3 weeks. The transplantation of fresh eggs on the vascular leg, as well as the free transplant of fruits and newborn eggs.

Feminizing therapy is carried out during puberty. With a sharp underdevelopment of secondary genital signs, a 0.1% oil solution of the zero radiol of dipropionate is prescribed 1 ml intramuscularly 1 time in 7-10 days. The treatment lasts 3-4 months to stimulate secondary sexual signs, after which they go to cyclic therapy. The estradiol dipropoia is prescribed 1 ml of 0.1% oil solution 1 time in 3 days, 5-7 intramuscular injections. Together with the latter injection, progesterone (1 ml of 1% oily solution) is introduced and then continue to enter it 7 days in a row intramuscularly. Such cyclic therapy courses repeat 4-B times.

Anomalies of the structure of the Yailor

Hermaphroditism (breakfast) is manifested by the presence of signs of both sexes in one individual.

There are true and false hermaphroditism. With true hermaphroditis in the germ, elements of both the testicular and ovarian tissue are developing in the germ. Sex iron can be mixed (Ovatiya), or, along with the ovary (more often on the left), there is an egg on the other side. Violation of the differentiation of the sex glands due to chromosomal mosaics XX / XY; XX / XXY; XX / XXYY, etc., but are also found at Ka-Riotype 46xx and 46XY.

Gonadny fabric develops unequal.

On the other side where the ovarian tissue is mostly developed, Ducti ParameSonphrici derivatives are saved (uterus, pipes). On the side where the testicle is being formed, DUETT MESONEPHRICI derivatives are preserved (seeding duct, egg appendition). Exterior genitals have a dual structure with a predominance of male or female genital signs. The morphothype of patients is determined by the prevalence of hormonal activity of one of the sex glands during puberty. Sexual member is developed, in the presence of hypospadia, under it is the underdeveloped vagina. Often, cyclic blood discharge from the vagina or the urinary sinus is observed.

Milk glands develop.

The mental sexual sex is determined more often by upbringing, not the structure of the external genital organs. Depending on the structure of the internal and external genital organs, corrective operational treatment is carried out, as well as therapy with female or male hormones. False male hermaphroditism is observed in individuals with a karyotype of 46XY, in which, if there are eggs, external genital bodies are developing on women's or intersexual type. The causes of false male hermaphroditism can be hormonal disorders during pregnancy, toxoplasmosis, intoxication.

A number of genetically determined diseases also lead to this anomaly of the testicles, of which the syndrome of feminizing testicles is most famous.

Syndrome of feminizing testicles.

This anomaly develops in persons with a male karyotype of 46XY and a female phenotype, it is due to the insensitivity of peripheral tissues to androgen. Exterior genitals are developed on the female type. In patients there are no uterus, uterine pipes, the vagina is underdeveloped, ends blindly. Milk glands are well developed. The testicles can be located in the thicker of large germ lips, in the inguinal canals, in the abdominal cavity.

Seed tubules are underdeveloped, the intermediate fabric is hyperplazed. The testicles produce a normal amount of androgens and an increased amount of estrogen. The disease is genetically due to a healthy woman, a recessive gene, half of his sons. Treatment by introducing exogenic androgens does not cause virilization. The testicles retain, as they are the source of estrogen. Conduct feminizing hormonal therapy (see Anorhis).

Chaninfelter syndrome (dysgenezia of seed tubules) is described in 1942. The disease is due to the presence of at least one additional X chromosome in the complex of genital chromosomes. The main form of karyotype 47hhh is installed P. Jacobs and 1. Strong In 1959, other chromosomal variants of this syndrome are also observed - XXXY, XXXXY, XXYY, as well as mosaic forms of XY / XXY, etc. The frequency of syndrome among newborn boys reaches 2.5 : 1000. The disease is manifested in the period of puberty from relatively normal boys. Adult men seek a doctor about infertility.

The clinical picture is characterized by the insufficient development of secondary sexual signs: high growth, eunuchoidal physique, small testicles, normally developed or reduced sexual member, poor hair growth on the egg and gynecomics on the female type in 50% of patients are revealed by gynecomastia. The clinical manifestation of androgen insufficiency is explained by the violation of testosterone tissues. Sometimes there is a different degree of mental underdevelopment (more burdened in patients with a large number of X-chromosomes). In the study of the ejaculate, azoospermia is detected. The presence of X-sex chromatin in the cores of the oral mucosa cells is established.

In biopsy of the testicles, the aplasia of the spermatogenic epithelium with the hyaline seed tubules and the hyperplasia of interstitial cells is determined. The hormonal pattern is characterized by low testosterone levels and high indicators of FSH and LH in blood plasma.

Treatment is to appoint testosterone and other androgens, vitaminotherapy. However, replacement therapy is not sufficiently effective due to impaired androgens reception cells of the target sex glands, genital organs and other tissues. Gynecomastia is subject to surgical treatment, as there is a risk of milignizing the mammary glands.

In the period of puberty and later treatment is carried out with a test latter, a Su-250 or Omnodron-250, which is injected intramuscularly 1 ml every 3-4 weeks. Treatment is aimed at the development of secondary sexual signs, the growth of the penis, maintain and strengthen the libido. Spermatogenesis is not restored.

