Developmental Disorders

Anatomic development that results in aberrant genital formation may manifest in later life
as male infertility. Main areas of maldevelopment include the testes, the external
genitalia, and the reproductive microductal system.
Intersex or Disorders of Sexual Development
Previously, intersex was divided into categories such as male pseudohermaphroditism,
female pseudohermaphroditism, true hermaphroditism, and mixed or complete gonadal
dysgenesis, with true hermaphrodites having components of both ovaries and testes.
Disorders of sex development (DSDs) are increasingly being understood as the
consequence of specific aberrant genes, and the current nomenclature used to describe
intersex now includes the karyotype, a clinically descriptive term, and the molecular basis
of the disorder if it is known. An example of an intersex description using this
nomenclature might be “46,XY DSD complete gonadal dysgenesis with SF1 mutation” .
Genes identified to be involved in DSD are too numerous to be listed here, and the reader
is referred to Ono and Harley for a current review. In general, the genes involved in
DSDs that manifest as male infertility do so by developmental anatomic abnormalities,
abnormal or absent spermatogenesis, general endocrinopathy, or encoding for defective
endocrine receptors and target complexes

EVALUATION AND MANAGEMENT OF THE NEWBORN

WITH AMBIGUOUS GENITALIA
The evaluation and initial management of the neonate with
ambiguous genitalia must be regarded as a medical and psychosocial
emergency and be handled with great sensitivity
toward the family. Ideally, a medical team including a pediatric
urologist, an endocrinologist, and a psychiatrist or psychologist
experienced in managing intersex patients should work closely with
the family. The team’s goal should be to make a precise diagnosis
of the disorder (which can be achieved in most cases) and,
with the involvement of the parents, to assign a proper sex of
rearing based on the diagnosis, the status of the child’s anatomy,
and the functional potential of the genitalia and reproductive
tract.
In obtaining the history, certain pieces of information may be
particularly valuable. A history of infant death within the family
might suggest the possibility of CAH, and infertility, amenorrhea,
or hirsutism might also suggest possible familial patterns of intersex
states. Certainly, maternal use of medications, in particular steroids
or contraceptives, during the pregnancy is of great importance.
The critical finding on physical examination is the presence
of one or two gonads. This finding effectively rules out overmasculinization
of the female. Because ovaries do not descend, a distinctly
palpable gonad along the pathway of descent is highly
suggestive of a testis. Rarely, an ovotestis undergoes descent to the
inguinal canal and may be suspected on the basis of asymmetry of
tissue texture of the poles of the gonad. This suspicion may be
further supported by ultrasound findings. The patient with bilaterally
impalpable testes or a unilaterally impalpable testis and
hypospadias should be regarded as having a DSD until proven
otherwise, whether or not the genitalia appear ambiguous. Kaefer
and associates (1999) studied the incidence of DSDs in patients
with cryptorchidism and hypospadias and without ambiguous
genitalia. With a unilateral cryptorchid testis, the incidence of
DSD was 30% overall—15% if the undescended testis was palpable
and 50% if it was impalpable. In the setting of bilateral
undescended testes and hypospadias, the incidence of DSD was
quite similar—32% overall but only 16% if both gonads were
palpable. If one of two undescended testes was impalpable, the
incidence of DSD tripled to 47%, comparable to the rate in
those with a unilateral, impalpable, cryptorchid testis. In addition,
posterior urethral meatal position was noted to be a strong
predictor of DSD in this group of patients—65%, versus 5% to 8%
with a midshaft to anteriorly located hypospadiac meatus (Kaefer
et al, 1999).
In addition to gonadal examination, penile size should be
assessed and an accurate measure of stretched penile length
recorded. The mean stretched penile length in full-term males born
in the United States is 3.5 cm (±0.04) (Lee et al, 2006).
An additional important finding on physical examination is the
presence of a uterus, which is noted as an anterior midline cordlike
structure on rectal examination. A more precise means of assessing
müllerian anatomy is by pelvic ultrasonography, which may be
performed immediately in the neonatal period. In addition to
defining müllerian anatomy and confirming the presence or absence
of a uterus, the gonads and adrenals should be studied. Normal
anatomy of an undescended gonad should be confirmed, and a cyst
within the gonad, consistent with ovotestis, should be ruled out.
