Medical-Social Assessment of Reproductive Health of Boys and Scientific Justification of Organizational Forms of Its Improvement

The dissertation is devoted to a comprehensive study of the medico-social aspects of reproductive health of boys of school and adolescent age and the development of scientifically substantiated organizational forms of its improvement in the Russian Federation. The investigation was conducted on a large statistical material — approximately 60,000 observations of boys from Saint Petersburg, Veliky Novgorod, and Novgorod Oblast aged 7 to 16 years and older. The work includes an analysis of the prevalence of andrological pathology, identification of medico-social risk factors, assessment of the state of sex education of youths, the quality of primary and inpatient andrological assistance, as well as the development of a model of the pediatric and adolescent andrological service. On the basis of the conducted investigation, a concept and model of the system of organization of andrological assistance to children and adolescents were proposed, which represents a new scientific and clinical direction — pediatric and adolescent andrology.

Relevance of the Problem.

As the WHO states, "Reproductive health implies that individuals should have a satisfying, responsible sexual life, the capacity for reproduction, the right to access appropriate health-care services that will enable them to — have a healthy newborn." The means for achieving reproductive health among adolescents, in the WHO's opinion, should include "understanding by all key groups in society, including youth, of the physical, psychological, and social aspects of adolescent reproductive health; the implementation of policies and programs most fully responding to the needs of adolescents" (WHO, European Regional Office, 1999).

The complex demographic situation that arose in our country at the end of the past century is largely attributable to the low state of reproductive health of young people entering family life (O.P. Shchepin, 1996, 2002; V.I. Starodubov, Yu.V. Mikhailova, A.E. Ivanova, 2003). At present, Russia has a relatively developed system of measures for the prevention and treatment of violations of reproductive health in girls and young women, which finds its practical embodiment both in programmatic and regulatory documents of health care and in practice (V.K. Yuryev, 1999; Yu.A. Gurkin, 2000; V.A. Medik, 2003). A system of analogous measures with respect to the younger generation of males is only beginning to develop, whereas approximately 60% of andrological diseases of childhood and adolescent age may in the future pose a threat to fertility. Today, pediatric andrology is not represented in health-care institutions of state jurisdiction. Parents of sick children receive contradictory information concerning the nature of the disease, its treatment, prognosis, the character and extent of surgical correction, the timing of its performance, the possibilities of hormone therapy, and so forth. For many of these patients, a system of dispensary observation has not been worked out, and organizational and legal questions remain unresolved (V.V. Mikhaillichenko, O.I. Tiktinsky, 1988; L.V. Okulov et al., 1990; W. Krause, 1996; T.Yu. Kozhukhovskaya, 2000).

Conditions and lifestyle are the leading factors determining the process of formation of reproductive health in children and adolescents (I.V. Polyakov, 2000). They have acquired particular significance during the period of socio-economic crisis. The changes that occurred in society were reflected in a shift of behavioral stereotypes in the youth environment — interest in sports declined, there is a lack of necessary knowledge and social motivations for the preservation and strengthening of their own health; at the same time, harmful habits such as smoking, the use of alcoholic and narcotic substances have become widespread, and the frequency of premarital sexual relations has increased (V.G. Balasanyan, 1998; P.N. Krotin, 1998; S.Yu. Molchanova, 2003; V.I. Orel, 2003).

In recent years, the number of medico-social investigations of individual problems of reproductive health in girls has significantly increased (V.K. Yuryev, 1998; Yu.A. Gurkin, 1998; V.G. Balasanyan, 1998; P.N. Krotin, 1998; E.S. Popova, 2002; D.I. Evzovich, 2002; S.Yu. Molchanova, 2003, et al.), whereas works devoted to the medico-social aspects of reproductive health of boys are isolated (N.B. Selverova, 1988; T.Yu. Kozhukhovskaya, 2000; V.K. Yuryev et al., 2000). To date, investigations of the medico-social assessment of reproductive health of boys have not been conducted in Russia. Publications on this topic by the author have not been found in the available literature.

Goal of the Investigation: To develop and scientifically substantiate proposals for the creation in the Russian Federation of a pediatric and adolescent andrological service based on the medico-social assessment of the state of reproductive health, risk factors, and living conditions leading to an increase in the prevalence of andrological pathology among children and adolescents, and an analysis of the state of curative and preventive assistance to children and adolescents suffering from andrological diseases.

Tasks of the Investigation:

1. To conduct an analysis of the main trends in the prevalence of andrological pathology among children and adolescents in the cities of Saint Petersburg and Veliky Novgorod, and in Novgorod Oblast.

2. To establish risk factors, features of conditions and lifestyle of parents, negatively affecting the state of the reproductive system of children and adolescents.

3. To assess the level of awareness of boys and youths concerning questions of sex, sexual behavior, and reproductive attitudes.

4. To conduct an analysis and provide an expert assessment of the quality of medical care and treatment of children and adolescents suffering from andrological diseases.

5. To develop and substantiate the main directions for improving the system of protection of reproductive health of boys and youths in the Russian Federation.

