Disorder of sex differentiation ( ambiguos genitelia )

1. DISORDERS OF SEX DEVELOPMENT
Presented by - Dr Anand Singh
MAX SUPER SPECIALITY HOSPITAL VAISHALI

2. DISORDERS OF SEX DEVELOPMENT(DSD)
Preferred over intersex, ambiguous genitalia or
pseudohermaphroditism
A condition in which development of chromosomal, gonadal or
anatomical sex is atypical.
 DSD is estimated to 1 – 2% of live birth and only 0.1 – 0.2 % require
surgery at some point.
 Only 4- 7% of infant with DSD have ambigious genitalia.
Thyen U, Lanz K, Holterhus PM, Hiort O. Epidemiology and initial management of
ambiguous genitalia at birth in Germany. Horm Res 2006;66(4): 195–203

3.  Most cases present in newborn, not in adolescence.
 It is a social & medical emergency.
 It creates tremendous anxiety for the parents.
 have life threatening salt wasting
nephropathy  if unrecognized can cause vascular
collapse & death (CAH)

4.  In 2006 a task force sponsored by the European Society for
Pediatric Endocrinology and the Lawson Wilkins Pediatric
Endocrine Society proposed a new nomenclature and
classification system as well as new management
recommen-dations for DSD
 These disorders were further subdivided into
 46,XY DSD (disorders of gonadal or testicular
development and impaired androgen synthesis or action),
 46,XX DSD (disorders of gonadal or ovarian
development and androgen excess),
 chromosomal DSD (numeric sex chromosome
anomalies).

6. WHEN TO SUSPECT
 Micropenis: Stretched penile length <2.5cm in a term
newborn
 Asymmetry of labioscrotal folds
 B/L cryptorchidism ( non palpable testis )
 U/L cryptorchidism with hypospadias
 B/L testes with perineoscrotal or penoscrotal hypospadias
 Female external genitalia with clitoromegaly or inguinal
hernia
 Overtly abnormal genitals like cloacal exstrophy
( abdominal organs exposed, splitting of genitals with sealed anus )
 WHY IMP :- Salt wasting CAH can be life threatening in
1st week of life.

7. Older patients
 unrecognized genital ambiguity
 female inguinal hernia
 delayed or incomplete puberty
 female virilization
 primary amenorrhea
 phenotypic male breast development
 cyclical gross hematuria indicative of
menstruation in a phenotypic male

8. Micropenis with hypospadias (arrowheads)
scrotum is bifid with a midline cleft (arrow)

9. EMBRYOLOGY
 Sexual differentiation-3 stages
1. Determination of genetic sex (at conception)
2. Gonadal sex differentiation (at 6-8 wks of gestation)
3. Phenotypic sex determination (at 8-12 wks of gestation)
 Stage 1 depends upon sex chromosome complement of
fertilizing sperm ( XX/XY )
 Stage 2 depends upon SRY gene of Y chromosome, causes
undifferentiated gonad to develop into testis.
 Stage 3 depends upon fetal testis secretion of testosterone
from leydig cells and anti mullerian hormone (AMH ) from
sertoli cell.

10. 2. Sexual Differentiation
 Gonadal differentiation at 6-8 wk gestation
 TDF – SRY ( Y-chromosome):
 stimulates gonads towards testicular differentiation
 Req association of other genes SOX 9, SF – 1, WT 1
 Absence of TDF:
 gonads differentiate into ovaries
 Ovary determining genes are also identified DAX 1, WNT
4, R Spondin 1

12. Male (requires DHT):
labioscrotal fold = scrotum
urethral fold / groove = urethra
urethra
genital tubercle = glans penis
Female (requires nil):
labioscrotal fold = labia majora
urethral fold = labia minora
genital tubercle = clitoris

13. Testicular synthesis of testosterone is stimulated by

15. Classification based on gonadal status
 Over-androgenized female (ovary + ovary)
 Under-androgenized male (testis + testis)
 True hermaphrodite (ovary + testis)
 Mixed gonadal dysgenesis (testis + streak)
 Pure gonadal dysgenesis (streak + streak)

16. Over androgenized female (ovary +
ovary)

17. Under-androgenized male (testis + testis)

18. True hermaphrodite
(ovary + testis)

19. 
EVALUATION

20. Pre natal evaluation
 Ambiguous genitalia should be suspected if the typical male or female
genitalia are not seen at prenatal US.
 In such cases a thorough fetal survey should be performed to detect
possible associated anomalies .
 Depending on the initial US findings and gestational age, repeat
prenatal US and MR imaging examinations.
 Along with imaging investigations, a fetal karyotype should be obtained
for assistance in counseling parents in the prenatal period.
Ogilvy-Stuart AL, Brain CE. Early assessment of ambiguous genitalia. Arch Dis Child 2004;89(5): 401–
407.