The chromatin-negative version of the Klinfelter syndrome with 47xyyy karyotype is described. Much less often in patients with a Poly Ower Y-chromosoma with a set of xyyy or xyyyy. Individuals with such a set of chromosomes are distinguished by high growth, large physical strength, psychopathic behavior with the features of aggressiveness and the easy degree of mental retardation. The frequency of this syndrome among newborn boys 1: 1000. Men with karyotype 47xyy fertile. Children from them may have a normal karyotype or sometimes a heteropoid set of chromosomes.

Sherchevsky Syndrome - Turner is a variant of pure dysgenezia glands.

The disease was described in 1925 by N.A. Sheershevsky in women, in 1938 Turner for characteristics of this syndrome proposed the main symptoms: infantilism, a wonderland cervical fold, the Valgusian deviation of elbow and knee joints. In addition, Sherchezhevsky - Turner syndrome is manifested by low growth (a wide shoulder belt, a narrow pelvis, shortening the lower limbs with the deformation of the fingers and legs). In this case, sexually expressed sex infantilism. The ovaries are underdeveloped, there are practically no follicular epithelium in them, estrogen products are located at a very low level. This leads to underdevelopment of the uterus, vagina, amenorrhea, infertility, the cooling of secondary sexual signs.

It was found that more than half of women with this syndrome have monosomy X-chromosomes, karyotype 45x0. The occurrence of this anomaly is associated with a violation of spermatogenesis or energenesis of parents. Mosaic forms are observed (x0 / xx, x0 / xy). Less often, the Turner's phenotypic syndrome is determined in men with a karyotype of 46XY. The etiology of the disease in this case is explained by the presence of translocation of the part of the X chromosome on the Y-chromosome. Sometimes the mosaic X0 / XY is detected. Turner syndrome manifests itself in men with low growth and indicated body changes, as well as anatomical and functional hypogonadism (genital hypotrophy, bilateral cryptorchism, low testosterone production, hypoplasiated testicles).

The treatment is to carry out feminizing therapy for women and appointing androgen men. To stimulate the growth of patients and the development of external genital organs, a somatotropin treatment can be carried out, anabolic hormones and vitamin therapy.

11. Options of hypospadia. 1 - Gunning; 2 - trunk; 3 - scrotum; 4 - Crossing.

Syndrome Del Castillo (Terminal Agnesia).

The ethnology of the disease is not sufficiently studied. The disease is manifested in adult men with normally developed outdoor genital organs and pronounced secondary sexual signs. The main complaint is infertility. Dicks in patients with normal sizes or slightly reduced. Gynecomastia is not detected.

In the study of the ejaculate is defined aspermia, less often - azoospermia. With histological study of the biopsy material of the egg, the absence of a spermatogenic epithelium in the tubules is revealed. The basal membrane is lined with only sustopocytes. The intermediate testicular fabric does not suffer from this syndrome. The secretion of sex hormones is reduced. Gonotrootropin levels are increased. In genetic studies, patients are installed normal karyotype 46XY.

Del Castillo et al. (1947) considered terminal aghensia congenital vice. In the future, similar, changes in the tubes of the testicles (terminal atrophy) were determined in patients after radiation exposure and in the experiment on animals when using cystostatic preparations.

The prognosis for the recovery of spermatogenesis is unfavorable.

Congenital testicular hypoplasia.

Etiology has not been fully studied. It is based on the underdevelopment of the genital glands in the embryonic period in the absence of cytogenetic deviations in patients with a male karyotype of 46XY. The hypoplasia is more often diagnosed by chance, when treating patients about a barren marriage. Characteristic for the whole group of patients with a decrease in the eggs located in the scrotum, hypoplasia of the appendages of eggs, a penis, prostate gland, insufficient terminal fragmentation, which is sometimes accompanied by the disproportionate development of parts of the body, pseudogine-generation. In the study of egg bioptats, a varying degree of spermatogenic epithelium hypoplication is detected in the tubules, spermatozoa is rarely found or completely absent. In the intermediate fabric, degeneration and accumulation of glandulocites are marked. The secretion of genital hormones is reduced at an increased or reduced level of gonadotropins.

Treatment is to carry out androgenic therapy or appointment of gonadotropins, biogenic stimulants, vitamins A, E, etc.

Anomalies of the penis and urethra

Hypospadia - congenital underdevelopment of spongy urethra with the replacement of the missing section by the connective tissue and the sparkling of the penis towards the scrotum. It is one of the most common anomalies of the urethra (in 1 of 150-100 newborns). The harospadd is developing due to a delay or violation of the formation of urethra at the 10-14th week of embryonic development. The reasons for it may be exogenous intoxication, intrafapho infections, hyperstroyments in the mother during the formation of the fetus of the genital organs and the urethra.

As a result, the outer opening of the urethra opens above the natural and can be located in the region of the corn-free groove, on the ventral surface of the penis, in the scrotum or perineum region (Fig. 11), depending on the localization of the outer opening of the urethra distinguishes the head, stem, scrotum and crotch hypospadia . With any form of hypospadias between the outer hole and the head, a narrow strip of the mucous membrane and a dense fibrium litigation (chord) is preserved. With this form of anomaly, the urethra becomes shorter than cavernous bodies. The presence of a shortened urethra and a short neelastic chord leads to the bertonation of a penis. The head of the penis naught the book, wide, and the prepucal bag has a view of a hood.

