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Bojesen A et al Increased mortality in Klinefelter syndrome J Clin Endocrinol Metab 2004 Aug;89(8):3830 4 [PMID: 15292313] Greenstein A et al Does sildenafil combined with testosterone gel improve erectile dysfunction in hypogonadal men in whom testosterone supplement therapy alone failed J Urol 2005 Feb;173(2):530 2 [PMID: 15643239] Lanfranco F et al Klinefelter s syndrome Lancet 2004 Jul 17 23;364(9430):273 83 [PMID: 15262106] Matsumoto AM et al Serum testosterone assays accuracy matters J Clin Endocrinol Metab 2004 Feb;89(2):520 4 [PMID: 14764756] Rhoden EL et al Risks of testosterone-replacement therapy and recommendations for monitoring N Engl J Med 2004 Jan 29;350(5):482 92 [PMID: 14749457] Wang C et al Measurement of total serum testosterone in adult men: comparison of current laboratory methods versus liquid chromatography-tandem mass spectrometry J Clin Endocrinol Metab 2004 Feb;89(2):534 43 [PMID: 14764758]
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About 95% of testicular tumors are germ cell tumors (seminomas or nonseminomas) Seminomas do not produce -fetoprotein, but about 5 10% produce some hCG Nonseminomas, on the other hand, produce increased serum levels of one or both of these markers in about 90% of cases Men with liver disease may have misleadingly high levels of -fetoprotein Most germ cell tumors are sensitive to cisplatin-based combined chemotherapy Sperm banking is advised About 5% of testicular tumors are Leydig or Sertoli cell tumors Leydig cell tumors tend to produce estrogen (75%) and cause gynecomastia and impotence on that basis; they may sometimes produce androgens that can cause pseudoprecocious puberty in boys Sertoli cell tumors may also produce estrogen (30%) with feminization; gynecomastia may be due to hCG secretion (25%) Some testicular tumors may be small and nonpalpable yet may secrete sufficient amounts of hCG or estrogen to cause gynecomastia or impotence Testicular ultrasound may help reveal small tumors After unilateral orchiectomy for testicular cancer, an elevated FSH level prior to further treatment indicates a patient at higher risk for cancer in the remaining testis
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One or both testes may be absent from the scrotum at birth in about 20% of premature or low-birth-weight male infants and in 3 6% at full term infants Cryptorchism is found in 1 2% of males after 1 year of age but must be distinguished from retractile testes, which require no treatment Cryptorchism should be corrected before age 12 24 months in an attempt to reduce the risk of infertility, which occurs in up to 75% of men with bilateral cryptorchism and in 50% of men with unilateral cryptorchism It is not clear, however, whether such early orchiopexy improves ultimate fertility Some patients have underlying hypogonadism The ultimate incidence of significant testicular neoplasia is about 0002% in normal males, 006% in cryptorchid males, and up to 5% in patients with intra-abdominal testes
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Prognosis of Male Hypogonadism
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If hypogonadism is due to a pituitary lesion, the prognosis is that of the primary disease (eg, tumor, necrosis) The prognosis for restoration of virility is good if testosterone is given
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CHAPTER 26 B Laboratory Findings
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Laboratory measurements of plasma levels of PRL (see Hyperprolactinemia) and the -subunit of hCG ( -hCG) Detectable levels of -hCG implicate a testicular tumor (germ cell or Sertoli cell) or other malignancy (usually lung or liver) Detectable low levels of serum -hCG (< 5 mU/mL) may be reported in men with primary hypogonadism and high serum LH levels if the assay for -hCG cross-reacts with LH Measurements of plasma testosterone and LH are valuable in the diagnosis of primary or secondary hypogonadism A low testosterone and high LH are seen in primary hypogonadism High testosterone levels plus high LH levels characterize partial androgen resistance Serum estradiol is determined but is usually normal; increased levels may result from testicular tumors, increased -hCG, liver disease, obesity, adrenal tumors (rare), true hermaphroditism (rare), or gain of function mutations affecting the aromatase gene (rare) Many estrogens and substances with estrogenic activity are not detected by estradiol assays Serum TSH (sensitive) and FT4 levels are also determined A karyotype (for Klinefelter syndrome) is obtained in men with persistent gynecomastia without obvious cause Investigation of unclear cases should include a chest radiograph to search for metastatic or bronchogenic carcinoma Needle biopsy with cytologic examination may be performed on suspicious areas of male breast enlargement (especially when unilateral or asymmetric) to distinguish gynecomastia from tumor or mastitis
If the testes are not palpable, ultrasound or MRI can be used to locate them Alternatively, hCG, 1500 units intramuscularly daily for 3 days, causes a significant rise in testosterone if the testes are present Therapy with hCG results in a testicular descent rate of about 25% Orchiopexy decreases the risk of neoplasia when performed before 10 years of age Orchiectomy after puberty is an option for intra-abdominal testes
Henna MR et al Hormonal cryptorchidism therapy: systematic review with metanalysis of randomized clinical trials Pediatr Surg Int 2004 May;20(5):357 9 [PMID: 15221359] Kolon TF et al Cryptorchidism: diagnosis, treatment, and longterm prognosis Urol Clin North Am 2004 Aug;31(3):469 80 [PMID: 15313056]
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