Management of Differences in Sexual Development: Evolution of an Approach for a Resource-Limited Setting

Background: The approach to management of patients with disorders of sex development (DSD) has been refined over the past two decades. We sought to review DSD cases at our hospital and hypothesized that age at presentation would decline over time. Methods: A retrospective review of patients presenting to our hospital between January 1, 2005 and July 31, 2018, with findings of ambiguous genitalia was performed. Results: A total of 44 patients were identified, 3 with cloacal exstrophy. Of the 41 remaining patients, the majority (n = 24) had ovotesticular DSD. Three time periods in the evolution to a multidisciplinary team (MDT) approach were identified: Period 1 (2003–2009), Period 2 (2010– 2013), and Period 3 (2014–present). Median presenting age in Periods 1, 2, and 3 were 7 years (95% CI: 0.5–15), 6.5 years (95% CI: 1–19), and 11 years (95% CI: 2–17), respectively, and were not statistically different. Conclusion: Management of patients with DSD poses a challenge to healthcare providers across the globe. The gradual evolution of patient management with incorporation of MDTs and progression toward delayed surgery is seen in this study. There is indeed a need to set up regional centers of excellence, public awareness programs, and healthcare personnel training programs for optimal management of these patients in low- and middle-income countries (LMICs).


Introduction
Disorders of sex development (DSD) represent a complex spectrum of conditions in which there is discordance across genetic, gonadal, and phenotypic sex. These conditions arise when abnormalities occur during the process of sex determination and differentiation (1). Several disorders fall under the umbrella definition of DSD and thus previously used terminology (pseudohermaphroditism, hermaphroditism, sex reversal, etc.) are now avoided (2,3). The major categories in the current classification of DSD are 46XX DSD, 46XY DSD, and sex chromosome DSD (4). The global incidence of DSD is estimated to be at 1 in 4500-5000 live births (5). There is a paucity of relevant African literature so that the true incidence in Africa is largely unknown. One study from South Africa reported 44 patients a prevalence of 15.1% (6), while studies from Sudan and Egypt have reported prevalence rates of 3.1 and 7.3% (7,8). There are no published prevalence rates from East Africa. Diagnosis and management are challenging everywhere but particularly in resource-constrained environments. Management strategies have changed over time. We sought to review DSD cases managed at our hospital and hypothesized that age at presentation would decline over time.

Materials and Methods
We performed a retrospective review of all patients who presented to our hospital between January 1, 2005 and July 31, 2018, with clinical findings of ambiguous genitalia and/or a diagnosis of DSD by pathologic testing of gonadal biopsy specimens. The study was approved as an exempted study by the Ethics Committee of our hospital (Aug 31, 2018, P. Halestrap, MD, Chair -Kijabe Hospital IRB).

Data collection
Data were collected from the patient electronic database (Access © 2007 Microsoft), the electronic pathology database (FileMaker Pro, 2019 Claris International Inc. Santa Clara, CA.), and operative case logs. These were searched for ambiguous genitalia, proximal hypospadias, intersex, DSD, gonadal biopsy, and diagnostic sinoscopy to identify patients for inclusion in the study (Figure 1). Diagnostic testing modalities were performed and results were collected. Patients with proximal hypospadias found to have bilateral testes and 46XY karyotype, when testing was available, were excluded. All patient diagnoses were assigned using the European Society for Pediatric Endocrinology and the Lawson Wilkins Pediatric Endocrine Society nomenclature and classification system (2). Clinical data collected included age at presentation, sex of rearing, family history of consanguinity, presence of Müllerian structures found during diagnostic procedures (laparotomy/laparoscopy/genito-urethroscopy), gonadal 12809 patients screened "genitoplasty" "sinoscopy" "diagnostic laparoscopy" "minilaparotomy" "gonadal biopsy" "ovotestis" "DSD" "intersex" "ambiguous genitalia" "cloacal exstrophy" clinical database operative caselogs pathology records The ANNALS of AFRICAN SURGERY | www.annalsofafricansurgery.com biopsy histology, diagnostic biochemical tests, karyotype, and age at first surgical intervention.

