CRYPTORCHIDISM IN LOCAL ARAB POPULATION IN LIBYA

Background: Cryptorchidism is the most common genital problem encountered in pediatrics, it was first described by Hunter in 1786 and despite more than 100 years of research the anomaly is still not well defined and controversial. Objective: To determine the incidence of undescende testes in pupils of age group between 6-15 years in close Arab


INTRODUCTION
he term cryptorchidism is applied to developmental defect characterized by failure of one or both testes to descend into the scrotum and remain in the inguinal canal called also undescended or retained testes.The retractile testes (testis redux) mean fully descended testes that move freely between the scrotum and inguinal canal owing to an exaggerated cremastric reflex.Ectopic testis describes a testis which has become lodged in some abnormal location after emerging from the external inguinal ring. [1,2]Cryptorchidism is the most common genital problem encountered in pediatrics, It was first described by Hunter in 1786 and despite more than 100 years of research the anomaly is still not well defined and controversial.Understanding the abnormalities of morphogenesis, the molecular and hormonal milieu are vital to the diagnosis of this extremely common abnormality. [3,4]yptorchidism shows familial clustering and increases in first degree relatives, suggesting that genetic and/or environmental factor, maternal hormones, geographical variability may contribute to the etiology. [5,6]9][10] There is possible association between congenital cryptorchidism and fetal exposure to antiandrogenic Dichlorodiphenyle-trichloroethylate (DDG), polychlorinated biphenyle (PCB3) and Dibutylphthalate and metabolite monobutylphthalate (MBP) through mother colostrums. [11,12]Maternal dietary factors may T play part like bioaccumulation of contaminants like fish and liver, pesticides like market fruits and potentially toxic food component like smoked products. [13]Accurate diagnosis is imperative to minimize the long term sequelae of infertility and cancer. [14]hysical examination (for palpable testes) and laparoscopy (for impalpable one) has proven to be the accurate diagnostic modalities. [15,16]

METHODS
Between March and April 2001, 7301 male pupils (in eleven schools) of age group between 6-15 years were screened.Each school has two duty shifts, the morning one is between 8 am-12 pm, the afternoon shift is between 2-5 pm (total daily duty time seven hours).The society in the city close tribal with two major clans in which people claimed descent from common ancestor, the marriages usually and exclusively within the clan.Pupils were placed in the frog leg position for examination, this position is important in fatty children with fatty infiltration of the scrotum, the testes milked down to the scrotum to eliminate the possibility of retractile testes.The positive cases were informed to report to the outpatient department for treatment, the included figures were finally determined.

RESULTS
From the 7301 pupils screened 172 found to have undescended testes accounting for about 2.3%, The location of right or left is shown in (Table -1), the unilateralist form the majority of the positive cases with slight deference between left and right distribution, 44.19% and 42.44% respectively and 12.21% bilateral.Table-2 shows the number of positive cases in each school screened, the relatively small number of positive cases in school number two in the table may be attributed to large number of foreign pupils and pupils from outside the city included in this school.Table-3 shows the number of hernias and contralateral retractile testes associated with the undescended testes, the cases of hernias were 3.49% on the site of undescended testes and 1.16% on the sound site.Clinically, 37.8% of undescended test were arrested in the inguinal canal.

DISCUSSION
Undescended testes are found in 3% of full term male infants and 33% in the premature babies at birth. [4[It is the most common birth defect in boys affecting 4-9% of new borns and 1-2% of boys 1 year of age. [5]The study which was done during the World War 2 showed the prevalence of undescended testes was 0.28%, positive family history was found in only 10%. [17]imilar study was done in local area in Nigeria gave an incidence of 2.5%, 42.5% were left sided, 45% right sided and 12.5% bilateral [18] (almost similar to figures obtained in our study).
Recent studies in UK and other European countries suggest that the prevalence of congenital cryptorchidism continues to increase. [19]Prospective clinical studies have shown that the prevalence of cryptorchidism among boys with birth weight less than 2500 grams has increased in UK from 2.7 to 4.1% between 1950s and 1980s , and in Denmark from 1.8 to 8.4% between the 1950 s and 1990s. [20]The increase in the incidence may be related to genetic background specially in a closed society, this need to be investigated.In the United States, the prevalence of undescended testes ranges from 3.7% at birth to 1.1% from age 1 year to adulthood.23][24] Cryptorchidism was identified in 1.5-4% of fathers and 6.2% of brothers of patients with these anomalies. [3]ta suggesting increasing prevalence are conflicting, possibly related to problems with diagnostic accuracy and significant number of cases being retractile and not true chryptorchoids. [22,25]In our study the prevalence is 2.3% in school pupils of age group between 6-15 years (relatively elevated), higher on the left and the left to right ratio was1/0.4,a marked departure from study carried out by Taha in 1995 which gave left to right ratio of 1/0.89. [26]he bilateralism in our screening was 12.2% a different finding from Colodng, in 1986 who gave a figure of 22.5%. [27]Descent of testes into the scrotum occurs by a complex multifactorial process involving the normal development of the testis, the hormonal action of insulin like growth factor 3, testosterone, an intact hypothalamic pituitary testicular axis, the patent processus vaginalis, gubernacular out growth and regression of intra abdominal pressure. [28]esticular descent occurs in two phases, during the first phase and before midge station the testis remains anchored to the inguinal area by insulin like hormone 3(INSL3) driven development of the gubernaculum.The second phase inguinoscrotal phase is dependent on testicular androgen and it is usually completed by the time of birth. [20]In most patients with unilateral undescended testes the testis can be felt in the inguinal canal or in the upper scrotum, some time it is difficult to palpate or even not palpable indicating either abnormality or agenesis of the gonads, for this reason MRI, laparoscopy and laparotomy are indicated to localize the missing testes. [29,30]In our study the majority of undescended testes were impalpable.When the testes are undescended in both sides the study of serum gonadotrophin is useful because serum luteinizing hormone is elevated when gonad tissue is missing and the patient usually infertile. [31]The effects of undescended testes are depression of spermatogenesis, vulnerability to trauma, torsion, malignant degeneration and psychological upset. [32]he depressed spermatogenesis affects not only the undescended testes but also the normally descended, and this will appear after age of two years, [33,34] for this reason it is now accepted the surgical repositioning of the undescended testes by age of two years. [35,36]The liability of the undescended testes for malignant changes is not fully understood, however, inherited abnormalities in the chryptorchoid is claimed.The longer the testis remains undescended and the higher the testes from the bottom of scrotum the more severe the histological changes. [37]In one side undescended testis the risk of testicular cancer may be increased in both testes, although to a much greater extent on the epsilateral side. [38]Cryptorchidism represents a risk feature for primitive testiculopathy associated with long term complications (infertility, torsion, neoplasia and hormonal changes) [10,24,39,40] Children with bilateral cryptorchidism without treatment in early age are certainly set to become infertile and the rate of infertility is inversely proportional to the age. [39]Hormonal therapy is the best initial treatment in most cases, if this is unsuccessful surgery should be performed without delay before the child first birthday to minimize the risk of impaired fertility. [24]n conclusion, figures obtained from our study compare with the other studies in fostering the hypotheses of gradual increase in the incidence of the undescended testes during the last decades.The prevalence of the undescended testes is variable especially in a closed and related society like that of our study.