|Year : 2016 | Volume
| Issue : 2 | Page : 79-84
Testicular characteristics of children with cerebral palsy: Our experience
Ibrahim Aliyu1, Abdulsalam Mohammed1, Raymond Belonwu1, Zainab Fumilayo Ibrahim2, Umar Isah Umar1
1 Department of Paediatrics, Aminu Kano Teaching Hospital, Bayero University, Kano, Nigeria
2 Department of Nursing, Aminu Kano Teaching Hospital, Kano, Nigeria
|Date of Web Publication||12-Apr-2017|
Department of Paediatrics, Aminu Kano Teaching Hospital, Kano
Source of Support: None, Conflict of Interest: None
Introduction: Cerebral palsy (CP) is a chronic neurologic disorder. The hallmark of CP is the abnormality of movement and posture, but there may be other associated abnormalities; however, association with absent testis is an area poorly studied.
Materials and Methods: This was a case–control study. Pretested questionnaire was administered by the researchers, and testicular size was determined using an orchidometer.
Results: Thirty-six (65.5%) of the caregivers in the cerebral palsy group had examined the testes of their wards while only 17 (30.9%) of those in the noncerebral palsy group had examined the testes of their wards. Absent testes were reported in 5 (13.9%) of the children in the cerebral palsy group while none was reported in the non-CP group. Three (60%) left testes were reported absent in the CP group, and two (40%) had both testes absent. Most caregivers (80%) could not remember the exact age at which the testes became nonpalpable, but one (20%) was reported at <1-year of life and none at birth. Only one caregiver (20%) complained of absent testes in the cerebral palsy group. A total of 8 (7.3%) testes were absent from the 110 testes (55 pairs); on the right side, 3 (5.5%) absent testes and 2 small testes were recorded among the CP group while only a single small testis was reported in the non-CP group.
Conclusion: Absent testes were more common among the CP group; routine check of its presence and size should be a part of their evaluation.
Keywords: Absent testes, cerebral palsy, spasticity, undescended testes
|How to cite this article:|
Aliyu I, Mohammed A, Belonwu R, Ibrahim ZF, Umar UI. Testicular characteristics of children with cerebral palsy: Our experience. Indian J Cereb Palsy 2016;2:79-84
|How to cite this URL:|
Aliyu I, Mohammed A, Belonwu R, Ibrahim ZF, Umar UI. Testicular characteristics of children with cerebral palsy: Our experience. Indian J Cereb Palsy [serial online] 2016 [cited 2017 Apr 26];2:79-84. Available from: http://www.ijcpjournal.org/text.asp?2016/2/2/79/204407
| Introduction|| |
Cerebral palsy (CP) is a chronic neurologic disorder; it is often defined as a nonprogressive neurologic disorder which results from insult to a developing brain. Its impact could be devastating, with varied clinical manifestations. It occurs worldwide with estimated incidence of 2–2.5/1000 live birth. It is the most common chronic neurologic disorder in our setting with the prevalence of 42.4%; the hallmark of CP is the abnormality of movement and posture, but there may be other associated abnormalities. However, its association with undescended testis is a rarity which has been reported in a few case reports and studies. In undescended testis, there is the absence of the testes in its normal location in the scrotal sac. This may be a congenital or acquired disorder; the congenital form occurs worldwide with estimated incidence of about 3% and 30% in full-term and premature males, respectively. Other established risk factors for undescended testis are low birth weight, maternal estrogen exposure in the first trimester, multiple gestations, and intrauterine growth restriction. Furthermore, hereditary factors may be involved because about 7% of siblings of children with undescended testes may also have cryptorchidism and spontaneous descent after the 1st year of life is uncommon. This disorder may be associated with other genetic disorders., However, the exact incidence of cryptorchidism is not completely known, but Ameh and Mbibu  in Zaria, Nigeria, reported an incidence of 0.5% in their 10-year review.
The pathophysiology of congenital cryptorchidism is poorly understood, and the proposed mechanism implicates mechanical and hormonal factors. However, acquired cryptorchidism has been associated in 50% of individuals of spastic cerebral palsy, which is attributable to spasticity of the cremaster muscle, pulling the testes into the inguinal canal. Physical development tethers the gubernaculum pulling the testis into the inguinal canal; similarly, poor growth of the spermatic cord which is not commensurate with body growth may also pull the testis into the inguinal canal.
| Materials and Methods|| |
The study was a case–control involving 110 children aged 2–14 years; 55 had cerebral palsy attending the neurology clinic, while 55 age-matched controls (who were seen for febrile illnesses such as upper respiratory infection, and malaria) without neurologic or congenital defect were selected from the Outpatient Department Clinic of Aminu Kano Teaching Hospital. Convenience sampling method was adopted. Approval for the study was obtained from the Ethics Committee of Aminu Kano Teaching Hospital, and written consent obtained from the parents/caregivers of the children. The severity of CP was classified using the gross motor function classification system expanded and revised.