Within the immediate neonatal period, a karyotype should be
obtained. Typically this requires 2 days to perform. Therefore an
attractive approach to obtain chromosomal data quickly is FISH,
which rapidly identifies X and Y chromosomes. It is typically used
to confirm the presence of a second X chromosome. The technique
is much more rapid than karyotyping, producing results within a
few hours.
Serum studies should be immediately sent to rule out a saltwasting
form of CAH. In addition to serum electrolytes, testosterone
and DHT should be measured early. Migeon and colleagues
(1994) emphasized that the androgen levels may drop quickly,
necessitating early study. In addition, they suggested that serum
17-hydroxyprogesterone should not be measured until day 3 or 4
to rule out 21-hydroxylase deficiency, because the stress of delivery
may result in physiologic elevation of this steroid precursor in the
first 1 or 2 days of life.
In the absence of palpable testes, the presence or absence of
testicular tissue should be determined by documentation of a markedly
elevated LH level, consistent with anorchia, or by means of an
hCG stimulation test, which can demonstrate normally functioning
testicular tissue (Jarow et al, 1986). In addition to ruling out anorchia,
the study can enable diagnosis of 5α-reductase deficiency (by
virtue of an increased ratio of testosterone to DHT) and can help
distinguish between impaired testosterone synthesis (deficient
response to hCG) and androgen insensitivity (normal response to
hCG). Serum MIS measurement should be included as a marker of
the presence of testicular tissue (Hughes et al, 2012).
Based on physical examination findings (largely, gonadal palpability),
the presence or absence of müllerian structures on
ultrasonography, 17-hydroxyprogesterone concentration, and
the karyotype, a reasonable differential diagnosis may be formulated
(Fig. 150-25). A precise diagnosis can virtually always be
achieved for the 46,XX DSD (overvirilized female) but in only 50% of 46,XY DSD
undervirilized males (Lee et al, 2006). The presence
of asymmetrical anatomy on examination and ultrasonography is
an important observation and suggests mixed gonadal dysgenesis if
the karyotype is 46,XY and ovotesticular DSD if it is 46,XX.
Performance of laparotomy or laparoscopy and gonadal biopsy
is usually the next definitive clinical step required when a firm
diagnosis based on the aforementioned data is impossible. Laparotomy
or laparoscopy in this setting remains a diagnostic
maneuver; removal of gonads or reproductive organs should be
deferred until the final pathology report is available and a gender
has been assigned. PCR characterization of the androgen receptor
in venous blood DNA may define the precise genetic abnormality
responsible for a given DSD, be it abnormal androgen receptor or
an enzyme abnormality. These studies should be performed in
specialized laboratories where normal values are well established.
Finally, anatomic definition of the urogenital sinus and ductal
structures contributes to the correct diagnosis and is necessary
before any surgical intervention. The urogenital sinus is well imaged
by retrograde contrast injection, which also opacifies ductal structures,
defines the entry of urethra and vagina into the sinus, and
outlines the cervical impression within the vagina. Endoscopy can
define these relationships further but is usually not necessary until
surgical reconstruction becomes imminent.
Gender Assignment
After a definitive diagnosis has been reached, a thorough and
candid discussion with the family regarding gender assignment
should take place. Issues related to the diagnosis-specific potential
for normal sexual functioning and fertility and the risk of
gonadal malignancy should be addressed. Parents should understand
that high-quality data regarding the long-term psychosocial
outcomes of gender assignment for the majority of DSDs are
lacking, although longitudinal studies are being pursued. Parental
involvement in the decision-making process is essential. If the diagnosis
of a DSD is made prenatally, it is important to present a plan
of management to the parents or risk termination of the pregnancy
(Nihoul-Fekete, 2004).
