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ORIGINAL ARTICLE |
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| Year : 2018 | Volume
: 23
| Issue : 4 | Page : 203-205 |
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Persistent mullerian duct syndrome: A single-center experience
Saravanan Natarajan, Manikandhan Periasamy, Saminathan Rangasamy, Shankar Mohan, Prabakaran Sundararajan
Department of Pediatric Surgery, Government Mohan Kumaramangalam Medical College, Salem, Tamil Nadu, India
| Date of Web Publication | 4-Oct-2018 |
Correspondence Address:
Dr. Saravanan Natarajan
5/113, Anna Street, Angammal Colony, Salem - 636 009, Tamil Nadu
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/jiaps.JIAPS_61_17
 Abstract | | |
Context: Persistent Mullerian duct syndrome (PMDS) is a rare disorder. It is a type of male pseudohermaphroditism, usually presenting as “Hernia Uteri Inguinalis”.
Aims: This study aims to present our experience of PMDS, over a 7-year period.
Settings and Design: Our center is a tertiary care facility, situated in Tamil Nadu, a southern state of India.
Subjects and Methods: This is a retrospective study. The study period was from 2007 to 2015. Seven cases presented during that period. The difficulties in diagnosis, treatment options discussed, along with a review of literature are presented.
Results: Seven cases of PMDS presented over 8 years. Only four were diagnosed preoperatively. Mullerian remnants were excised in five cases.
Conclusions: PMDS is rare. Orchiopexy should be the goal of treatment.
Keywords: Male pseudohermaphroditism, Orchipexy, persistent Mullerian duct syndrome, transverse testicular ectopia
How to cite this article:
Natarajan S, Periasamy M, Rangasamy S, Mohan S, Sundararajan P. Persistent mullerian duct syndrome: A single-center experience. J Indian Assoc Pediatr Surg 2018;23:203-5 |
How to cite this URL:
Natarajan S, Periasamy M, Rangasamy S, Mohan S, Sundararajan P. Persistent mullerian duct syndrome: A single-center experience. J Indian Assoc Pediatr Surg [serial online] 2018 [cited 2019 Sep 16];23:203-5. Available from: http://www.jiaps.com/text.asp?2018/23/4/203/242719 |
| Introduction | |  |
Persistent Mullerian duct syndrome (PMDS) is a rare form of male pseudohermaphroditism (MPH), which is characterized by the lack of regression of mullerian derivatives-uterus and tubes, in otherwise normally masculinized males. It is usually discovered during surgery for hernia or undescended testis (UDT), as “hernia uteri inguinalis.”[1] The failure of testicular descent is due to mechanical restraint from abdominal Mullerian organs.[2] Vas deferens and epididymis are present, so fertility is possible if spermatogenesis occurs.[3] PMDS is often familial, presenting as an autosomal recessive trait.[4]
| Subjects and Methods | | |
This is a retrospective study of seven children with PMDS from 2007 to 2015 admitted in our institution. Age and mode of presentation, clinical findings, investigations, peroperative findings, and postoperative complications were studied. Case details are summarized in [Table 1].
| Results | | |
Seven cases of PMDS presented during 8 years. Age group varied from 1.5 to 4 years. The diagnosis was made preoperatively only in five cases based on clinical examination and ultrasound of abdomen. Ultrasound of abdomen was done in five cases, and Mullerian structures were detected only in two cases. In one case, which presented as transverse testicular ectopia (TTE), a diagnostic laparoscopy just before surgery, confirmed the diagnosis of PMDS. Four cases presented as inguinal hernia on one side, with UDT on the other side, two cases presented as TTE, one case presented as bilateral UDT. Bilateral orchiopexy was done in six cases, corporal, or partial hysterectomies, leaving behind cervix, were done in five cases. Complications noted were, injury to the vas on the right side in one case, and recurrence of inguinal hernia in twin brothers that presented in our series [Figure 2]. Though the twins were treated by different surgical procedures, they developed recurrence of hernia for no apparent reason. Both were repaired and doing well. | Figure 1: Mullerian remnants retained after left herniotomy, both testes brought down to left scrotal sac and right testis taken into right scrotal sac through median raphe
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| Discussion | | |
PMDS is a rarely reported disorder of sexual development. The incidence and prevalence are not well established. It was first described by Nilson in 1939, as hernia uteri inguinalis. This disease is often familial, inherited as autosomal recessive trait. PMDS is a rare form of MPH characterized by the presence of Mullerian structures, in 46xy phenotypic males.
PMDS is a distinct entity and can be explained by inadequate Mullerian suppression from hormonal influence. The hypothesis for causation of PMDS includes failure of synthesis or release of Mullerian inhibiting substance (MIS) or failure of end organs response to MIS.[5]
The gene responsible is chromosome 19. The primary function of MIS also known as anti-Mullerian hormone is, regression of Mullerian ducts in the male fetus. MIS is first secreted in effective amount during 56–62 days after fertilization, and Mullerian regression is completed by 77 days.[6] Another important function of MIS is to initiate testicular descent.