Scientific Novelty of the Investigation:

On the basis of a large statistical material (approximately 60,000 observations) taking into account the age of schoolboys (from 7 to 16 years and older) and the region of residence (Saint Petersburg, Veliky Novgorod, and Novgorod Oblast), data on the prevalence of andrological pathology in boys are presented, based on the results of targeted screening examinations. Violations of the reproductive and sexual organs in schoolboys of the Northwestern Region occur with a frequency of 167.8‰. The level of prevalence of andrological pathology in boys of Veliky Novgorod and Novgorod Oblast amounted to 345.0‰. The prevalence of andrological pathology in boys of Saint Petersburg was established at 153.1‰. Violations of the reproductive system were classified both as andrological diseases proper (cryptorchidism, varicocele, etc.) and as diseases and deviations from the norm that may subsequently directly or indirectly affect the state of reproductive health (phimosis, synechiae, etc.). On the material of the conducted preventive examinations, it was proven that the level of prevalence of andrological pathology depends on age. In the age period from 7 to 14 years, the frequency of andrological diseases decreases (7–9 years — 168.9‰, 10–13 years — 152.6‰); at the age of 14–16 years, in connection with hormonal restructuring, it has a tendency to increase — 187.4‰; and at the age older than 16 years it decreases again to 148.3‰.

The conditions and lifestyle of boys were studied with account of their influence on reproductive health. It was proven that among mothers of boys with andrological pathology, there are more than twice as many women employed in manual occupations, three times as many unemployed and housewives, and significantly fewer white-collar workers than in the control group. In families where mothers are more educated, boys more frequently exhibited such pathology as cryptorchidism and varicocele.

Medico-social risk factors influencing the formation of reproductive function were identified. It was proven that the formation of andrological pathology (cryptorchidism, varicocele, phimosis) is statistically significantly (p<0.001) influenced by smoking by women before pregnancy, as well as passive and active smoking during pregnancy. The statistically significant (p<0.001) influence of alcohol abuse by the father before pregnancy on the formation of phimosis and varicocele in boys was established. Even periodic use by the father of narcotics before the birth of the child influences (p<0.001) the formation of cryptorchidism in the son. Abortions in the mother's anamnesis statistically reliably influence (p<0.001) the frequency of the formation of phimosis and cryptorchidism in sons. The influence of transferred latent infections in the mother and father (p<0.001) before pregnancy on the formation of cryptorchidism and phimosis in children was proven. The formation of varicocele is influenced by the presence of venous pathology on the maternal side, on the paternal side, and the presence of similar diseases among close relatives (p<0.001).

It was proven that reproductive attitudes of youths are characterized by ideal-romantic, contrasting, illusory representations of marriage and family. The majority of youths have low reproductive attitudes; the family-marital orientation of contemporary adolescent youths is directed toward the creation of a small-nuclear, child-poor family, with a tolerant attitude toward divorce. Among youths, the potential of knowledge in the field of anatomy, physiology, and sexual relationships between men and women is extremely low. In schools, work in the area of sex education and education of students is conducted poorly. Classes on ethics and psychology of family life were attended by only 18.9% of respondents in Saint Petersburg and 30.2% in Veliky Novgorod.

In the course of assessing the state of primary curative and preventive assistance to children with andrological pathology, it was established that the work of the primary link of health care, directed toward its early detection, is poorly organized. After the detection of pathology, only 20.8–46.3% of children are placed on dispensary observation, while 6.4–25.9% of patients receive no prescriptions whatsoever. The main method of detecting andrological diseases in boys is targeted examinations, which yield a good effect: 40.5% of cases of phimosis, 26.3% of cryptorchidism, and 60.8% of varicocele are detected during examinations. At the same time, 47.0% of boys in Saint Petersburg and 26.3% in Veliky Novgorod have never been examined by a pediatric andrologist-urologist.

Upon assessing the quality of inpatient treatment of boys with andrological pathology, it was established that many patients with andrological diseases are prescribed surgical treatment immediately after referral (37–55% of cases). At the same time, the problem of inpatient treatment has not yet been resolved; specialized pediatric andrological departments are absent. The majority of patients who have undergone operations require prolonged dispensary observation and staged rehabilitation. However, only 11.9–16.2% of operated boys are placed on dispensary observation.

A classification and diagnosis of synechiae as one of the most prevalent andrological pathologies in children and adolescents was proposed;

A classification of groups of health states of children and adolescents requiring dispensary observation concerning andrological diseases was proposed;

A methodology for normative design of organizational structures of the pediatric and adolescent andrological service was developed;

A model of the pediatric and adolescent andrological service of the Russian Federation was developed, substantiated, and presented;

A new scientific and clinical direction of domestic medicine — pediatric and adolescent andrology — was substantiated.

Scientific and Practical Significance of the Work:

On the basis of the investigation, the main provisions of a program for the provision of medical assistance to children with andrological diseases were developed. A system of measures of medico-social and organizational character, directed toward the preservation and strengthening of reproductive health of boys, was proposed.