Data analysis
Data were captured in Excel (© 2018 Microsoft) and the Statistical Package for Social Sciences (SPSS, Version 23 © 2015 IBM Corp. Armonk, NY) was used for analyses. Descriptive statistics for categorical data were expressed as counts, percentages, and/or frequencies.
Continuous data were expressed as mean and standard deviation or median and range. Nonparametric tests were used to compare ages across time periods.

Results
A total of 44 patients with a diagnosis of DSD were identified. Within the study cohort, all patients had an assigned gender at the time of presentation, with 30 patients being raised as male (68%) and 14 as female (32%). Three patients (9%) reported a history of consanguinity. The median age at presentation was 6.5 years (birth-34 years) (Table 1). Three patients had cloacal exstrophy and did not undergo karyotyping or other DSD-specific diagnostic testing. Two of these patients had typical cloacal exstrophy on examination and one patient had an atypical cloacal exstrophy with an intact bladder plate and the hindgut plate attached to the caudal edge of the bladder plate.

Diagnostic modalities
Of the 41 non-cloacal exstrophy patients, one patient had a karyotype and future diagnostic testing planned when older, while 40 patients had one or more diagnostic procedures to evaluate internal genitourinary anatomy: minilaparotomy via Pfannenstiel incision, diagnostic laparoscopy, genitoscopy, and/or gonadal biopsies. Five patients had buccal smears to look for Barr bodies. A total of 21 patients had karyotyping, two of which also had fluorescence in situ hybridization (FISH) for SRY gene assay. Twelve patients had completed a serum hormonal testing (17-OH Progesterone, dehydroepiandrosterone sulfate, androstenedione, testosterone, dihydrotestosterone, 17-beta-estradiol, luteinizing hormone, and/or follicle stimulating hormone).

Findings
The DSD classification of patients is shown in Table 2.
Of the 24 patients found to have ovotesticular DSD, 12 did not have karyotyping. Congenital adrenal hyperplasia (CAH) was presumed in 3 of 5 patients based on the presentation of ambiguous genitalia, bilateral ovaries, and present Müllerian structures. Four patients did not have enough diagnostic data to classify. These patients presented between birth and 15 years old with a male gender assignment, and all were found to have Müllerian structures. One had bilateral ovaries; the second had a single ovary, and the third was found to have 10% Barr bodies on buccal smear. The gonadal status of the fourth was unknown.
Three cloacal exstrophy patients underwent hindgut tubularization shortly after birth. In all, 27 patients had reconstructive genital procedures at a median age at first reconstructive operation of 12 years (2-34 years); while a total of 14 patients, with median age of 2 years (0-16) at presentation, were yet to undergo reconstructive procedures.

Evolution of management
The workup of patients with ambiguous genitalia was found to evolve as healthcare resources and trained personnel changed over time. We identified three periods in the evolution of management of patients with DSD at our hospital ( Figure 2).