22. POST NATAL EVALUATION
 Family history – CAH, hypospadias, cytorchidism,
infertility, pubertal delay, corective genital surgery,
genetic syndromes
 Ambiguous genitalia, infertility or unexpected
changes at puberty may suggest a genetically
transmitted trait
-CAH ---autosomal recessive--occur in siblings
-Partial androgen insensitivity---X-linked
 Consanguinity ↑↑the risk of autosomal recessive
disorders

23.  Neonatal death – male death from vomitting or dehydation may suggest
undiagnosed CAH
 Maternal drug exposure – androgens (testosterone,danazol) anti androgens
(spironolactone,finesteride), estrogen, progestin, antiseizure medications( phenytoin,
trimehadione)
 Maternal virilization – maternal CAH, virilizing renal or adrenal tumour, placental
aromatase defeciency
 Placental insufficiency – first trimester synthesis of testosterone in fetal testis is
dependent on placental hCG
 Prenatal findings – oligo, renal anomalies(genitourinary anomalies) skeletal
anomalies( campomelic dysplasia)
Adolescent Pt
 When ambiguity first noted?
 Any pubertal signs?

24. PHYSICAL EXAMINATION
Overall assessment
 Abnormal facial appearance or other dysmorphic features
suggesting a multiple malformation syndrome
 Evidence of salt wasting  skin turgor, poor tone dehydration, low
BP, vomiting, poor feeding
 Hyper pigmentation of the skin due ↑↑ ACTH
 Abdominal masses
 In adolescent  evidence of hirsutism/ virilization

25. PHYSICAL EXAMINATION
External genitals
 stretched penile length, engorgement, chordee, position of
urethral opening, vaginal opening, pigmentation and
symmetry of scrotum or labioscrotal fold
 Normal clitoris < 1 cm
 Normal stretched penile length from pubic ramus 2.5 cm
 Increased anogenital ratio ( posterior fusion of
labioscrotal fold ) > 0.5  first trimester androgen
exposure
 Distance b/w anus and post fourchette/distance between
anus and base of clitoris

26.  Gonadal size, position and descent – inguinal hernia,
abnormal genitals with clitoromegaly, apparently well
formed penis with empty scrotum CAH
 Unilateral gonads s/o Mixed gonadal Dysgenesis
 Labioscrotal folds
 separated or fused  fusion is an androgen effect
 skin texture  rugosity suggestes exposure to androgens
 color of the skin ↑↑ pigmentation may be evidence for
CAH
Assymetric labioscrotal region s/o Gonadal Dysgenesis

27.  Orifices
should be determined & recorded on a diagram
are there two openings ? or single perineal orifice
(urogenital sinus)
urethral meatus on glans, shaft or perineum
vaginal introitus
 Bimanual rectal examination – cervix or uterus
 Associated anomalies

28.  In addition the infant should be examined for other
midline structural anomalies
 1. cleft lip or cleft palate
 2. endocrinopathy, which may point to a pituitary-
hypothalamic abnormality.
 3. If clinical evidence indicates that such entities may
be present, an examination with MR imaging or
another imaging modality should be considered.