In the setting of a 46,XX karyotype and masculinized female,
gender assignment is usually appropriately female. In CAH, cortisol
suppresses the undesired androgen; and if maternal androgen
is responsible for virilization, its discontinued stimulation is corrective.
In both cases there are normal ovaries and müllerian ducts,
and a normal reproductive potential exists. If the karyotype is
46,XY, the issue is a more complex one and includes factors such
as penile length and evidence of androgen insensitivity. For
example, 46,XY patients with complete (severe) androgen insensitivity
are appropriately assigned a female gender, whereas those
with 5α-reductase deficiency may be more appropriately assigned a
male gender. The most frequent abnormal karyotype is 45,X/46,XY
mosaicism, which has a variable phenotypic spectrum. The degree
of masculinization of the external genitalia appears to vary with the
amount of testicular tissue present, and gender assignment depends
on the functional potential of the gonadal tissue, reproductive
tracts, and genitalia. The best predictor of adult gender identity is
initial gender assignment (Cohen-Kettenis, 2005b). Some investigators
have suggested deferring the issue of gender assignment until
patients reach an age at which they may declare their own gender
identity. Such an approach, although rational, is difficult to implement
given cultural norms and not recommended in the consensus
statement (Lee et al, 2006). As Elliott (1998) states, “We treat these
children the way we do (as male or female) because this is the way
we see the world; most importantly it is the way that the children,
themselves, are taught to see the world.”
Overall, it is well to remember in the management of ambiguous
genitalia the parameters of optimal gender policy outlined by
Meyer-Bahlburg (1998):
• Reproductive potential (if attainable at all)
• Good sexual function
• Minimal medical procedures
• An overall gender-appropriate appearance
• A stable gender identity
• Psychosocial well-being
The importance of transparency with the family and patient in
management of DSDs cannot be overemphasized. Uncertainties in
outcomes with different gender assignment for different disorders
mandate involvement of the parents in early decision making. In
the long run, transparency is essential for a healthy physicianpatient
relationship as the child develops into adolescence and
adulthood, affording them knowledgeable engagement in DSD
management for the long term.
Ultimately, management of patients with disorders of sexual
differentiation remains a challenging and humbling process. On the
one hand, physicians have at their disposal sophisticated molecular
biologic techniques that have enabled them to identify genetic disorders
responsible for the majority of DSDs. On the other hand,
the mysteries of brain dimorphism in the setting of sexual ambiguity
remain to be solved to optimize the long-term psychosocial
outcome of gender assignment for the individual patient.

KEY POINTS: EVALUATION AND MANAGEMENT OF

DISORDERS OF SEX DEVELOPMENT

• The team’s goals should be to make a precise diagnosis of

DSD (which can be achieved in most cases) and, with the
involvement of the parents, to assign a proper sex of rearing
based on the diagnosis, the status of the child’s anatomy,
and the functional potential of the genitalia and reproductive
tract.
• The patient with bilaterally impalpable testes or a unilaterally
impalpable testis and hypospadias should be regarded
as having a DSD until proven otherwise, whether or not the
genitalia appear ambiguous.

Lippincott:
Disorders of sexual differentiation
A. Disorders of chromosomal sex occur when the number
or structure of the X or Y chromosome is abnormal.
1. Klinefelter’s syndrome (seminiferous tubule dysgenesis)
is the most common major abnormality of sexual differentiation,
with an incidence of approximately 1 in 1,000
males. Patients often present after the time of expected puberty
and are diagnosed incidentally. Patients characteristically
have small, firm testes, impaired sexual maturation,
azoospermia, gynecomastia, and elevated levels of urinary
gonadotropins.
Hyalinization of the seminiferous tubules is a typical
histologic finding. The common karyotype is either a
47XXY pattern (classic form) or 46XY/47XXY (mosaic form,
milder phenotype), due to nondisjunction during meiosis.
Plasma levels of LH and FSH are high, the latter being a
consequence
of damage to the seminiferous tubules. Mean plasma
levels of estradiol are also elevated, leading to insufficient
masculinization
and enhanced feminization. Most patients benefit
from injections of testosterone cypionate or testosterone enanthate.