Discussion
Management of patients with DSD poses a challenge to healthcare providers across the globe. Great advances have been made in the past two decades that have refined the approach to management of DSD. However, there is still limited evidence to accurately guide decisionmaking concerning gender assignment, timing of surgery, and fertility preservation (3). Furthermore, disparities in management between resource-rich and resource-limited settings are glaring. The present study presents a cohort of DSD patients from one institution in East Africa and describes the evolution and development of a pragmatic approach to diagnosis and management within the regional context. The majority (54%) of our patients were found to have ovotesticular DSD with 11% diagnosed with confirmed or presumed CAH. While reports from high-income countries (9) and text books (10) report CAH as the most common type of DSD, similar rates of CAH and a predominance of ovotesticular DSD have been noted in other centers in Africa, including referral centers in Kenya (6,11,12,13). In a newborn CAH screening program in the United States, the incidence of classic CAH among black Americans was 1:42,000 in contrast to an overall incidence of 1:16,000 (14). These data suggest an underlying genetic difference among patients with African heritage and a likely European and North American epidemiological ethnic bias in the literature published from high-income countries. Our finding of 54% ovotesticular DSD is still higher than that seen in other African literature. This could be the result of a small dataset or referral bias, but our data are insufficient to explain this difference. Khayat (15) and Shawky (8) have reported rates of consanguinity in their respective cohorts of DSD patients of 40% and 55%, respectively, attributable to various religious and cultural practices. In the present study, the rate of consanguinity was at least 7%, as underreporting may have played a role. High rates of consanguinity may affect inheritance patterns and genetic profiling of DSD. In the present study, the median age at presentation was 6.5 years. Other authors have reported similar delays in presentation, some as late as adolescence (16).
Approach to care in the first two periods of study have been previously described (17). The challenges highlighted included late patient presentation, inadequate facilities to make an accurate diagnosis, sociocultural influence of the African community, and loss to follow-up. Similar challenges have been noted in other centers within Sub-Saharan Africa (16). Africa has unique sociocultural influences. African culture [and most low-and middle-income countries (LMICs)] is largely patriarchal and thus the majority of the children born with ambiguous genitalia will be raised as males (18). In one report, more children raised as boys were presented to medical facilities for evaluation of ambiguous genitalia than those raised as girls (5). This bias toward male rearing was also seen in the present study, as 70% of patients with atypical genitalia were raised as males. Additionally, despite the growth of an MDT approach, the median age at presentation of patients did not decrease as hypothesized. This is likely still due to the limited access to care and lack of nationally recognized treatment centers and programs. The median age at reconstruction was also stable across time periods commensurate with the late presentation. Optimal models of DSD Care teams have been described (3,19). Approach to care in the present study was largely driven by availability of skilled clinical personnel, accessibility of diagnostic tools, and the financial capability of the patients. Progress in the development of a multidisciplinary approach to care over the study period is evident. Emerging subspecialties of pediatric endocrinology, pediatric surgery, and pediatric urology have gradually been incorporated into the patient care team. Involvement of a pediatric endocrinologist has improved patient evaluation and incorporated highly selective targeted testing as a cost saving measure to aid in diagnosis. Furthermore, a team of nurses, chaplains, and social workers now provide contextually appropriate psychosocial and psychosexual support both at the family and community levels. However, patient support groups have yet to be established. With this evolution of care into an MDT approach, the trend has been toward delaying reconstructive procedures until the child is of age to participate in a shared decision-making process.
Initial clinical evaluation of patients presenting with DSD is well described (3). While most of the relevant and recommended tests became progressively available within the course of the study period, their high cost made routine use prohibitive. Reports from other resource-limited settings showed that poverty was the main factor affecting long-term outcomes of patients with DSD (20). The majority of our patients rely on NHIF to access healthcare. Despite progressive NHIF expansion to provide more funding for operative procedures and investigative studies, tests considered key for patient workup (Karyotype and Biochemical assays) are yet to be incorporated. In view of this, there was a heavy reliance on diagnostic procedures (genitoscopy/laparoscopy) and histopathologic analysis of gonadal biopsies to aid in diagnosis. Minimally invasive diagnostic and therapeutic procedures have replaced the use of imaging modalities such as ultrasound and MRI, which, in our context, are either unreliable due to user variability or financially prohibitive. A similar pragmatic approach is in practice in other parts of Africa (11). None of our patients was able to undergo a complete diagnostic workup required for a comprehensive diagnosis. Similar challenges have been reported from other centers in the country (21). The gains of this minimalistic approach notwithstanding, it is our assertion that at the very least karyotyping, 17hydroxyprogesterone (17-OHP) and anti-Müllerian hormone (AMH) testing should be incorporated as mandatory first-line investigations for all patients presenting with atypical genitalia. These would ideally be incorporated into a "DSD diagnostic package" offered by NHIF at a center of excellence.

Conclusion
Management of patients with DSD poses a challenge to healthcare providers across the globe. The gradual evolution of patient management with incorporation of MDTs and progression toward delayed surgery is evident in the current study. However, the unique setting in LMIC presents challenges not typically encountered within high resource settings that may necessitate alteration of standards of practice. There is indeed a need to set up regional centers of excellence, public awareness programs, and healthcare personnel training programs for optimal management of these patients in LMICs.