TESTICULAR VOLUME MEASUREMENT: COMPARISON OF PRADER ORCHIDOMETER, ULTRASOUND SCAN AND WATER DISPLACEMENT A DISSERTATION SUBMITTED BY DR MBAERI, TIMOTHY UZOMA MBBS (Port Harcourt) DEPARTMENT OF SURGERY NNAMDI AZIKIWE UNIVERSITY TEACHING HOSPITAL, NNEWI TO THE NATIONAL POSTGRADUATE MEDICAL COLLEGE OF NIGERIA IN PART FULFILMENT OF THE REQUIREMENTS FOR THE AWARD OF THE FINAL FELLOWSHIP OF THE MEDICAL COLLEGE IN SURGERY (FMCS) JUNE 2011 1 DECLARATION I hereby declare that the research project leading to this dissertation was actually carried out by me under the guidance of my supervisors. The work has neither been presented in part nor in full to any other College for a Fellowship; also it has not been submitted elsewhere for publication. ..................................................... DR MBAERI TIMOTHY UZOMA 2 DEDICATION I DEDICATE THIS WORK TO MY DEAR WIFE AMAKA WHO BORE THE BURDEN OF MY NEGLECT IN THE COURSE OF MY PROGRAMME, HER PATIENCE, PRAYERS AND ENCOURAGEMENT. TO MY PARENTS MR. AND MRS. REUBEN IBEBUKA MBAERI WHO INSPITE OF ALL ODDS MADE ME QUALIFY AS A DOCTOR IN THE FIRST PLACE. 3 CERTIFICATION This is to certify that I supervised Dr Mbaeri Timothy Uzoma in carrying out the research project leading to this dissertation titled “Testicular volume measurement: Comparison of Prader orchidometer, ultrasound scan and water Displacement” Signed ......................................................................................... Prof. Mbonu O.O. MB (Lond), FRCS(Ed), FRCS(C), FWACS, FMCS. Consultant Urologist Department of Surgery Nnamdi Azikiwe University Teaching Hospital Nnewi. Signed ............................................................................................ Prof. Orakwe J.C. FMCS, FWACS Consultant Urologist Head Department of Surgery Nnamdi Azikiwe University Teaching Hospital Nnewi. Signed............................................................................................. Prof. Nwofor A.M.E. FMCS, FWACS Consultant Urologist Dean Faculty of Medicine Nnamdi Azikiwe University . Signed ........................................................................................... Dr .Oranusi C. K. FWACS, FMCS Consultant Urologist Department of Surgery Nnamdi Azikiwe University Teaching Hospital Nnewi. 4 TABLE OF CONTENTS Content Page Title Page.......................................................................................................i Declaration Page............................................................................................ii Dedication Page.............................................................................................iii Certification ……………………………………………………………………….iv Table of Content…………………………………………………………………..v Abbreviations……………………………………………………………………..vi Acknowledgement………………………………………………………………..vii Summary …………………………………………………………………………viii CHAPTER 1. Introduction……………………………………………………………….1 2. Literature Review…………………………………….............................4 3. Aims and Objectives...........................................................................24 4. Materials and Method……………………………..................................25 5. Results................................................................................................30 6. Discussion………………………………………….................................41 7. Conclusion and Recommendation…………………………..................47 References …………………………………………………………….................48 Appendix I- Picture of orchidometer Appendix II- Proforma Appendix III-Ethical committee approval 5 TABLE OF ABBREVIATIONS Abbreviation Meaning L Length W Width H Height Formula 1 Length x Width x Height x 0.52 Formula 2 Length x Width2 x 0.52 Formula 3 Length x Width x Height x 0.71 Sig significance 6 ACKNOWLEDGEMENT I wish to thank Prof O.O. Mbonu for his fatherly disposition during this work and for the rare honour and opportunity of having him read through my work. I want to express my profound gratitude to Prof. J.C Orakwe and Prof. A.M.E. Nwofor my mentors in the strictest sense of the word, who screened my topics, guided me and inspired me all the way from the beginning to the end of this study. They breached protocols; receiving my work on the corridors, offices, in their homes despite their very busy schedule in soft and hard copies for review, constantly urging me on and allaying my fears. The reviews came out as quickly as I made them ready. Prof J.C Orakwe taught me my first orchidectomy, a core component of this study. Prof. Nwofor through his tireless effort got my proposal returned when it was unduly delayed. I shall ever remain grateful to them. I want to thank specially Dr. C.K Oranusi, through whom my topic finally came with the initial materials to kick start this dissertation, availing me the opportunity to tap from his own experience at no cost. I thank Dr Akukwe and Abiahu who helped in making sure I got all the samples from my patients for the purpose of this study. Dr Egwuonwu, for his advice and encouragement and my other colleagues who one way or the other, contributed to the success of this study Finally my gratitude goes to God almighty for giving me the strength and wisdom to make this work a reality. 