Decrease in anogenital distance among male infants with prenatal phthalate exposure.

Prenatal phthalate exposure impairs testicular function and shortens anogenital distance (AGD) in male rodents. We present data from the first study to examine AGD and other genital measurements in relation to prenatal phthalate exposure in humans. A standardized measure of AGD was obtained in 134 boys 2-36 months of age. AGD was significantly correlated with penile volume (R = 0.27, p = 0.001) and the proportion of boys with incomplete testicular descent (R = 0.20, p = 0.02). We defined the anogenital index (AGI) as AGD divided by weight at examination [AGI = AGD/weight (mm/kg)] and calculated the age-adjusted AGI by regression analysis. We examined nine phthalate monoester metabolites, measured in prenatal urine samples, as predictors of age-adjusted AGI in regression and categorical analyses that included all participants with prenatal urine samples (n = 85). Urinary concentrations of four phthalate metabolites [monoethyl phthalate (MEP), mono-n-butyl phthalate (MBP), monobenzyl phthalate (MBzP), and monoisobutyl phthalate (MiBP)] were inversely related to AGI. After adjusting for age at examination, p-values for regression coefficients ranged from 0.007 to 0.097. Comparing boys with prenatal MBP concentration in the highest quartile with those in the lowest quartile, the odds ratio for a shorter than expected AGI was 10.2 (95% confidence interval, 2.5 to 42.2). The corresponding odds ratios for MEP, MBzP, and MiBP were 4.7, 3.8, and 9.1, respectively (all p-values < 0.05). We defined a summary phthalate score to quantify joint exposure to these four phthalate metabolites. The age-adjusted AGI decreased significantly with increasing phthalate score (p-value for slope = 0.009). The associations between male genital development and phthalate exposure seen here are consistent with the phthalate-related syndrome of incomplete virilization that has been reported in prenatally exposed rodents. The median concentrations of phthalate metabolites that are associated with short AGI and incomplete testicular descent are below those found in one-quarter of the female population of the United States, based on a nationwide sample. These data support the hypothesis that prenatal phthalate exposure at environmental levels can adversely affect male reproductive development in humans.

Testicular microlithiasis and its relation to testicular cancer on ultrasound findings of symptomatic men.

PURPOSE: We reviewed testicular microlithiasis (TM) on scrotal ultrasound in relation to the incidence of testicular neoplasm in males 17 to 45 years old with scrotal symptoms. MATERIALS AND METHODS: We reviewed the radiographic and medical records of males age 4 weeks to 84 years with symptomatic complaint of scrotal pain or swelling between September 1998 and April 2002. Subgroup analysis was performed on 160 male patients between 17 and 45 years old since they were at higher risk for testicular carcinoma. RESULTS: TM was found in 12 patients (8%) and concomitant testicular neoplasm was found in 4 (33%) symptomatic individuals age 17 to 45. In the 148 (93%) patients without testicular microlithiasis, concomitant testicular neoplasm was found in 2 individuals (2%). Statistical analysis revealed a relative risk of testicular neoplasm in the presence of TM to be 36.5 (CI 4.2-429.6) in our symptomatic population. Sensitivity and specificity were 0.67 and 0.95, respectively. CONCLUSIONS: Symptomatic patients with TM exhibited an incidence of testicular neoplasm greater than that of the general population. An algorithm for the surveillance of patients with TM should be developed. The fact that our patient population was symptomatic at referral preselected toward a higher incidence of TM and testicular neoplasm compared to accepted incidence in the general population. Further investigation will require a multicenter trial to generate an adequate patient pool due to the low incidence of TM and testicular malignancy.

Primary surgical repair of combined gastroschisis and bladder exstrophy.

The combination of bladder exstrophy and gastroschisis has not been reported previously. The authors describe this rare combination of congenital anomalies, as well as the successful multidisciplinary management of this unusual problem.

Adrenal hemorrhage mimicking an abdominal aortic aneurysm.

The adrenal gland is the most common site of extranodal spread from primary lung cancer. We report a case of adrenal hemorrhage secondary to metastasis in a patient with primary large cell carcinoma of the lung presenting as a suspected ruptured abdominal aortic aneurysm.