A pretested questionnaire was administered by the researchers, and relevant information such as the sociodemographic characteristics was obtained; furthermore, the children were examined to determine the presence of the testes and testicular size was measured using an orchidometer; findings obtained were documented in a pro forma. The testes were characterized as absent by manual palpation and the sizes for those present were further characterized as small, normal, or large using the orchidometer.
Data obtained were analyzed using Statistical Package for Social Sciences (SPSS) Version 16 (SPSS Inc., Chicago, Illinois, USA). Variables were summarized using mean and standard deviation for continuous variables and frequency table for qualitative variables whereas the statistical test of significance using Fisher's exact test for qualitative variables was used with P value set at <0.05 as statistically significant.
| Results|| |
The mean age of the study group was 3.95 ± 3.05 years for both groups.
Thirty-six (65.5%) of the caregivers in the cerebral palsy group had ever examined the testes of their wards while only 17 (30.9%) of those in the noncerebral palsy group had examined the testes of their wards. The caregivers reported absent testes in five (13.9%) of the children in the cerebral palsy group, while none of those in the noncerebral palsy group reported absent testes. Three (60%) of the left testes were reported absent by caregivers in the cerebral palsy group, and two (40%) had both testes absent [Table 1].
Majority of the children in the cerebral palsy and non-cerebral palsy groups were delivered at term (92.7% vs. 98.2%, respectively). Most of the caregivers (80%) could not remember the exact age at which the testes became nonpalpable, but one (20%) was reported at <1 year of life and none at birth. Only a caregiver (20%) had ever complained about the absent testes in the cerebral palsy group while four (80%) were silent. All the caregivers were worried about the absent testes. Their concerns were on the possibility of the absence resulting in infertility. The left testis was noticed to be absent in three (60%) children; both testes were absent at the same time in one child (20%), whereas in one (20%) child, the progression was not remembered [Table 2].
|Table 2: The gestational age and age at detection of absent testes and pattern of testicular retraction reported by caregivers|
Click here to view
On physical examination, a total of 8 (7.3%) testes were absent from the 110 testes (55 pairs). On the right side, 3 (5.5%) absent testes and 2 small testes on the right side were recorded among the CP group while only a single small right testis was reported in the non-CP group. On the left side, five absent (9.1%) testes and four (7.3%) small testes were documented in the CP group while five small testes were documented in the non-CP group [Table 3].
Although there were more abnormal testicular sizes in the CP group when compared with the non-CP group, this relationship was not statistically significant.
Similarly, on the left testes, no absent testis was recorded among the normal group; however, more small-sized testes were recorded among the normal group, but these observations were not statistically significant [Table 4].
Most of the children studied were of term delivery, and all the children with absent testes documented in the CP group were of term delivery [Table 5].
|Table 5: Relationship of the gestational age and the testicular characteristics|
Click here to view
Those with absent testes were of higher severity of defective gross motor function, but these were of no statistical significance [Table 6].
|Table 6: The relationship of the type of and severity of cerebral palsy and testicular characteristics|
Click here to view
| Discussion|| |
This study showed that majority of caregivers in the control group had never examined the testes of their ward; the practice of self-examination is still alien to most society; little wonder why useful practices such as breast self-examination and testicular self-examination (TSE) are poorly practiced despite the immense health benefits that may accrue from it.,,, Therefore, this attitude may extend the care for their wards whereby the need for them to regularly examine their wards when they are apparently healthy may appear strange. Although the low yield in the controls may be related to the recommendations of most guideline on TSE which stipulates self-testicular examination from the ages of 15 to 35 years, therefore those outside this age range may unlikely practice the art of self testicular examination.
Time to detection (TTD) of undescended testis even by health practitioners is an issue of concern; reports from developed countries with well-established health preventive programs which include routine testicular examination by general practitioners or trained nurses have given varied results; Hougaard et al. reported a median age of 8.37 years among their cohort born between 1981 and 1987; however, the TTD was lower at 5.59 years among their 1988–1994 cohort; in our study, most caregivers were unsure of the timing of detection, but only one (20%) reported between 1 and 5 years. This implies that the advantages of routine self-examination by both caregivers and health practitioners are grossly underutilized. There was concordance by both the caregivers and researchers in detecting absent testes; however, the caregivers were poor at determining testicular size. This may be attributable to lack of knowledge on the technique of self-examination; therefore, only gross anomaly such as an absent test could easily be appreciated. However, only one caregiver complained to medical personnel about absent testis. Possibly, caregivers read little importance to the absent testes; this is exemplified by the report of Chung et al., whereby about 89.6% of parents would prefer surgical treatment after the age of 1 year.