7 SUMMARY OBJECTIVE: To determine the accuracy of the Prader orchidometer and ultrasound (different methods) for measuring the testicular volume by comparing the resultant measurement with the actual testicular volume in humans. BACKGROUND: Since seminiferous tubules comprise 80 to 90% of testicular mass, the testicular volume is believed to be an index of spermatogenesis. Therefore accurate testicular volume is one way to assess testicular function. MATERIALS AND METHODS: The testicular volumes of 121 testes from 62 patients with prostate cancer (mean age 72.74+ 9.38) were measured using the Prader orchidometer and ultrasound before therapeutic bilateral orchidectomy. The ultrasound measurements of testicular volume were calculated using three formulas: length (L) x width (W) x height (H) x 0.52, L X W2 X 0.52, L X W X H X 0.71. The actual testicular volumes were determined by water displacement of the testis. RESULTS: The mean actual testicular volume of the 121 testes was 10.6+3.5ml. A strong correlation was found between the actual testicular volume and volume calculated by the three ultrasound formulas (r=0.853 to 0.871, p= 0.0001) and Prader orchidometer (r=0.921,p=0.0001). The smallest mean difference from the actual testicular volume was observed with the formula L X W X H X 0.71, which underestimated the actual volume by 0.41ml (3.89%). The measurements using the Prader orchidometer correlated with the testicular volume calculated using the three ultrasound formulas (r=0.848 to 0.854, p= 0.0001). However the orchidometer measurements had a mean difference from the actual testicular volume of 2.66ml (25.14%) CONCLUSION: The result of this study has shown that measuring the testicular volume by ultrasonography is more accurate than by Prader orchidometer, and the formula L X W X H X 0.71 is the most accurate for calculating the testicular volume. 8 CHAPTER ONE INTRODUCTION Testes are the paired oval shaped organs located in the scrotum. They are responsible for the production of spermatozoa and testosterone in man. The word “testis” is a Latin word enshrined in Roman legal practice as “testis unus, testis nullus” (one witness equals no witness), meaning that testimony by any one person not corroborated by the testimony of another is to be disregarded. Since two witnesses were needed and they often came in pairs, this was also extended to the testis. Therefore, it is supposed to be a “Witness” of virility.1 Reliable and accurate determination of testicular volume is of great potential benefit in evaluation of patients with a variety of disorders affecting testicular growth, development and function. Approximately eighty to ninety percent (80% - 90%) of testicular volume is made up of seminiferous tubules and germ cells.2,3 Thus, a reduction in the number of these cells is manifested by reduction in testicular volume. This was corroborated by Lipshultz et al4 who found that decreased testicular size, whether unilateral or bilateral, correlates with impaired spermatogenesis. Studies in infertile men have also shown that testicular volume has a direct correlation to seminal fluid and sex hormone assay, just like the simple measurement of testicular length, width and depth.5-8 Total testicular volume (i.e. summation of right and left) of 30 ml and above is indicative of normal 9 testicular function. 5,6. These findings underscore the great importance of testicular volume measurement in the management of male infertility. In the management of adolescent varicocele, testicular volume measurement aids in deciding when to operate since getting seminal fluid analysis could be seen to be psychologically and ethically incorrect.9-13. Other important uses of testicular volume measurement are in the monitoring of patients following varicocele ablation in children and adults, and orchidopexy for undescended testes14,15. It is also a vital tool in staging puberty, as it is the first clinical evidence of puberty16, in making a diagnosis of hypogonadal hypogonadism and Klinefelter’s syndrome. 17-22 Over the years, many instruments have been used in an attempt to accurately, reliably, and conveniently measure the testicular volume in vivo. These include rulers, tapes, vernier callipers, orchidometry, graphic models and ultrasound scan. Earlier works using these tools have shown conflicting results and the search continues for a more