Clinical assessment of sexual maturation in adolescentsjped.com.br/conteudo/01-77-S135/ing.pdf · 2002. 3. 7. · 1). Stage 1 (Tanner 1) corresponds to the prepubertal phase and stage

Jornal de Pediatria - Vol. 77, Supl.2 , 2001 S135

S135

0021-7557/01/77-Supl.2/S135Jornal de PediatriaCopyright © 2001 by Sociedade Brasileira de Pediatria

REVIEW ARTICLE

Clinical assessment of sexual maturation in adolescents

Eugenio Chipkevitch*

AbstractObjective: to present the methods for clinical evaluation of sexual maturation in adolescents.

Methods: bibliographic review concerning the practice of pubertal staging.

Results: the assessment of sexual maturation is an essential step in the comprehensive health care ofadolescents, allowing for the evaluation of their developmental stage. In addition, this assessment allowsestablishing a correlation between different pubertal events, following up diseases, and interpretinglaboratory tests appropriately. Pubertal stage is assessed by the examination of breasts and pubic hair infemales, and genitals and pubic hair in males. A new photographic standard for pubertal staging and a newmethod for clinical measurement of testicular volume are presented.

Conclusions: the assessment of sexual maturation is an important feature in the health care ofadolescent patients and must be included in the clinical practice of pediatricians involved in adolescentmedicine.

J Pediatr (Rio J) 2001; 77 (Supl. 2): S135-S142: adolescence, puberty, sex maturation.

* Director of the Paulista Institute for Adolescence, former director of theAdolescent services of the Children’s Hospital Darcy Vargas, São Paulo.

Introduction

Puberty is a period of biological maturation marked bythe appearance of secondary sexual characteristics, growthspurt, and changes in body composition. With the exceptionof the fetal period, there is no other stage in humandevelopment in which height growth and changes in bodycomposition are as intense and rapid as during puberty. Thegrowth spurt, for example, lasts three to four years andrepresents approximately a 20% and 50% gain in relation toadult height and weight, respectively.1

In adolescence, chronological age is not a reliableparameter for biological, psychological, and socialcharacterization of individuals. Adolescents with the sameage are frequently in different stages of puberty consideringthat its onset and progression are highly variable. Mostpubertal events (maximum growth velocity, menarche, finalheight, and so on) and most pathologies associated topuberty (acne, scoliosis, gynecomasty, and so on) are moreoften correlated to specific stages of puberty than tochronological age.1 Pubertal staging allows doctors toassess the maturation of adolescent patients; to correlateseveral pubertal phenomena; to estimate age at menarche,growth spurt, and final height; to offer early orientation toyoungsters in relation to upcoming pubertal events; to offer

S136 Jornal de Pediatria - Vol. 77, Supl.2, 2001

advice on choice of proper sports modalities; to assessexams properly; and to treat pathologies associated topuberty.1

In this sense, pubertal staging is an important measurefor characterizing the maturation of adolescents and foreasier understanding and handling of the most commonclinical problems for this age group. Our objective is tooffer a brief review on the practice of pubertal staging, andto present a new photographic model on the stages of sexualmaturation and a new method for measurement of testicularvolume.

Pubertal staging

Though certain models of pubertal staging had alreadybeen proposed during the 1940s and 1950s,2-4 doctor J.M.Tanner was the one who presented a standardized methodfor staging of sexual maturation,5 which became widelyused during the 1960s and is still the most widely usedmethod.

Staging of sexual maturation is carried out with breastand pubic hair growth examination for girls, and withgenital and pubic hair growth for boys. Breasts and genitalsare examined according to size, shape, and characteristicsand pubic hair according to quantity and distribution (Table1). Stage 1 (Tanner 1) corresponds to the prepubertal phaseand stage 5 (Tanner 5) corresponds to late-pubertal (adult)phase. In this sense, stages 2, 3, and 4, or the midpubertalstages, represent puberty. Stages 2 to 4 are conventionallycalled sexual maturation stages, or Tanner stages.