This study showed that a total of 8 (7.3%) testes out of 110 testes (55 pairs) were absent while additional six testes were of small size among the CP group while only one small testis was reported in the control group. Therefore, the CP group had a higher frequency of undescended testes; however, this observation was not statistically significant. Furthermore, those with spastic cerebral palsy had a higher frequency of undescended testes among all forms of CP; this finding is similar to that reported by Smith et al.; therefore, the postulation that spasticity of the cremaster muscle may result in retraction of the testis out of the scrotum is plausible. In their submission, it is suggested that the testes are palpable in the scrotum at birth; the spermatic cord measures about 4–5 cm at birth; following growth of the scrotum; there is failure of commensurate growth and elongation of the spermatic cord; therefore, the testes remain stationary at the same position as was at birth, while the scrotum moves further down, distancing from the testes; however, Smith et al. also demonstrated the presence of fibrous tissue in the spermatic cord which makes it retractile even with attempts at pulling it down into the scrotum.
| Conclusion|| |
This study demonstrated that undescended testes are more common in children with cerebral palsy than in the children without neurologic disease; furthermore, those with spastic cerebral palsy had more reports of undescended testes than in other forms of CP.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Ashwal S, Russman BS, Blasco PA, Miller G, Sandler A, Shevell M, et al.
Practice parameter: Diagnostic assessment of the child with cerebral palsy: Report of the Quality Standards Subcommittee of the American Academy of Neurology and the Practice Committee of the Child Neurology Society. Neurology 2004;62:851-63.
Winter S, Autry A, Boyle C, Yeargin-Allsopp M. Trends in the prevalence of cerebral palsy in a population-based study. Pediatrics 2002;110:1220-5.
Belonwu RO, Gwarzo GD, Adeleke SI. Cerebral palsy in Kano, Nigeria – A review. Niger J Med 2009;18:186-9.
Beckung E, Hagberg G. Neuroimpairments, activity limitations, and participation restrictions in children with cerebral palsy. Dev Med Child Neurol 2002;44:309-16.
Aliyu I. Acquired cryptorchidism with spastic cerebral palsy. Indian J Cereb Palsy 2015;1:42-4. [Full text]
Jadhav S, Kumar P. Role of ultrasonography and orchidopexy in undescended testis in semi urban setting of a developing country. Internet J Urol 2013;11:1.
Silver RI, Docimo SG. Cryptorchidism. In: Gonzales ET, Bauer SB, editors. Pediatric Urology Practice. Philadelphia: Lippincott-Raven; 1999. p. 499.
Ameh EA, Mbibu HN. Management of undescended testes in children in Zaria, Nigeria. East Afr Med J 2000;77:485-7.
Backhouse KM. The natural history of testicular descent and maldescent. Proc R Soc Med 1966;59:357-60.
Smith JA, Hutson JM, Beasley SW, Reddihough DS. The relationship between cerebral palsy and cryptorchidism. J Pediatr Surg 1989;24:1303-5.
Wardle J, Steptoe A, Burckhardt R, Vögele C, Vila J, Zarczynski Z. Testicular self-examination: Attitudes and practices among young men in Europe. Prev Med 1994;23:206-10.
Onyiriuka AN, Imoebe FE. Testicular-self examination among Nigerian adolescent secondary school boys: Knowledge, attitudes and practices. J Prev Med Hyg 2013;54:163-6.
Yakubu AA, Gadanya MA, Sheshe AA. Knowledge, attitude, and practice of breast self-examination among female nurses in Aminu Kano Teaching Hospital, Kano, Nigeria. Niger J Basic Clin Sci 2014;11:85-8. [Full text]
Tu SP, Reisch LM, Taplin SH, Kreuter W, Elmore JG. Breast self-examination: Self-reported frequency, quality, and associated outcomes. J Cancer Educ 2006;21:175-81.
Millon-Underwood S, Sanders E. Testicular self-examination among African-American men. J Natl Black Nurses Assoc 1991;5:18-28.
Hougaard KS, Larsen AD, Hannerz H, Andersen AM, Jørgensen KT, Toft GV, et al.
Socio-occupational class, region of birth and maternal age: Influence on time to detection of cryptorchidism (undescended testes): A Danish nationwide register study. BMC Urol 2014 28;14:23.
Chung JM, Lee CY, Kang DG, Kim JS, Cho WY, Cho BM, et al.
Parental perception of optimal surgical age for correction of cryptorchidism: A multicenter surveillance study. Urology 2011;78:1162-6.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]