29. PRADER SCALE
0 ‘Normal’ female anatomy
1 Enlarged phallus
2 Enlarged phallus with visibly separate urethral and vaginal
openings
3 Enlarged phallus with single urogenital sinus opening
4 Enlarged phallus with hypospadias
5 ‘Normal’ male anatomy

30. DIAGNOSTIC TESTS
 First line test
 Karyotype for sex chromosome
 Serum electrolyte
 Creatinine
 BUN
 Testosterone
17 OH progesterone
newborn cord blood 1000 – 3000
> 24 hrs – less than 100
adults – less than 200 nd/dl
 Other tests FSH / LH / PRA ( plasma renin )

31. DECISION MAKING INVESTIGATIONS
1. ACTH stimulation test – adrenal steroid synthesis
 done with iv bolus of 0.125 -0.25 mg of ACTH
and measure 17 OHP before and 30 to 60 minutes after
2. hCG stimulation test – testicular function
 done within 2-3 month of life
 HCG 500 IU IM every alternate day for 3 dose
 After 24 hr of final dose measure DHEA, Testosterone, DHT
3. For Testicular Tissue : - hCG stimulation test , AMH
 AMH :- peak at 6 month of 115 ng/ml , during adolescence 4 ng/ml
4. Biopsy of gonads
5. Gene analysis

33. Radiographic imaging
abdominal & pelvic U/S 
adrenal glands, pelvis, inguinal, perineal, and anal regions.
During the neonatal period, the uterus and ovaries are
prominent because of maternal hormonal stimulation and thus
can be easily found at US
 Voiding Cystourethrography and Genitography
Voiding cystourethrography and genitography are useful in
defining the internal anatomy of the urethra, vagina, cervix.
All perineal orifices should be examined

34.  MR Imaging—MR imaging can provide more detailed anatomic
information because of its superior tissue characterization and
multiplanar capability.
US had a sensitivity of 76%, specificity of 100%, and accuracy of 84%
for the detection of nonpalpable testes
MR imaging had a sensitivity of 86%, specificity of 79%, and accuracy
of 85%.
 US and MR imaging had equal sensitivity in depicting pelvic gonads,
but MR imaging had greater sensitivity than US for the localization
of intraabdominal gonads
Kanemoto K, Hayashi Y, Kojima Y, Maryuyama T accuracy of USG and MRI imaging
for diagnosis of nonpalpable testis INT J Uro 2005

35. Computed Tomography —(CT) is the modality of
choice for imaging evaluations of DSD associated
malignancies and staging of germ cell tumors
Endoscopic examination of genitourinary tract
Exploratory laproscopy

37. (A) VIRILIZED 46 XX FEMALES ( 46 XX DSD )
Over-androgenized Female
 Most common form of intersex
 Karyotype = 46 XX
 Gonads are ovary so no significant AMH production so
uterus, fallopian tube, cervix develop
 External genitalia virilized ( male differentiation ) mostly
bse of exposure of female fetus to excessive androgen
exogenous or endogenous
 1. Congenital adrenal hyperplasia ( mc )
 2. Placental aromatase deficiency
 3. Maternal hyper androgenic Cdn

38. HTN – 17, 11 hydroxylase defeciency
MALE PSEUDOHERMAPHRODITISM – 17, 3
FEMALE PSEUDOHERMATHROIDITISM – 21, 11
ACTH stimulates cholestrol delivery to
mitochondria for steroidogenesis

39. CONGENITAL ADRENAL HYPERPLASIA
 AR disorder of cortisol biosynthesis
 90 % CAH are due to 21- hydroxylase def
 Males are normal at birth
 Ambigious genitalia in femlaes
 Between 7 – 14 days of life present as life threatening cdn
 1. CLASSICAL FORM:- 1 in 15000 birth
Salt wasting form - 70%
-severe defeciency of G + M + androgen excess
-Simple virilizing form - 30%
-adequate M + androgen excess
-BP normal, no salt wasting, clitoral enlargement & labial fusion
2. NON CLASSICAL FORM :-1 in 1000 birth,more in Jews, Hispanics
-Normal M + G + excess androgen
-Present in childhood with hirsutism, acne , oligomenorrhoea, premature pubarche

40. a. 17 hydroxylase defeciency -> excess mineralocorticoid
no androgen so males feminization
b. 21- hydroxylase deficiency  95% no mineralo, no gluco, excess androgen
↑ 17-OH P
PP in males, virilization in females
c. 11 β-hydroxylase deficiency  ↑ 11-deoxycortisol ( mineralo ) – HTN, salt retention
- excess androgen so female virlization, male PP
d. 3 β-hydroxysteroid dehydrogenase def  all features similar to 21 hydroxylase
↑ pregnelonone