The conclusions and practical proposals of the work may serve as the basis for the organization of a pediatric and adolescent service on the territory of all of Russia. Methodological approaches developed in the course of the dissertation investigation may be used for the development and scientific substantiation of other types of specialized assistance to children and adolescents in the conditions of domestic health care. The obtained data may be used for forecasting the demographic situation in Russia and for planning ambulatory-polyclinic and inpatient medical assistance to children and adolescents.

Implementation of the Work:

The results of the dissertation investigation found reflection in methodological and program-targeted documents directed toward the improvement of andrological assistance to children in Novgorod Oblast (Information Letter for Pediatric Surgeons, Pediatric Urologists, and Pediatricians, Order No. 1134 of 14.06.05 of the Committee on Population Health Protection of Novgorod Oblast), in Barnaul ("Methodological Guidelines for Pediatricians, Pediatric Surgeons, Urologists, and Andrologists," Order No. 307 of 15.11.02 of the Health Committee of the City of Barnaul), in Stavropol (a decision approved by the Stavropol City Duma No. 166 of 08.11.01, on the use of the present dissertation investigation in the program "Education and Health" in the conditions of health care reform"). On the basis of the investigation materials, methodological recommendations "Tasks of Pediatric Polyclinics for the Early Detection of Andrological Pathology in Boys" (Order No. 134/21 of 16.09.04 of the Ministry of Health and Social Development of the Russian Federation) were developed, approved, and introduced into the practice of health care of Russia.

Propositions to be Defended:

1. Contemporary trends in the prevalence of andrological pathology in boys and youths of school age indicate that every sixth child of Saint Petersburg, Veliky Novgorod, and Novgorod Oblast requires medical assistance and treatment from an andrologist. The level and structure of violations of the reproductive system in boys and youths of school age directly depend on the region of residence and the age of the child.

2. The share of medico-social risk factors in the appearance of andrological pathology in boys amounts to approximately 40%. The leading role in the development of violations of the reproductive system in boys belongs to hereditary factors, the degree of whose influence amounts to up to 60%. The most significant risk factors are the presence of a similar disease in relatives predominantly on the paternal side, complicated course and prematurity of the pregnancy, and the effect of tobacco combustion products on the fetus during pregnancy.

3. The organizational-resource basis for the construction of the pediatric and adolescent andrological service of the Russian Federation is the regional infrastructure of the system of provision of medical services to the population, encompassing curative and preventive institutions of various forms of ownership. A special methodological basis may be constituted by the developed concept and model of the system of organization of andrological assistance and treatment of children and adolescents in the country.

4. The structure of the pediatric and adolescent andrological service of the Russian Federation should include four levels: the first — district pediatricians and physicians of educational institutions; the second — uroandrological offices of pediatric polyclinics; the third — city (oblast) centers of reproductive health of children and adolescents or city (oblast) uroandrological dispensaries; the fourth — specialized andrological departments of pediatric multidisciplinary hospitals. A special methodological basis for the construction of the structure of the pediatric and adolescent andrological service of the Russian Federation may include the developed methodology for their design and the results of its practical testing in the conditions of Saint Petersburg.

5. The concept of the pediatric and adolescent andrological service of the Russian Federation represents a new scientific and clinical direction of medicine — pediatric and adolescent andrology — based on contemporary principles of construction, functioning, and management of the provision of medical services to the population of the country.

Author's Contribution:

The author conducted a content analysis of official documents, carried out the planning of the investigation, composed its program, developed statistical accounting forms, and performed the collection of factual data. The author organized and personally participated in the conduct of screening examinations of boys, in the conduct of an expert assessment of primary medical documentation, and carried out a sociological survey and questionnaire of children and their parents. The analysis, interpretation, and presentation of the obtained data, the formulation of conclusions and practical recommendations were performed personally by the author. The author's share in the collection and processing of accumulated data exceeds 95%, and in the generalization and analysis of the investigation material — 100%.

Testing of the Work:

The main provisions of the dissertation were reported and discussed at conferences: "Sexual Health of Humanity at the Turn of the Centuries" (Moscow, 1999); "Eco-Social Questions of Protection and Preservation of Health of the Young Generation on the Path to the XXI Century" (Saint Petersburg, 1998); "Problems and Paths to Improvement of Quality of Life in the North"; "New in the Diagnosis and Treatment of Andrological Patients" (Yekaterinburg, 2001); "Hygienic Training and Upbringing of the Population in the Prevention of Diseases" (Saint Petersburg, 2003); "Actual Problems of Public Health and Health Care at the Regional Level" (Ivanovo, 2003); "New Methods of Diagnosis, Treatment, Prevention, Rehabilitation, and Medico-Social Organization in Pediatrics" (Saint Petersburg, 2002); "Social and Clinical Problems of Sexology and Sexopathology" (Moscow, 2003); "Sexual Health of Humanity at the Turn of the Centuries" (Moscow, 1999), I Congress of Sexologists and Andrologists of Ukraine (Kyiv, 2004); Interdepartmental Scientific Conference of the NNII 03 RAMN (Moscow, 2005).

Based on the dissertation, 34 works were published, including 6 works in peer-reviewed scientific journals recommended by the Higher Attestation Commission, and two monographs.