Clinical picture.

Complaints of the patient depend on their age and from the type of hypospadia. If children are concerned mostly urination disorder, then adults are difficulty or impossibility of sexual intercourse.

At the head of hypospadia, which accounts for almost 70% of all hypospadias, children and adult complaints are almost presented. The urethra opens at the place of the usual location of the bridle, which does not cause special disorders. Complaints occur only if there is a stenosis of the outer opening or with a too tilted head when urine can fall on his feet.

With trunk hypospadia, the deformation of the penis is more pronounced. The outer hole is located on the rear surface of the penis between the head and the root of the scrotum. During urination, the jet is directed a book, which makes it difficult to empty the bladder. The erection becomes painful, and the deformation of the penis violates sexual intercourse.

With a scrotum hypospadia, the penis is somewhat reduced and reminds the clitoris, and the outer opening of the urethra is located in the region of the split, resembling sexual lips, scrotics. The patients are routine on the female type, urine is sprayed, which causes the maceration of the inner surfaces of the hips. Newborn with scrotal hypospadhery is sometimes mistaken for girls or false hermaphrodites.

In the saming hypospadia, the hole of the urethra is located even more for the hide, on the perineum. Sex member also resembles the clitoris, and the split scrotum is sexy lips. Cinepathic hypospadia is often combined with cryptorchism, which even more difficult to the sex differentiation of patients.

Children early begin to understand their inferiority, become closed, irritable, retreat. After the end of puberty, they complain about the impossibility of committing sexual intercourse.

The diagnosis of typical hypospadias of special difficulties does not cause. However, differentiate the scrotal and crotch hypospadium from female false hermaphroditism is sometimes very difficult. It is necessary to pay attention to the extreme flesh, which in boys with hypospadhery is located on the dorsal surface of the penis. With false hermaphroditis, it goes to the ventral surface of the clitoris and merges with small sexual lips.

The vagina in these patients is well formed, but sometimes as the diverticulus comes out of the enlightenment of the urethra. It is also necessary to explore the content of 17-CC in the urine and identify male and female chromatin. From radiological data is used genitography (for the detection of uterus and appendages), urethrography (for the detection of urinary sinus) and oxygenosuprewography. Significant opportunities have magnetic resonance tomography and ultrasound diagnostics. In particularly difficult cases, laparoscopy or laparotomy are produced to identify ovaries.

Treatment.

Gunning hypospadia and hypospadia of the distal stem third of the urethra, if there is no significant curvature of the penis or stenosis, do not need surgical correction. In other cases, operational treatment is the method of choice.

To date, many different operational treatment methods have been proposed, but the following recommendations are common to all: to produce an operation in the first years of life, i.e. even before the appearance of irreversible processes in the cavernous bodies; The first stage of the operation - straightening the penis - is carried out at the age of 1-2 years; The second stage is to create a missing segment of urethra - aged 6-13 years.

12. Operations for the rectification of the penis under hypospadia (1-5).

13. Scheme of plastics of the skin defect in Smith - Blackfield in the modification of Savchenko (1-3 - steps of the operation).

15. Plastic circuit of the urination channel by Cecil - Kappo (1-5 steps of the operation).

The first stage lies in a thorough excision of chord (scar tissues on the rear surface), the fibrous septum of the cavernous bodies, mobilizing the penis from the scarring in the scarf and excision of the bridle. Simultaneously produce the outer opening of the urethra and move it up. For the normal development of cavernous bodies, a penis defect formed after straightening is subject to closure of the skin flap. Many different methods of closure of the skin defect are used (bridges of belly or thigh skin, moving the skin of the extreme flesh from the top of the penis head on the bottom, the use of Fidatovsky stem, etc.). However, these methods have not been widespread.

Most often, the so-called unified scheme is used to replace the defect, when the skin of a pre-bag and scrotum is used in the form of mobile triangular flaps on a wide supply base [Savchenko N.E., 1977] (Fig. 12). Unification allows you to mobilize and move the stocks of the skin of extreme flesh and scrotum according to the Smith - Blackfield method in the modification of N.E. Savchenko (Fig. 13). As a rule, after surgery, the urination channel is observed in the proximal direction and an increase in the degree of hypospadia. However, this does not affect the further course of operations. Sex member then fixed for 8-10 days to belly skin. The operation ends with a dye through a urethral catheter.

The second stage of the operation is carried out no earlier than 5 months after the first. About 50 different ways of forming a urethra canal are proposed. However, the most promising are methods using nearby fabrics! So, for example, in a duple, on the bottom surface of the penis from the head and around the hole of the urethra cut the skin flap and form the urethra (Fig. 14). Then the urethra is immersed by crosslinking along the midline remaining on the sides of the flaps. If the skin is not enough, you can immerse the newly created urethra you can be counter triangular flaps.

If the skin defect is totalful throughout the penis, then the urethra can be temporarily immerse in the scrotum. After the engraft on the scrotum, parallel cuts are made and the flaps are cut to cover the newly formed urethra channel. Cecil - Calpa (Fig. 15). Methods of operation in the modification of N.E. Savchenko allows you to unify the plastic of the urethra with all types of hypospadia and is the method of choice. In order to avoid erection, all patients after surgery are prescribed tranquilizers, valerian or bromide (montobromide camphors, sodium bromide).