Clarence classified PMDS into three categories.[7] (1) Bilateral intraabdominal testis in apposition analogue to ovaries (60%–70%), (2) One testis in scrotum with contralateral inguinal hernia where the contents are testis, uterus and tubes, known as hernia uteri inguinalis (20%–30%), (3) both testis in the same inguinal sac (10%) as TTE.
Ultrasonography, magnetic resonance imaging, and computed tomography scan have been used in successful detection of PMDS, with no clear advantage of one over the other.
There have been controversies in the management of PMDS, in dealing with Mullerian structures. One school of thought is that all mullerian structures due to the risk of malignant transformation should be removed.[8],[9],[10] The other group, on the contrary, is against excision of Mullerian structures as they may lead to ischemia and traumatic changes to vasa deferentia. Moreover, they suggest that optimal treatment is orchipexy, leaving uterus, and tubes in situ.[11] However, out of 262 cases reported 11 cases had developed malignancies of the Mullerian structures. Nearly 3.1%–8.4% of males develop Mullerian malignancies. To eliminate the risk of malignancy and spare, the patient of a lifelong follow-up Mullerian structures should be removed whenever possible, and the aim of management should be, to preserve the testis and hence the fertility potential.[12]
| Conclusions | | |
PMDS is rare. It commonly presents as inguinal hernia one side and UDT on the other side. The diagnosis should be made preoperatively itself, by having a high index of suspicion when a child presents with bilateral inguinoscrotal problems, confirmed by a good ultrasonogram, and should no more be a surprise finding. If suspected clinically, but not supported by ultrasonogram, a diagnostic laparoscopy just before surgery could be helpful. Orchiopexy should be the goal of management, and whenever possible, excision of Mullerian structures meticulously, avoiding injury to vas, should be performed.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Nilson O. Hernia uteri inguinalis beim manne. Acta Chir Scand 1939;83:231.  |
| 2. | Josso N, Fekete C, Cachin O, Nezelof C, Rappaport R. Persistence of müllerian ducts in male pseudohermaphroditism, and its relationship to cryptorchidism. Clin Endocrinol (Oxf) 1983;19:247-58. |
| 3. | Brook CG, Wagner H, Zachmann M, Prader A, Armendares S, Frenk S, et al. Familial occurrence of persistent mullerian structures in otherwise normal males. Br Med J 1973;1:771-3. |
| 4. | Sloan WR, Walsh PC. Familial persistent müllerian duct syndrome. J Urol 1976;115:459-61. |
| 5. | Thompson ST, Grillis MA, Wolkoff LH, Katzin WE. Transverse testicular ectopia in a man with persistent müllerian duct syndrome. Arch Pathol Lab Med 1994;118:752-5. |
| 6. | Nayak VJ, Kamath AS, Krishnappa MH, Bylappa SK. Persistent mullerian duct syndrome: A case report and review of the literature. Int J App Basic Med Res 2014;4:125-7. [ PUBMED] [Full text] |
| 7. | Clarnette TD, Sugita Y, Hutson JM. Genital anomalies in human and animal models reveal the mechanisms and hormones governing testicular descent. Br J Urol 1997;79:99-112. |
| 8. | Thiel DD, Erhard MJ. Uterine adenosarcoma in a boy with persistent müllerian duct syndrome: First reported case. J Pediatr Surg 2005;40:e29-31. |
| 9. | Romero FR, Fucs M, Castro MG, Garcia CR, Fernandes Rde C, Perez MD, et al. Adenocarcinoma of persistent müllerian duct remnants: Case report and differential diagnosis. Urology 2005;66:194-5. |
| 10. | Shinmura Y, Yokoi T, Tsutsui Y. A case of clear cell adenocarcinoma of the müllerian duct in persistent müllerian duct syndrome: The first reported case. Am J Surg Pathol 2002;26:1231-4. |
| 11. | Vandersteen DR, Chaumeton AK, Ireland K, Tank ES. Surgical management of persistent müllerian duct syndrome. Urology 1997;49:941-5. |
| 12. | Shalaby MM, Kurkar A, Zarzour MA, Faddan AA, Khalil M, Abdelhafez MF, et al. The management of the persistent müllerian duct syndrome. Arab J Urol 2014;12:239-44. |
Editorial comments
All patients with bilateral inguinoscrotal anomalies should have ultrasonography of lower abdomen and CT scan to arrive at a diagnosis. USG & CT lower abdomen help delineating the anatomy. Laparoscopy should be done before definitive surgery.
[Figure 1], [Figure 2]
[Table 1]
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