Int. J. Chem. and Life Sciences ISSN: 2234-8638 www.ijcls.com Case Report

Bilateral Undescended Testis: A Rare Anomaly Dhananjay Kumar 1* and V. Shanmukha Varalakshmi 2 *1,2 Department of Anatomy, Shri Ram Murthy Smarak Institute of Medical Sciences, Bhojipura, Bareilly (U.P.), India

Received for publication: April 21, 2013; Accepted: June 11, 2013

Abstract : is a condition in which one or both the testes have not descended or are not retractable down the scrotal sac. It may be unilateral or bilateral. It is categorized as true undescended testes in which testes are present in the normal route of descent and ectopic testes in which testes may lie outside its normal path of descent at abnormal site. Common complications of Cryptorchidism are testicular cancer, sub fertility, testicular torsion and inguinal hernia. In a male cadaver, both testes were found between the superficial inguinal ring and the . On dissection the scrotal ligament was observed to be attached to the pubic crest. The genital branch of genitofemoral (GFN) enters the through deep inguinal ring and supplies cremaster and the skin of the scrotum in males, but in this case it does not supply to scrotum.

Keywords : Cryptorchidism, Scrotal Ligament, , Genitofemoral Nerve.

Introduction In the early fetal period the testes are located Case Report: posteriorly in the abdominal cavity. During descent, During routine dissection of inguinal region, testis reach the iliac fossa in third month, at deep at Department of Anatomy, Shri Ram Murthy inguinal ring in seventh month, pass through the Smarak Institute of Medical Sciences, Bareilly, in an inguinal canal during seventh month and are in adult male cadaver, both testis were found in scrotum by end of eighth month of intra uterine life. inguinal region (Figure.1). The position of testis was Descent to the scrotum is influenced by anatomical obliquely placed above pubic crest and upper pole and hormonal control (gonadotropins and of testis were very closely placed at the superficial androgens), insulin-like hormone 3 (Insl3), calcitonin inguinal ring. gene-related peptide (CGRP)[1] . Normally, Genitofemoral nerve originates from the L1 and L2 We dissected the region to see scrotal ventral rami and is formed within the substance of ligament. It was seen as a large band extending from psoas major and divides above the inguinal lower pole of testis and was attached to pubic region ligament into genital and femoral branches. The and scrotal sac. The scrotal sac was opened and was genital branch enters the inguinal canal through found empty, containing only loose connective deep inguinal ring and supplies cremaster and the tissue. (Figure.2) skin of the scrotum in males. The femoral branch passes behind the and enters the after piercing the anterior layer of the femoral sheath and fascia lata supplies the skin anterior to the upper part of the .

Clinically undescended testis (UDT) may be arrested at any point along its route into the scrotum i.e., in the , at the deep inguinal ring, in the inguinal canal, or between the superficial inguinal ring and the scrotum. UDT can be associated with a higher risk of infertility and testicular tumours, particularly seminoma. The risk is highest in Figure.1: SIR- Superficial Inguinal Ring, T- Testis abdominal testes. In this case we describe bilateral UDT and unusual supply of genital branch of GFN.

*Corresponding Author: Dhananjay Kumar, Assistant Professor, Department of Anatomy, Shri Ram Murthy Smarak Institute of Medical Sciences, Bareilly-Nainital Road, Bhojipura, Bareilly, U.P. India 1204

Dhananjay Kumar and Shanmukha Varalakshmi: Int. J. Chem. and Life Sciences, 2013, 02 (07), 1204-1206

is not supplying motor to the or sensory to the scrotum, it passes behind the inguinal ligament and provide cutaneous innervation to the upper part of femoral triangle (figure-4), Left side GFN bifurcate just above inguinal ligament but it doesn’t supply either cremaster or scrotum, which may be one of the strong reasons for UDT.

Figure.2: T- Testis, SL- Scrotal Ligament, SS- Scrotal Sac.

Both testes along with spermatic cords were removed and measurements were taken (Figure.3). The measurements were as follows

Right side: Length of spermatic cord- 7.0 cm, weight of testis- 6.9 gm. Dimensions of the testis- Length -3.0 cm, Breadth- 2.0cm, antero-posterior thickness – 2.0 cm

Left side: Length of spermatic cord- 8.0 cm, weight of testis- Figure.4: A- Genitofemoral Nerve (GFN) of right 7.4 gm. Dimensions of the testis-Length-3.0 cm, side: B- Psoas major: C- Femoral branch of GFN: Breadth-2cm, antero-posterior thickness-2.3cm. D- Genital branch of GFN: E- GFN of left side: F- Genital branch of GFN: G- Femoral branch of GFN.