16. Epispeadia options. 1 - Gully shape; 2 - epispadia of the penis; 3 - full epispadia.

Epispadia - Plug for the development of the urethra, for which the underdevelopment is characterized or the absence of a larger or smaller over the top of its wall. It is less common than hypospadia, about 1 of 500,000 newborns. The boys distinguish the epispatic of the head, the epispatic of the penis, total epispadia. The urinary channel in these cases is located on the dorsal surface of the penis between the split-colored codes.

With any form of epispathia, the sexual member is in one degree or another complied and shortening due to the suspension to the front abdominal wall, and the extreme flesh is preserved only on its ventral surface. The cause of the epispadia is the incorrect development of the urinary sinus, the sexual tubercle and the urogenital membrane. As a result of the displacement of the ugrave plate, it turns out to be a gender tubercle. Sexual folds in the formation of the urethra do not grow up, leaving the cleft of its upper wall.

Clinical picture.

Symptoms depends on the form of Epispadia. The epispadia of the penis head is characterized by splitting the spongy body of the head on the dorsal surface, where the outer opening of the urethra is determined in the crustaceous groove. The head is flattened. With erection, there is a slight, curvature of the penis up. Urination is not impaired, there is only an abnormal direction of urine jet.

Epispadia of the penis is accompanied by flattening, shortening and curvatting it up. The head and cavernous bodies are cleaved, according to the dorsal surface is free from the extreme flesh, which is preserved on the ventral side of the penis. The outer hole in the form of a funnel opens on the body of a penis or at the root of it (Fig. 16). From the outer opening to the head stretch the urethral chute, lined with a strip of the mucous membrane. The sphincter of the bladder is preserved, nevertheless there is often a weakness of it. Therefore, at the strain of the abdominal press, urinary incontinence may be observed. Significant urine splashing makes urinate sitting, pulling off the penis for the crotch. Adults join complaints about the difficulty or impossibility of committing sexual intercourse due to the deformation and curvature of the penis that are increasing during the erection.

Total epispiadia is characterized by the complete absence of the front wall of the urethra, splitting throughout the cavernous bodies and the urinary sphincter of the bladder. Sexual dick will bend it upside down and tighten to the stomach. The outer hole of the urethra canal in the form of a wide funnel is located at the base of the penis and is limited from top of the skin folding of the front abdominal wall. Due to the permanent leakage of urine, there is a crotch and thigh skin macerants. With a total epispade, there is a significant discrepancy between the bones of the pubic symphim, in connection with which the patients have a duck gait and a melt belly.

The disease is combined with cryptorchism, testicular hypoplasia, with underdevelopment of scrotum, prostate gland and vices for the development of upper urinary tract. Total epispyadia causes the greatest degree of urination disorders and fully deprives adult patients with sexual function.

The diagnosis of epispadia of difficulties does not cause and is based on a simple inspection of patients. It is necessary to explore the kidneys and the upper urinary ways to eliminate the anomaly and pyelonephritis.

Treatment.

Epispadia Heads in the correction cup of all does not need. In other cases, surgical treatment is shown, which should be directed to the restoration of the urethra, the neck of the bladder, the correction of deformations and the curvature of the penis. The choice of the method of operation should be carried out depending on the shape of the epispadia and the individual characteristics of the patient. Operational correction is performed at the age of 4-5 years. Before the operation, it is necessary to eliminate the muscles and maceration of the skin.

Significant difficulties occur when the urinary bubble sphincter is restored, followed by a plastic of the urethra. Plastics of bladder cervical and urethra on juno-dissy and plastics of the bladder cervice were obtained the greatest distribution.

Jung-Diss's operation consists in excision of the scar tissue and the formation of the rear urethra and the neck of the bladder at the expense of the bladder. The bladder is revealed by a cut from the top to the outer sphincter: 2 triangular sections of the mucous membrane are cut off and excised. From the remaining median path of the mucous membrane form a urethra. Remucosted side flaps mobilize and stitch the peaks, forming the neck of the bladder. Lobo bones bring together by kapron ships. The formed distal part of the urethra is immersed by stitching the cavernous bodies over the butter and the skin of the penis (Fig. 17). For. Urine's leads are used epicistine.

a - the bladder is opened in the midline, the triangular flaps of the mucous membrane (dottedry) are taken and excised; b - mobilized wall bladder walls sewn tolane; From the median plate is formed on the yetra catheter.

18. The plastic of the neck of the bladder on the holder with a complete epispade. a - the imposition of the first row of seams, narrowing the neck of the bladder; B - overlaying the second row of seams.

The operating of the Derzhanin is to form a bladder sphincter without dissection of the wall due to the longitudinal corrugation of the neck and the wall of it. The front wall of the bladder is exposed by longitudinal ancillary dissection. Then, on the catheter, two rows of submersible seams ingweed each time the longitudinal strip of the bladder is about 3 cm wide for 6 -7 cm (Fig. 18). Having achieved a tight coverage of the catheter with stitched fabrics, draining the lame-raised space, stirred the wound. The catheter is left for 12-14 days to drain the bladder.