Surgery is the only available means to correct the gynecomastia.
Surveillance for breast carcinoma (eightfold
greater risk) should be instructed. Paternity can sometimes be
achieved with intracytoplasmic sperm injection (ICSI).
2. XX male syndrome is a rare disorder in which a 46XX
karyotype is present. Eighty percent of patients have the
Y-linked testis-determining factor (SRY), presumably from
translocation of a fragment of the Y chromosome to the X
chromosome. This occurs in about 1 in 20,000 to 24,000 male
births. Affected persons lack female internal genitalia and
have a male psychosexual identification. Ten percent have
hypospadias. Clinical features in those with the SRY gene resemble
those in Klinefelter’s syndrome, including small testes,
gynecomastia, azoospermia, and hyalinization of the seminiferous
tubules; genitalia are otherwise usually normal. Plasma
gonadotropin and estradiol levels are elevated and mean
testosterone levels are low. Management is similar to that of
Klinefelter’s syndrome. All are infertile.
3. Turner’s syndrome (gonadal dysgenesis) is characterized
by sexual infantilism, short stature, shield chest,
webbed neck, neonatal lymphedema, primary amenorrhea,
and bilateral streak gonads in phenotypic females. Multiple
congenital anomalies are noted; 10% to 20% have cardiac
anomalies, most commonly coarctation of the aorta, and 30%
to 60% have renal anomalies. The incidence is 1 in 2,500 live
births. The karyotype varies: 45X in 50%, mosaicism in 30%
to 40%, and isochrome X in 12% to 20%. The mosaic patients
who contain Y-chromosomal material have a 30% chance of
developing gonadoblastoma, and therefore gonadectomy is
indicated
at diagnosis. Mosaicism with a normal chromosomal
complement (46XX/45XO) lessens the severity of the gonadal
abnormality, and the likelihood of menses and breast development
is greater in such cases. Plasma gonadotropins are elevated
from the neonatal period to 4 years of age, normalize
until age 10, and then rise to abnormally high levels thereafter.
Management involves administration of recombinant
human growth hormone with the anabolic steroid oxandrolone
during childhood in an effort to increase the final adult height.
Estrogen replacement therapy should be given at the time of
expected puberty to patients without spontaneous feminization.
Gonadectomy is indicated in mosaics when SRY material
is present in the karyotype because of the possible development
of gonadoblastoma. Maternity can be achieved in some
patients.
4. Mixed gonadal dysgenesis is a disorder in which phenotypic
males or females have a testis on one side (usually
intraabdominal) and a streak gonad on the other. Müllerian
structures accompany the streak gonad and wolffian structures
the testis. Most have 45X/46XY mosaicism, thought to
be due to difficulties with mitotic anaphase. After congenital
adrenal hyperplasia, it is the most common cause of ambiguous
genitalia reported in neonates. The phenotype ranges
from Turner’s syndrome (see above) to ambiguous genitalia
to phenotypic male. Two-thirds are raised as girls. Gonadal
tumors develop in 15% to 20% of patients. In phenotypic females,
prophylactic gonadectomy should be performed. In
phenotypic males, all streak gonads should be removed and
testes may be preserved with close observation if they can be
brought to a scrotal location. Wilms’ tumor is also associated
with mixed gonadal dysgenesis (e.g., in Denys–Drash syndrome),
and screening is indicated.
5. Dysgenetic male pseudohermaphroditism. The
karyotype is 45X/46XY or 46XY, and patients have bilateral
dysgenetic testes. Ambiguous genitalia and müllerian structures
are dependent on relative testicular function.
6. True hermaphroditism is a condition in which both a
functional ovary and testis or an ovotestis (60% of gonads) is
present. Seventy percent of cases have a 46XX karyotype,
10% have a 46XY karyotype, and the remainder are chimeric
(e.g., 46XX/47XXY). Three-fourths are sufficiently masculinized
to be raised as boys. Most of these patients have hypospadias,
and half have incomplete labioscrotal fusion. Most
phenotypic females have an enlarged clitoris, a urogenital
sinus, and a hypoplastic uterus. The internal genitalia tend
to follow the ipsilateral gonad. At puberty, a variable degree
of feminization or masculinization occurs. Breast development
occurs in three-fourths, and half menstruate. Hormonal
replacement is initiated as needed. Sex assignment depends
largely on external and internal anatomic findings in the
newborn, and external genitalia should be modified accordingly.