41. HTN – 17, 11 hydroxylase defeciency
MALE PSEUDOHERMAPHRODITISM – 17, 3
FEMALE PSEUDOHERMATHROIDITISM – 21, 11

42.  Diagnosis :- screening on filter paper measure 17- OHP
between 48 to 72 hours
 False +ve :- before 48 hr, preterm, VLBW, ill pts
 False – ve :- prenatal betamethasone administration so
recheck after 3- 5 days
 Clinical suspicion or abnormal screening confirm with by serum
17 OHP.
 Newborn screening may not detect mild simple virilizing 21OH
defeciency so ACTH stimulation test

43.  Mild simple virilizing 21 – OH deficiency with equivocal
17 OHP
require ACTH Stimulation Test
 done with iv bolus of 0.125 -0.25 mg of ACTH
and measure 17 OHP before and 30 to 60 minutes
after
 Carriers will have higher ACTH stimulated 17 OHP

44. External genitalia of a patient with congenital
adrenal hyperplasia secondary to 21-hydroxylase deficiency,
showing labioscrotal fusion and clitoromegaly

45. Management
 Medical –
-Stablisation of general condition
-Correction of electrolyte abnormalities weight, fluid balance
-Electrolytes should be monitored closely with blood sample
every 2 days for hyponatremia, hyperkalemia.
-After stabilisation – replacement of glucocorticoid and / or
mineralocorticoids depending on the general condition
-Once infant is stabilized, NaCl 1 to 2 gm daily, q 6 hrly
dosing, should be added to formula

46. Glucocorticoid replacement :
 Hydrocortisone – 20 mg/m2/day TDS
 Doule/ triple dose in stress ( infection, surgery )
 Maintain linear growth along percentile lines
 Inadequate therapy may develop adrenal testicular tumour,
which regress with increased steroid use.
Mineralocorticoid replacement :
 fluorohydrocortisone – 0.1-0.2mg/d bd dose
 Older infants 0.05 – 0.1 mg daily fludrocortisone
 Monitor tachycardia, HTN, SE , Plasma Renin activity
 Newer approaches like flutamide, anastrazole, GH w/without
LHRH Agonist

47.  Surgical –
Females with severe virilisation –
Surgery between 2-6 month of age
early reduction of clitoris followed by vaginoplasty
revision surgery in adolescence is often necessary
Mild virilisation – medical treatment is adequate

48. ANTENATAL MANAGEMENT
Maternal S/E :- edema, wt gain, hypertension, glucose intolerance, cushingoid features, severe
striae
Children S/E :- LBW, increased shyness, effect on personality

49. (B) UNDERVIRILIZED MALES ( 46 XY MALES )
 Very diverse group
 Karyotype = 46 XY
 Internal genitalia Testis
 Phenotypic range broad
 may even resemble normal female
 Externl genitelia are either not completely
virilized/atypical
 When gonads found, contain Testicular elements,
development ranges from rudimentary to normal
- Process of complex normal virilization , there are many
varieties and etiology is not identified in 50% cases.

50. Defects in androgen action
1. 5 α Reductase deficiency
- AR
- defect in 5 alpha reductase type 2
-Testo  5alpha R  DHT
wolffian external genitalia
structures
- phenotypically boys who have small phallus, bifid scrotum,
urogenital sinus, wolfian structures normal, no mullerian
structure
- Secondary sexual characters and spermatogenesis normal
- normal testosterone, low DHT, hCG stimulated testosterone:
DHT ratio > 17,

51. 2. ANDROGEN INSENSITIVITY SYNDROME
Most common form of male DSD, 1/20000 genetic males.
X linked recessive disorder, due to mutation in androgen receptor
 CAIS:-
 Extreme failure of virilization
 INFANCY -Genetic male but Ext genitalia phenotypically female
 Vagina end as pouch, absent uterus due to AMH by testis
 Testes may be intra-abdominal/inguinal
 INFANTS - Elevated LH suggest diagnosis
 PREPUBERTY – detected when Inguinal mass detected as testis
 PUBERTY – amenorrhea with Normal breast (due to peripheral aromatization of
testosterone), Absent pubic hair
 PAIS :- male with ambigious genitals
 perineoscrotal hypospadiasis, bifid scrotum, cryptorchidism to clitoromegaly
and labial fusion
 Reifenstein syndrome, Gilbert Dreyfus syndrome, Lubs syndrome
 Reifenstein syndrome – hypogonadism, hypospadiasis, gynecomastia

