Dr. Perri Klass on family health.
When you learn how to examine the female reproductive system in medical school, you generally work with a professional surrogate patient, and there is often a humiliating moment when you try to palpate the ovaries only to be told, in no uncertain terms, that you are way off-target. At such a moment, the male reproductive system seems quite simple and accessible.
Yet simple it is not. Recent research suggests that we should be paying closer attention to male development, not just to help boys understand and care for a particularly sensitive and vulnerable part of their anatomy — but also to help answer larger questions about what is happening to boys and their growth.
As part of examining every baby boy, pediatricians check for a relatively common condition known as cryptorchidism, which means a hidden or secret testicle. Between 3 and 5 percent of newborn boys have at least one testicle that fails to descend into the scrotum, with a higher incidence in premature babies.
In cases of cryptorchidism, the testicle may descend of its own accord during the first months after birth. If it doesn’t, there’s an operation, orchiopexy, that releases it into the scrotum. Most surgeons prefer to operate when the boy is about a year old. If the testicle remains in the abdomen, where the body temperature is higher, germ cells don’t mature properly and future sperm production and fertility are at risk.
Doctors also worry about those undescended testicles because of a link to cancer down the line. A major new analysis published this month in The Archives of Disease in Childhood found that boys born with undescended testicles have three times the usual risk of developing testicular cancer. Boys who had this problem at birth need to know about it as they grow up, and need to learn how to do regular testicular self-exams.
“The message for parents is get them seen and checked by a specialist,” said Dr. Robert Carachi, professor of surgical pediatrics at the University of Glasgow and one of the authors of the study. “Adolescent men should be examining themselves. If there’s swelling or enlargement, get it checked early.”
Regular self-exams for all — that is, for those not at higher risk of cancer — are not currently recommended because they can cause anxiety and have not been shown to improve outcomes in boys or men who aren’t at particular risk.
Pediatricians discuss other risks with boys who play sports, and we urge them to wear proper protection, a message that is sometimes lost, and not just on adolescents.
For all their protective equipment, professional football players, for example, tend not to wear protective cups to shield their genitals from the dangers on the field. According to Dr. Stephen G. Rice, director of the Jersey Shore Sports Medicine Center in Neptune, N.J., cups are rarely worn in soccer and football, where the players must change direction frequently as they run, as opposed to baseball, where most of the running is in a straight line.
“For a lot of sports, it’s going to get in the way,” said Dr. Rice, who was one of the lead authors of the 2012 American Academy of Pediatrics policy statement on how to keep children safe when playing baseball and softball. The statement recommended cups for all participants. “Baseball is the exception because of how hard the ball is and how fast it comes,” he said. “It’s random chance, nothing to do with your skill level.”
An injury from a flying baseball can cause excruciating pain, and learning to take responsibility for protecting yourself is part of maturity. And there is new evidence, also related to the testicular exam, that the pace of maturity may be shifting in disturbing ways for boys, as it is for girls. As boys grow toward puberty, the first invisible changes brought on by the hormonal signals occur in the testicles. They begin to grow and enlarge. Compared with the physical development of girls, these modest increases in testicular volume are not really noticeable to parents, or even to the boys themselves, said Marcia E. Herman-Giddens, adjunct professor of maternal and child health at the University of North Carolina.
But a 2012 study of 4,131 boys by Dr. Herman-Giddens and her colleagues found that subtle testicular enlargement, which signals the onset of puberty, is happening earlier than seen in previous studies. The changes could be measured, on average, by the age of 10. Over all, the researchers concluded, male puberty seems to be beginning 6 months to 2 years earlier than it used to.
Dr. Herman-Giddens was also one of the lead authors on the comparable study published in 1997 that caused an uproar by suggesting that female puberty was coming earlier. Some of the factors thought to be associated with earlier female puberty — obesity, diet changes, chemicals in the environment that affect hormones — may be at work in boys, too, but the mechanisms aren’t understood.
Dr. Herman-Giddens said there was much less media attention to the news about puberty in boys, pointing out that the early changes in males — in particular the enlargement of the testicles — are much less visible than early breast development is in girls. But parents — and fourth- and fifth-grade teachers — need to be aware that relatively young boys may be dealing with the confusions and hormonal effects of early puberty.
“The sex hormones and especially testosterone are increasing in the boy’s body, and that’s what’s making the testes start to grow and that’s going to have an effect on the boy’s behavior,” Dr Herman-Giddens said. “Judgment, other aspects of psychological maturity — that’s not happening any faster.”
These subtle physiological changes tell us something more: that boyhood itself may be changing in ways we don’t completely understand, and that we need to be attentive to helping boys and young men take care of themselves as they grow.