The classical work of Tanner included a set of black-and-white photographs for illustration of each maturationstage for both sexes.5 A few years later, a Dutch grouppublished a set of color photographs for these same stages.6

In this article, we reproduce our black-and-white model forsexual maturation (Figures 1, 2, 3, and 4) originally publishedin 1995.1 This is the first published Brazilian model and thethird in the international literature.

For each sex, staging is carried out according to twosteps: breasts (B) and pubic hair (P) growth for girls, andgenitals (G) and pubic hair (P) for boys (Table 1). It isrecommended to always assess these two steps separately;for example, B3P3 instead of stage 3. Adolescents may bein different maturation stages for each of the twocharacteristics, for example, B4P5 or G2P1 consideringthat maturation of the characteristics depends on differenthormonal and genetic mechanisms. Pubertal events correlatedifferently to specific components of maturation staging;for example, age at menarche is more correlated to breastdevelopment than to pubic hair growth. Most adolescentsdo not present differences of more than one stage betweenB and G in relation to P; however, situations of G1P3,G4P1, or M3P1, though rare, can be observed in normaladolescents. Nevertheless, important differences as suchcan also be an indication of a pathology (supra-renal,testicular, etc).7

Male genitals

G1 Childlike penis, testicles, and scrotum.

G2 Initial increase in testicular volume (>4ml). Thetexture of the scrotal skin becomes reddenedand thinner. The enlargement of the penis isminimal or absent.

G3 Increased length of the penis. Great enlargementof testicles and scrotum.

G4 Increased length and circumference of the peniswith great enlargement of the glans. Enlargedtesticles and scrotum, and increased scrotal skinpigmentation.

G5 Full development of genital organs, with adultappearance.

Breasts (females)

M1 Childlike, with elevated papilla.

M2 Breast bud: initial increase of the mammarygland, with elevated areola and papilla, forminga small mound. Areolar diameter and texturechange.

M3 Great enlargement of the breasts and areola,without contour separation.

M4 Greater enlargement of the breast and areola. Asecond mound is formed above the breastcontour.

M5 Adult mature breasts. Recession of areola to themound of breast tissue.

Pubic hair (both sexes)

P1 No pubic hair. Vellus over the pubes in nofurther developed than that over the abdominalwall.

P2 There is sparse growth of long, slightlypigmented, downy hair, straight or only slightlycurled, appearing chiefly at base of penis oralong the labia majora).

P3 Hair is considerably darker, coarser, and morecurled, and spreads sparsely over junction ofpubes.

P4 Hair is now adult in type but there is no spreadto the inner thighs.

P5 Adult quantity and distribution with hair presenton inner thighs.

P6 Hair spreads above the pubes.

Table 1 - Sexual maturity rating

During puberty, there is an increment in nipple (papilla)and nipple areola in both girls and boys, but especially in theearlier. The increment in nipple diameter is greater duringstages B4 and B5, which helps to differentiate stages B3,

Clinical assessment of sexual maturation... - Chipkevitch E


Figure 1 - Stages of sexual maturation in males - genitals



Figure 2 - Stages of sexual maturation in males - pubic hair



Figure 3 - Stages of sexual maturation in females - breasts



Figure 4 - Stages of sexual maturation in females - pubic hair



B4, and B5. The nipple presents little increase betweenstages 1 and 3 and marked increase between stages B3 andB4 (diameter averages of 3 mm for B1; 3.4 mm for B2; 4.7mm for B3; 7.3 mm for B4; and 9.4 mm for B5).7,8

Initially, the appearance of thelarche (B2) may occur inonly one breast; the contralateral breast will usually startgrowing weeks or months later. Breast asymmetries,however, can persist for some time between B2 and B4 or,in some women, be permanent. The stage B4 is not observedin all girls; apparently, some female individuals go directlyfrom B3 to B5 or stage B4 occurs so rapidly that it is notregistered in successive medical appointments. Conversely,in other girls breast development may stop in stage B4.