Discussion The understanding of testicular descent has changed much in last 25 years. Undescended testes were reported in the literature. [2, 3] Kalyan et al reported a rare unilateral congenital undescended testis in the pelvic part of abdomen near the deep inguinal ring, such congenital testicular variations may leads to inguinal hernia, testicular cancer and testicular torsion infertility or low sperm count. [4] Recent evidence suggests that undescended testis involves two phases, transabdominal and inguinoscrotal, that are regulated by distinct morphological and endocrine factors. Descent of testis is proposed by different hypothesis. I. Two - stage hypothesis (Transabdominal phase & Inguinoscrotal phase) II. Genitofemoral nerve Figure.3: SC- Spermatic Cord, E- Epididymis, SL- hypothesis. Scrotal Ligament, and Blue arrow shows Sinus of

Epididymis I. Two - stage hypothesis

Transabdominal phase : Testis descent by its We then traced the blood supply which was movement across the abdomen to the entrance of found normal by testicular arteries arising directly inguinal canal i.e. deep inguinal ring is influenced from abdominal aorta and testicular veins draining by anti Mullarian hormone (AMH) secreted by on the right side into inferior vena cava and on the Sertoli cells. left side into left renal vein.

Inguinoscrotal phase : Testis moves through the Right genitofemoral nerve gives genital and inguinal canal into the scrotum. During this phase femoral branch at much higher level, genital branch normal attachment of gubernaculum (scrotal

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Dhananjay Kumar and Shanmukha Varalakshmi: Int. J. Chem. and Life Sciences, 2013, 02 (07), 1204-1206 ligament) plays important role in complete descent male births. After 3 months of postnatal life, testis if of testes into the scrotal sac. Calcitonin Gene Related found undescended is brought into scrotal sac by Peptide (CGRP) a neuropeptide released by GFN Orchidopexy. In this case bilateral UDT is found in plays an important role to act on CGRP receptors of adult male cadaver. We suspect the UDT in this case gubernaculums [5, 6, 7]. In present case, the scrotal may be influenced by improper course of genital ligament, which is remnant of gubernaculum, is branch of GFN and pubic attachment of attached to the pubic region. So this might be the gubernaculum. cause for undescended testis. References II. Genitofemoral nerve hypothesis 1. Hutson JM., A biphasic model for the hormonal As per the study by Lewis in 1948 [8] and control of testicular descent, Lancet 1985, 2, 419 - 21. GFN hypothesis proposed by Hutson in 1987 [9] cutting the GFN in neonatal rats caused 2. Sullivan OO, Bannon C, Clyne O, Flood H. undescended testes (UDT), due to denervation of Hypospadias associated undescended testis in a spigelian hernia. Irish Journal of Medical Science cremaster muscle. Keeping these studies in view we 2006, 175, 77-8. traced genitofemoral nerve in this present case. In support of this view we found that genital branch is 3. Sadiqali AS, Herekar NG. Cryptorchidism - A Case not supplying to the cremaster or cutaneous Report. 2013, 6, 79-80. innervation to the scrotum. Genital branch is passing below the inguinal ligament to provide 4. Kosuri Kalyan Chakravarthi, Uma MN, Karuneswari cutaneous innervation to the upper part of femoral Devi. Congenital Cryptorchidism - Its Anatomical triangle, which has been never reported Aspects, Embryogenesis and Clinical Consequences. anatomically in any other article previously. Int. J. Bioassays 2013, 2, 961-63.

5. Moller H, Cortes D, Risk of testicular cancer with The incidence of undescended testis among cryptorchidism and with testicular bio PMC: 28664. men is approximately one in 1,000 to one in 2,500 [10]. psy: cohort study. BMJ 1998,317, 729. Torsion of testis and inguinal hernia are common complications of undescended testis. It has been well 6. Habenicht UF, Neumann F. Hormonal regulation of documented that men with the history of testicular descent. Adv Anat Embryol Cell Biol 1983, undescended testis have 10 times higher chance of 81, 1 - 54. development of testicular cancer than the normal and the incidence goes on increasing with advance 7. Backhouse KM., Embryology of testicular descent and maldescent, Urol Clin North Am 1982, 9, 315 - 25. in age. The increased risk of malignancy in UDT may be caused by persistence of a few neonatal 8. Lewis LG. Cryptorchidism. J Urol 1948, 60, 345- 56. gonocytes and their subsequent mutation (caused by abnormally high temperature) into carcinoma in situ 9. Hutson JM, Beasley SW. Annotation, The mechanism (CIS) cells and subsequent frank malignancy [11]. of testicular descent. Aust Paediatr J 1987, 23, 215 - 6. Early detection of tumour by ultrasonography, Laparoscopy and MRI will help the surgeons to 10. Pinczowski D, McLaughlin JK. Occurrence of perform inguinal orchidectomy (the surgical testicular cancer in patients operated on for removal of one or both testes). cryptorchidism and inguinal hernia. J Urol. 1991, 146, 1291–4.

Conclusions 11. Hutson JM, Hasthorpe S. Anatomical and functional A unilateral undescended testis is present in aspects of testicular descent and cryptorchidism, 3% of boys at birth and 1% of boys by 3 months of Endocr Rev 1997, 18, 259 - 80. age. Bilateral maldescent is seen in just over 1% of

Source of support : Nil , Conflict of interest: None Declared

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