The plastic of the urethra is used as an independent operation in an epispade head or penis, it can also be the final stage in the treatment of total epispade. Various methods for the formation of the urethra in an epispade differ from each other degree of mobilization of the mucous membrane when creating a urethral tube, as well as moving it to a ventral surface or leaving on the back surface of the penis.

19. Stages of plastic urethra in duplea at Epispadia (A - D).

Operation Duplea (Fig. 19). By cutting, the outer opening of the urethra and continued on the border of the mucous membrane and skin about the cover, the flap is cut, the width of which should be at least 14-16 cm. The edges of the flap are separated from cavernous bodies by 3- 4 mm and stitched on a catheter with thin synthetic threads Throughout the stem. The second number of seams bring cavernous bodies, third-skin. For urine leads, the urethral catheter is used or impose cysto. With this operation, there is a danger of the formation of urethral fistulas along the coincidence of the seams of urethra and skin.

20. Plastic Urethra in Tierrasha at Epispadia (A - B - steps of operation).

This disadvantage is deprived of the method of Tirsch (Fig. 20). With it, the lines of the internal and external seams are in different projections. In addition, due to mobilization of skin flaps it is possible to form a large-size urethral tube. With a lack of Krzhi, the wound of the penis can be felt in the front abdominal wall, followed by the use of belly skin to close the skin defect (Fig. 21).

21. Closure of the wound defect with a plastic of urethra about Epispadia (A - B).

Plastic Urethra in Junga is to move the newly formed urethra to the ventral surface of the penis (Fig. 22). The incision is made on both sides of the urethral groove and fuse the outer opening of the urethra, which is then mobilized to the Bullbose Department. The edges of the flap over the rest are completely separated from one of the cavernous bodies and spongy body head. On the other hand, the flap mobilize only for seizing seams.

After the formation of the urethral tube on the catarier, it is moved to the ventral surface and fixed there due to the crosslinking of the cavernous and sponnolation bodies above it. After that, the third above the veneer cross the skin of the penis. Urine diversia is carried out using strata.

22. Stages of Plastic Urethra in Yunu at Eppispect (A - E).

In adults during the plastic of urethral, \u200b\u200bwe obtained the best results from the Jung operated according to the method. It should be noted that with all the variants of operations, the most breast moment is the formation of the head of the urethra.

The hidden penis is considered a fairly rarely found definition of development, in which the penis does not have its own skin and is located under the skin of the scrotum, pubis, crotch or hips. This anomaly must be differentiated from micropenis, from ectopia, or from the congenital absence of a penis, in which the splitting of the scrotum is often noted, and the outer hole of the reduced urethra opens on the crotch or in the rectum.

Treatment should be operational and to enter the release of a penis from the fiber and forming their own skin.

For the prevention of disorders of the psychic condition of the child, as well as to create favorable conditions for the development of cavernous bodies, operational treatment is shown aged from 3 to 6 years.

Memorial member.

With this anomaly, the skin of the scrotum departs from the middle or even at the head of the penis. Pretty frequent anomaly, diagnosed, however, in adult men, since it makes it difficult for sexual intercourse.

Treatment operational.

The sexual member is released by transverse dissemination of the midges. The incision after mobilizing the penis stitched longitudinally. Sometimes you have to resort to partial excision of the scrotum.

Phimosis

Frequent definition of the development of the penis is phimosis - the narrowing of the extreme flesh that prevents the release of the head from the prepucitorial pawn.

With phimosis, the white-cooled substance (Smegma), produced by glands, located on the head of the penis, accumulates inside the preparatory bag. Smegma can be thickened, inlaid with salts, and when the infection is attached - to decompose, causing inflammation of the head and the extreme flesh of the penis (balanopostitis), which can later lead to the development of cancer. The pronounced phimosis may cause urination in children, urine delay and even cause the expansion of the upper urinary tract (ureterohydronphrosis).

Treatment.

Children often manage to free the head of the penis after expanding the opening of the extreme flesh and separation of loose adhesions between the head and the inner leaflet of the extreme flesh of the metal probe. In adults, as well as a pronounced phimosis in children, the operation is shown - circular excision of the extreme flesh with the subsequent crosslinking of the inner and external leaflets of it, the dissection of the extreme flesh, etc.

Paraphomy.

One of the dangerous complications of phimosis is paraphomosis, when due to any causes (sexual act, masturbation, etc.), the narrowed extreme flesh is shifted by the head of the penis, its edema develops, which leads to the infringement of the head and impaired its blood supply. In the absence of urgent assistance, necrosis of the undumminated head of the penis can develop.

Treatment of paraffimose is to attempt to refuel the head of the penis by abundantly lubricated with vaseline oil. If these attempts do not lead to success, they make a dissection of the infringerating ring. Subsequently, there is a circular excision of the extreme flesh in a planned order.

A short bridle of the penis can accompany phymsu or dating yourself. A short bridle prevents the release of the head of the penis from the pre-school bag, causing the curvature of the penis when the erection and the occurrence of pain during sexual intercourse. At the same time, the short bridle is often abandoned, causing bleeding.

OL Tiktinsky, V.V. Mikhailichenko

Properties of sexual development in boys are associated with the pathology of secretion or action of androgen. The clinical picture depends on what age the problem arose.