52.  DIAGNOSIS :-
- 46 XY chromosome,
- Presence of Testis
- N / Eleveted Testosterone & LH level
- IGF 2 & IGFBP 2 production by genital skin fibroblast is decreased in CAIS.
- Postnatal surge in testosterone & LH is decreased in CAIS but not in PAIS
- High level of testosterone that don’t increase when hCG given & ratio of
testosterone:androstenedione , testosterone : DHT is normal then its PAIS
D/D from other XY undervirilized male :-
- low level of testosterone in neonatal period
- Failure to respond to hCG in prepubertal period

53. FURTHER EVALUATION
1. Monthly 25-50 mg IM testosterone for 3 months
- No increase in size of penis by 2 +/- 0.6 cm - PAIS
2. Genetic studies for mutation in receptor
3. Sex assignment
- CAIS - female with normal appearing ext genitals and absent
mullerian and wollfian structures, they are raised as females
- remove testis as risk of seminoma
- replacement therapy with estrogen at puberty
- PAIS – extremely complex & depend on phenotype
- therapy with androgen
 Supportive counseling for infertility
 Genetic counseling for family members

54. Microphallus
 < 2.5 cm in full term neonate with/ without
cryptorchidism
 Causes :-
 Kallman syndrome
 Septo optic dysplasia
 GH defeciency
 CHARGE association
 Prader willi, Noonan, Fanconi syndrome
 Mx :- testosterone enanthate 25 mg IM monthly for
3 mnth

55. CRYPTORCHIDISM
- 3 : 1000 more in premature
- By 1 month incidence is 1: 1000
- USG / MRI for inguinal/ intra abdominal testis
- FSH, LH, testosterone levels measured if testicular tissues are not found (rise after
birth & elevated up to 6 month in boys )
- If testosterone is low  hCG stimulation test :- elevated LH with low testosterone
 absent / nonfunctioning testis
- Undetectable serum AMH – s/o b/l anorchia rather than undescended testis
- Orchidopexy at 1 year
- If not possible for orchidopexy remove them –bse of risk of germ cell cancer

56. Issues of sex assignment
 DSD is a challenging and complicated situation, but
when understood can often be dealt with effectively
 Counseling of parents
 Multidisciplinary approach involving urology,
endocrinology, genetics and social work is essential
 Guarded approach in immediate revealing of sex
 Thorough investigation
 Until a sex assignment is made withhold, giving
gender specific names or references

57. What Are The Issues
 Fertility Potential - females virilized because of CAH
or maternal androgens are potentially fertile. Most
other conditions → fertility reduced/absent
 Capacity for Normal Sexual Function - size of the
phallus and its potential to develop into a sexually
functional penis at puberty. Presence/ absence of
vagina.
 Endocrine Function - ability of the gonads to produce
appropriate hormones.

58. Malignant Potential
 patients with DSD have an increased risk for gonadal
malignancies, particularly germ cell tumors such as
seminomas, dysgerminomas, and nonseminomas. The risk
appears to be higher in those with an XY genotype and
undermasculinization
 Overall, 20%–30% of children with 46,XY complete
gonadal dysgenesis and 15%–20% of those with mixed
gonadal dysgenesis develop malignancies within the 1st to
2nd decade of life therefore streak or dysgenetic gonads
should be removed.
 Klinefelter syndrome have increased risks for germ cell
tumor of the mediastinum, testicular stromal tumor, and
breast malignancies

59.  Uterus with absent gonads s/o virilized XX female –
raise as females
 Absent uterus +/- gonads s/o undervirlized XY male
measure LH, T, DHT & who are totally feminized
reared as female
- Complete androgen resistance – raise as female
- PAIS - Hypospadias only – raise as male
 5 alpha reductase deficiency - raise as a male

60. References
 1. Sperling 10th edition
 2. Ghai 8th edition
 3. Cloherty 7th edition
 4. Nelson 19th edition
 5. www.pediatrics.evms.edu
 6. radiographics.rsna.org