Fertility is possible in females but has not been reported
in males. Gonadal tumors occur in 10% of patients
with 46XY karyotype and 4% with 46XX. Therefore, once gender
assignment has been established, unnecessary gonadal
and internal genital structures are removed.
B. Disorders of gonadal sex are characterized by an abnormal
differentiation of the gonads without a chromosomal
abnormality.
1. Pure gonadal dysgenesis is a syndrome in which phenotypic
females have a 46XX karyotype, streak gonads with
otherwise normal internal and external genitalia, sexual
infantilism,
and no somatic anomalies. Growth is normal. It
has been observed to be an autosomal recessive trait within
families. Estrogen deficiency is variable, and feminization occurs
in 40%. Management with estrogen replacement therapy
is started at puberty and is maintained throughout life.
2. Complete gonadal dysgenesis occurs in 46XY females
with streak gonads but otherwise normal internal and external
genitalia. Sexual infantilism persists, and amenorrhea is
noted. Risk of gonadal tumors is 30%. Gonadectomy and hormone
replacement at puberty are indicated.
3. Absent testis syndrome occurs in 46XY males with absent
testes in whom endocrine function of the testis was variable
during embryogenesis and fetal development. The clinical
features range from absent or incomplete virilization of the
external genitalia to bilateral anorchia in otherwise
normalappearing
males. The degree of virilization depends on the
timing of testicular failure during gestation—that is, whether
it occurred before or after the development of the seminiferous
tubules and the onset of Leydig’s cell function. Müllerian
inhibiting
substance production prior to testicular failure leads
to regression of müllerian structures. Management depends
on the clinical features. Depending on the patient’s phenotype,
either estrogen or androgen replacement therapy is given to
allow appropriate secondary sexual development.
C. Disorders of phenotypic sex
1. Female pseudohermaphroditism is a disorder of the
46XX female in which the ovaries and müllerian derivatives
are normal, but the feminization of the external genitalia is
abnormal. Virilization of the female fetus is secondary to excess
androgens from either the maternal circulation or the
fetal adrenal gland.
a. Congenital adrenal hyperplasia is the most common
cause of ambiguous genitalia in the newborn. It is also
the most common cause of female pseudohermaphroditism.
In males, the phenotype is precocious puberty, not ambiguous
genitalia.
(1) Pathophysiology. The etiology of congenital adrenal
hyperplasia is a deficiency in one of the five following
enzymes of adrenal steroid production: 21-hydroxylase
(95% of cases), 11β-hydroxylase (5% of cases), 3β-hydroxysteroid
dehydrogenase, 17-hydroxylase, and cholesterol side-chain
cleavage enzyme (rare). The end result is low
cortisol and up-regulation of adrenocorticotropin. In the
first three defects listed, resultant androgen production is
too high and often aldosterone too low.
(2) Diagnosis. Congenital adrenal hyperplasia can be
mild or severe. In the severe form, decreased mineralocorticoid
production can lead to life-threatening salt wasting
and dehydration. This usually happens in the first
weeks of life. Failure to recognize this problem can result
in severe hypotension and ultimately to circulatory
collapse. Adrenal crisis is a urologic neonatal emergency.
In addition to a complete history and physical examination
(including a family history of sudden infant
death), measurement of serum electrolytes, chromosomal
analysis, and determination of enzymatic defect should
be performed. 21-Hydroxylase deficiency results in elevated
plasma 17-hydroxyprogesterone by radioimmunoassay,
11β-hydroxylase deficiency leads to elevated
plasma 11-deoxycortisol and 11-deoxycorticosterone, and
3β-hydroxysteroid dehydrogenase deficiency leads to
elevated 17-hydroxypregnenolone and dehydroepiandrosterone.