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The formation of the male reproductive system is continuously until the end of the adolescence. Doctors distinguish the 3 phases of the separation of genital organs. For each of them, their dominant influences and certain physiological meaning are characteristic.

Stages of formation:

• intrauterine;
• apprentice;
• puberta.

Intrauterine period

The intrauterine period begins conception and ends with the appearance of a child to light. At the time of fertilization of the egg, the chromosomal sex of the child is determined. The resulting genetic information remains unchanged and affects further ontogenesis. A person has a set xy determines the male floor. Up to 5-6 weeks, female and men's embryos develop equally. Primary genital cells have the ability to differentiate both one and over a different option of up to 7 weeks of pregnancy. Prior to this period, two internal ducts are laid: Wolfs (mesonfral) and mullers (paramenevonephral). Primary gonad to 7 weeks - indifferent (indifferent in boys and girls). It consists of a cortical and brain layer.

After 6 weeks of development, sexual differences appear in differentiation. Their occurrence is due to the effect of the SKY gene, which is located on the short shoulder of the chromosome y. This gene encodes a specific "male membrane protein" H-Y-antigen (emergency development factor). The antigen affects the cells of the primary indifferent gonad, makes it transform into male type.

Embryogenesis of eggs:

• the formation of genital cords from the cortical substance of the primary gonad;
• the appearance of leildig and sertoli cells;
• formation of convinced seed tubules from sex cords;
• the formation of a protein shell of the cortical substance.

Leesig cells begin to allocate testosterone, and sertols - anti-flask factor.

On the 9th week of intrauterine development on sex ducts, the effect of chromosomal and gonadal sex affects. Antimulam factor causes atrophy of paramenevonefral duct. Without this influence of the duct, the uterus is formed, phallopyes pipes, the top one third of the vagina. Regression factor leaves only rudimia in the men's body.

Testosterone Stimulates the development of Wolf Ducts. By the beginning of 14 weeks, the fetus are formed by the appendages of testicles, seed bubbles, seed and seed-milling ductures. Primary sex cells are transformed into sperm.

On the intrauterine stage a great influence belongs digidotestosterone. This hormone is formed from testosterone using an enzyme 5A reductase. Dihydrotestosterone participates in the formation of external bodies (penis, scrotum).

In the intrauterine period, the eggs are lowered into the scrotum. By birth, this process is completed in 97% of the docking boys and in 79% premature.

• vices of a ligament guide;
• dysgenesia gonad;
• hypogonadism in the intrauterine period;
• immaturity of the femoral sex nerve;
• anatomical obstacles on the movement of the egg;
• weakening of the tone of the abdominal muscles;
• testosterone synthesis and action violation.

Applying period

The apparent period is characterized by relative functional peace. In the first months after birth, the child in the blood can determine high levels (due to the receipt of maternal). Next, the concentration of FSH and LH, as well as testosterone drops to extremely low values. The apparent period is called "juvenile pause". It lasts until the end of the prepubertat.

Publit period

In the pubertal stage, the synthesis of testosterone in the testicular is activated. At first, at 7-8 years, the boy increases the level of androgen blood from the adrenal glands (adrenarche). Then, at the age of 9-10 years, braking in the centers of the hypothalamus responsible for sexual development is reduced. This increases the levels of gonadoliberins, LH and FSH. These hormones affect the testicle, increasing the production of testosterone.

Men's genital steroids:

• enhance the growth of internal and external genital organs;
• affect the development of the apparent glands;
• form genital signs (secondary, tertiary);
• strengthen linear body growth;
• increase the percentage of muscle tissue;
• affect the distribution of subcutaneous fiber tissue.

In Pubertate, the ripening of embryonic cells and the formation of mature spermatozoa is begins.

Normal principle of sexual development and determination of its delay

Pubertat in boys starts with zoom. The average age of this feature is 11 years.

Table 1 is the average values \u200b\u200bof the volume of testicles in different age periods (by Jockenhovel F., 2004).

The pace of puberty is the rate of appearance of the signs of Pubertata.

Possible pace:

• medium (all signs are formed in 2-2.5 years);
• accelerated (the formation occurs less than 2 years);
• slow (formation takes 5 years or more).

The normal sequence of sexual ripening signs in Pubertate:

1. increased tesculus (10-11 years);
2. an increase in the penis (10-11 years);
3. prostate development, increase in the size of the larynx (11-12 years);
4. a significant increase in testicular member (12-14 years);
5. lobka Observation of Female Type (12-13 years old);
6. nodes formation in the field of chest glands, (13-14 years);
7. the beginning of the voice mutation (13-14 years);
8. hair appearance in armpits, on the face (14-15 years);
9. pigmentation of the scrotum skin, the first ejaculation (14-15 years);
10. maturation of sperm (15-16 years);
11. lobkovoy Men's Type (16-17 years old);
12. stop the growth of the skeleton bones (after 17 years).

Pubertat's stage is estimated by Tanner.

Table 2 - assessment of the stage of sexual development on a tanner.

Delay of sexual development in boys

The delay in sexual development is determined if the boy by 14 years the volume of the eggs is less than 4 ml, there is no growth of the penis in length and increase the scrotum. In this case, it is necessary to start a survey to identify the cause of pathology.

The reasons

Sexual delay may be due to:

• constitutional features (family);
• disorders of hypothalamic-pituitary regulation ();
• primary insufficiency of testicular tissue ();
• severe somatic pathology.

Diagnostics

• collection of anamnesis;
• evaluation of heredity;
• score estimate by radiograph;
• general inspection;
• inspection of external genital organs, assessment of the volume of testicles and sizes of the scrotum;
• hormonal profile (LG, FSH, testosterone, prolactin, tg);
• tomography of the brain, the X-ray of the skull;
• citogenetic study.

Treatment

Treatment depends on the reasons for the delay of sexual development.

Family forms of sexual delay can adjust with. Anabolic steroids are prescribed to prevent low-speed teenagers with this form of the disease.

In secondary hypogonadism, gonadotropins and gonadojeline are used in the treatment. This therapy is prevention of infertility in the future. The use of hormones of the hypothalamic-pituitary area stimulates the development of testicles and.

With primary hypogonadism, since 14 years, the boys prescribe replacement therapy testosterone.

Premature sexual development in boys

Prematurely consider the emergence of signs of puberty in boys under 9 years old. This condition can lead to social disadaptation. In addition, premature sexual development is one of the reasons for shortness.

The reasons

Premature sexual development is divided into:

• true (associated with the work of the hypothalamic-pituitary area);
• false (associated with autonomous secretion of hormones with adrenal glands or tumors).

True premature sexual development is complete (there are signs of masculinization and activation of spermatogenesis).

The cause of such a state may be:

• idiopathic;
• associated with CNS diseases;
• associated with primary;
• arising against the background of long-term hyperandrode (for example, with adrenal tumors).

False premature sexual development is usually not accompanied by activating spermatogenesis (except for the cases of family testosterone toxicosis).

Causes of false premature sexual development:

• congenital hyperplasia of adrenal cortex;
• , testicles;
• cushing syndrome;
• tumors secreting;
• leesig cell hyperplasia (family testosterone toxicosis);
• androgen treatment;
• isolated premature adrenarch.

Diagnostics

An examination with the signs of premature sexual development includes:

• collection of anamnesis;
• general inspection;
• inspection of genital organs;
• hormone tests (LG, FSH, Testosterone, TSH,);
• samples with gonadoliberin;
• study of bone age;
• x-ray skull, tomography of the brain, etc.

Treatment

For the treatment of true premature puberty uses synthetic analogs of gonadoliberin. This drug suppresses the impulse secretion of LG and FSH. If the cause of the disease is the pathology of the CNS, then the patient is appointed by appropriate treatment (neurologist, neurosurgeon).

The treatment of false premature puberty depends on the causes that caused it. If pathology is associated with an isolated adrenarch - only observation is carried out. If a hormonally active tumor is detected - radical treatment (operation, radiation therapy) is performed. In cases of congenital hyperplasia of adrenal cortex, therapy is selected with corticosteroids.

Endocrinologist Tsvetkova I. G.

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Obesity for the female type (guinided) is found in men less often than abdominal. Nevertheless, the level of people with such a type of excess weight is growing steadily. Obesity in the female type arises mainly due to hormonal failure. In this case, fat fabrics appear in the field of hips, buttocks, chest. The male figure is rounded, the similarity of female, hence the name of the pathology. The article will analyze the causes of the disease in detail, we will tell about the methods of its treatment, about possible consequences. You will learn whether this pathology can develop in teenage boys, look at the photo and video on the topic.

Why does obesity develop on the female type?

Normally in men, the level of androgen and estrogen is maintained at a balanced level. Testosterone prevails, responsible for forming muscles, wide shoulders, narrow thighs. Estrogen, although is present in the body, but does not have a noticeable effect on the formation of adipose tissue and type of figure.

A completely different picture is drawn if, with a hormonal, the level of estrogen prevails over the amount of testosterone. In this case, the body reacts accordingly, the potency decreases, the fat on the hips and buttocks are deposited. Often, fat fabrics develop in the chest area. Therefore, the main reason for the development of obesity in men in the female type of doctors consider violation in the work of the endocrine system.

By the way, in adolescence, boys occur rebuilding the body. At the age of 10-15 years, the hormonal failure - the phenomenon is incredible, so adolescents can observe hynoid obesity. As a rule, pathology passes with age.

Other possible causes of pathology:

• power violation;
• mental disorders;
• sedentary lifestyle;
• ecological situation.

Doctors notice that heredity also plays a role. If parents have obesity in the female type, then the child has the likelihood of such pathology.

How obesity is determined by the female type

When handling a man to a doctor, a specialist finds out the details about the lifestyle of the patient. Needless to be embarrassed, answer questions about nutrition, day mode, medication reception. The presence of obesity can be calculated in the body mass index. The kind of figure indicates the type of figure: the deposition of fat on the hips and buttocks makes a figure like a pear.

See also: Body Mass Index: Table and calculations

Put the accurate diagnosis will help the surrender of testosterone and estrogen tests. If the predominance of female sex hormone is revealed - the doctor will be able to say with confidence about the development of obesity in a man or a teenager in the female type.

At the final stage of the survey, it will be necessary to make an MRI or ultrasound of internal organs. It is necessary to determine the presence of visceral fat on the organs, its number and degree of dystrophy of the organs.