Prior 24-hour urine collections are now only necessary
for evaluating response to therapy. Abdominal and
pelvic US are necessary to confirm müllerian structures.
(3) Management of congenital adrenal hyperplasia
should focus on the issues of salt-wasting crisis, degree of
virilization, and psychosocial concerns surrounding the
sexual assignment of the child. Replacement therapy
with cortisone and mineralocorticoids is essential to prevent
salt wasting. In addition, a properly treated child
can maintain fertility if gender remains chromosomal.
Surgical intervention involves reconstruction of the
genitalia (clitoral reduction and creation of a vaginal
introitus and labial skin folds), which can be performed
either during early infancy or later in childhood.
b. Exogenous androgens and progestogens represent
another cause of female pseudohermaphroditism. In
the past, progestational agents with androgenic side effects
were administered during pregnancy to prevent abortion,
resulting in virilization of the female fetus. Female
pseudohermaphroditism
may also occur when the mother has a
virilizing ovarian or adrenal tumor.
2. Male pseudohermaphroditism results from inadequate
virilization of the 46XY male embryo.
a. Abnormalities in androgen synthesis lead to incomplete
virilization of the fetus. The phenotypes range
from penoscrotal hypospadias to phenotypic female. There
are five known defects of testosterone synthesis within
the adrenal gland, each involving a crucial enzymatic step
in the conversion of cholesterol to testosterone. They exhibit
autosomal recessive inheritance. The enzymes cholesterol
side-chain cleavage enzyme, 3β-hydroxysteroid dehydrogenase,
and 17α-hydroxylase are common to the synthesis of
other adrenal hormones in addition to androgens, and their
deficiency leads to congenital adrenal hyperplasia and male
pseudohermaphroditism. Glucocorticoids are deficient in all
three; mineralocorticoids are elevated in 17α-hydroxylase
deficiency and deficient in the first two. On the other hand,
17,20-lyase and 17β-hydroxysteroid oxidoreductase deficiency
are involved only in androgen synthesis. A deficiency
in either leads solely to male pseudohermaphroditism. In
the latter, a phenotypic female can become virilized at puberty
owing to gonadotropin-increasing androgen concentrations.
Müllerian structures are absent in all five defects
because of intact müllerian inhibiting substance.
b. Abnormalities of androgen action may cause impaired
male development as a result of resistance to androgen
action in target cells.
(1) Deficiency of 5_-reductase is an autosomal recessive
disorder associated with failure of dihydrotestosterone
formation from testosterone, resulting in normal
male wolffian duct derivatives but defective masculinization
of the external genitalia. Phenotype ranges from severe
perineoscrotal hypospadias to marked ambiguity
with a blind vaginal pouch opening into the urogenital
sinus. At puberty, variable degrees of masculinization
occur with increased levels of testosterone sometimes
changing a female phenotype to male.
(2) Androgen receptor disorders. The most common
of these disorders is complete testicular feminization,
due to loss of the androgen receptor on Xq11
and 12. Since androgen lacks effect but the müllerian inhibiting
substance effect is unchanged in utero, neither
müllerian nor wolffian structures are present. The gonads
can be abdominal or labial and have the histologic
appearance of undescended testes. The clitoris is normal
or small, and the vagina is short with a blind ending, but
the external genitalia are unambiguously female. As a
newborn, testosterone, dihydroxytestosterone, and gonadotropin
levels are normal. With puberty, estradiol increases
secondary to increased gonadotropin; therefore,
breast development, general habitus, and distribution of
body fat are female in character. Because of increased
tumor formation in the undescended testis (2% to 5%),
gonadectomy is recommended after puberty and feminization.
Partial androgen resistance is known as
Reifenstein’s syndrome; the phenotype can vary from
a normal-appearing infertile man to marked ambiguity.
c. Leydig cell aplasia/LH receptor abnormalities
lead to an XY male with phenotype ranging from female
(short vagina, absent müllerian structures) to male phenotype
with sexual infantilism.