Having in hand results of analyzes and surveys, the doctor will select suitable treatment.

How is the hyneoid obesity in men

The principles of treatment of obesity on the female type are the same as under abdominal form. Regardless of the causes that caused pathology, the fight against it begins with the transition to a diet. From the diet of men, the following products are gradually excluded:

• fried and fatty dishes;
• flour products;
• sweet and sugar;
• tea, coffee, juices.

Instead of excluded food, cereal, fresh vegetables and fruits, greens are added. Meat is allowed, but no more than two times a week and preferably dietary, for example, rabbit. Instead of excluded beverages, it is recommended to drink ordinary water. The volume of daily fluid consumed should not be less than two liters.

Simultaneously with the transition to the therapeutic diet, the lifestyle is adjusted. The doctor recommends a man more time to devote hiking, run, ride a bike. From exercises, those that help burn excess fat in problem parts of the body are suitable. Good effect give daily squats. At this stage, it is important to know: first of all, visceral (internal) fat is burned. Therefore, if obesity from the buttocks and the hips does not leave immediately - do not despair.

Until now, it is necessary to deal with myth, as if the original human embryo is developing on the female way, and only then for future boys under the action of androgens from the female genital organs forms men's. This is not true.

Genetic determination of gender occurs when fertilization. Y-chromosome - determinant genetically male (the zygote contains 22 pairs of autosomes + germ chromosomes XY, i.e. 46xy). Kariotype zigotes genetically female - 46xx.

Approximately the 6-7th week of the intrauterine life of the embryo, his gonads are developing identical both in men and women. This is the so-called indifferent stage Development of the embryo when the genital system of both sexes develops on one genetic program.
During the formation of the gonadal sex, the fetus is developing male ( wolf) and female ( mullerov) Doubles. Initially, the development of these ducts begins unipotential, i.e., regardless of the future gender, and only one of them can develop into a sex tract associated with a specific genetic floor of the fetus. In particular, Wolfs duct turns into the structures of the male sex tract, and Muller - female. The simultaneous presence at this stage of Wolf and Muller Duchs - heritage from our distant alerts-hermaphrodites, who lived hundreds of millions of years ago.

Primary sex cells are formed in the wall of the yolk bag and at the 5th week of embryogenesis begin to migrate into the gonadny rollers - the primitives indifferent Gonad. IN indincher period The development of primary gonads in their stromal tissue contains two types of cells. One type of cells on the gonadal stage of the floor differentiation is developing into granular cells of the ovaries or in the cells of the seminal tubes in the testicles. The second type of cells at the gonad stage is differentiated into the cells of the transparent shell (theca pellucida) in the ovaries or in the lesig cells in the sementes.

At the embryo male At the 6-7th week of embryonic life after migration of primary sex cells in primary gonads in the presence of Y-chromosome containing Sry GenDifferentiation occurs cells of sertoli.. In the process of differentiation, the cells of the sertoli are located around the primary genital cells, the resulting the development of the tubes of the seeds in primary gonads. Differentiation of mesenchymal (stromal) gonad cells in interstitial leesig cellsWho will later secretly secrete the male sex hormone testosterone, begins with the 8-9th week and ends at the 10th week of development of the fetus.
In the female embryo, the differentiation of primary gonad into the ovaries (determined gene Foxl2) Starts from the 9th week when X-chromosomes are activated. In case of failure in the work of the Foxl2 gene, primary gonads will develop in ... Eggs!

Development internal men's genital organs The fetus occurs under the influence of testosterone. The secretion of testosterone cells of Leidig in the fruit of male begins about the 8-9th week of development, under the influence of the chorionic gonadotropin of the placenta, whose secretion is stimulated by the growth hormone. Under influence testosterone Wolfov Dukes are transformed in their development in the appendages of testicles, seed-winning ducts and seed bubbles.
Fetal Eggs Serrtoli Cells Secrets mullers inhibiting factor (synonym - anti-muller hormone), causing regression Muller ducts at the fruit of male.

Fruit evolving for female type, Granular cells and cells of the transparent shell do not secrete anti-mullers hormone and testosterone. In the absence of anti-Muller's hormone hormone, the duct turns into internal female reproductive organs (uterine pipes, uterus, the upper part of the vagina), and at the same time occurs regression Wolf ducts due to the lack of testosterone secretion in the fetus.

The differentiation of the outer genital organs occurs from the urinary sine, sex tuberca, sex folds and sex rollers. The development of external genital organs depends on the genital hormones.
Fruit evolving on male type, under influence testosterone The urogenital sine gives the beginning of the prostate and bulboelectric glands.
5-alpha reductase catalyzes Testosterone transformation into dihydrotestosterone. Approximately the 12th week of intrauterine development of sexiproof under the influence dihydrotestosterone Differentiates to the sexual term, sex folds form a distal part of the urethra, and the sex rollers develop into the scrotum.
Fruit evolving for female type, In the absence of androgens, about the 14th week of intrauterine development of the urogenital sine, it develops into the lower part of the vagina, the sexual tubercle - to the clitoris, and the sex folds and sex rollers are differentiated into small and large sex lips, respectively. Women's sex hormones contribute to differentiation of the extractional organs of the female sexual system.

As we see, the fruit with karyotype xy in one stage cannot be considered a female fruit.