The stage 6 of pubic hair growth is observed inapproximately 80% of men and 10% of women; in certainindividuals, it will only be complete years after puberty isover.

Testicular volume

The measurement of testicular volume represents anadditional instrument for assessment of male sexualmaturation.

The most widely used method for measuring testicularvolume uses the Prader orchidometer, which includes 12ellipsoid testicular models made of wood or plastic andattached to a string. The models have volumes of one to 25ml.9 To assess testicular volume, the doctor palpates thetestis with one hand while holding the orchidometer in theother, examining the patient for the model that is moresimilar to the palpated testis.

Takihara et al.10 proposed a new orchidometer thatconsists of a graded series of punched-out elliptical ringswith the volume of the ellipsoids indicated on each ring forvolumes of 1 to 30 ml.

Considering that orchidometers are not easily availablein our setting, other methods that offer similar precision canbe applied. Thus, it is also possible to measure the two axesof the testis with a transparent ruler or, better yet, with acaliper (similar to that used for measurement of skinfold)and calculate the volume using the formula V = 0.523 x Lx C2 (with V for volume, L for longitudinal diameter, and Cfor cross-sectional diameter).

The measurement of testicular volume byultrasonography employs the same principle, though it hasbeen reported as the most precise method.11 We were ableto show, in a different article, that all methods offercomparable reliability as long as the volumes obtained arecorrected using the equations of the linear structural model.12

In this sense, it was possible to propose a method for visualcomparison of the palpated testes with graphic models forestimation of testicular volume (Figure 5); this new proposedmethod is, thus, simple and its reliability comparable to thatof orchidometer and ultrasonography.12


Figure 5 - Scheme for graphic measurement of testicularvolume. The testicle is palpated and visuallycompared with the graphic models. Testicular volumeis determined according to one of the six volumes orone of the intermediate volumes between twoconsecutive volumes depicted . The entiremeasurement scale includes 13 volumes: less than2ml, 2ml, 3.5ml, 5ml, 7.5ml, 10ml, 12.5ml, 15ml,17.5ml, 20ml, 22.5ml, 25ml, and greater than 25ml

In general, the testes of children have one to two, andsometimes three, ml in volume. Testes with four ml or moreare, almost as a rule, characteristic of puberty. Consequently,


Correspondence:Dr. Eugenio ChipkevitchInstituto Paulista de AdolescênciaRua Alcides Ricardini Neves, 12 - cjs. 906-909CEP 04575-050 – São Paulo, SP, BrazilPhone/fax: + 55 11 5506.9005E-mail: [email protected]

2. Schonfeld WA. Primary and secondary sexual characteristics:Study of their development in males from birth to maturity, withbiometric study of penis and testes. Am J Dis Child 1943; 65:535-49.

3. Reynolds EL, Wines JV. Individual differences in physicalchanges associated with adolescence in girls. Am J Dis Child1948; 75:329-50.

4. Reynolds EL, Wines JV. Individual differences in physicalchanges associated with adolescence in boys. Am J Dis Child1951; 82:529-47.

5. Tanner JM. Growth at adolescence. Oxford: Blackwell; 1962.

6. van Weringen JC, Waffelbakker F, Verbrugge HP. GrowthDiagrams, 1965, Netherlands. Leiden: Netherland Institute forPreventive Medicine; 1971.

7. Wilson JD, Foster DW, Kronenberg HM, Williams RH, ed.Williams Textbook of Endocrinology. 9th ed. Philadelphia: Saun-ders; 1998; p.1509-625.

8. Kreipe RE. Normal somatic adolescent growth and development.In: McAnarney ER, Kreipe RE, Orr DP, Comerci GD, eds.Textbook of Adolescent Medicine. Philadelphia: Saunders; 1992;p.44-67.

9. Prader A. Testicular size: Assessment and clinical importance.Triangle 1966; 7:240-3.

10. Takihara H, Cosentino MJ, Sakatoku J, Cockett ATK. Signifi-cance of testicular size measurement in andrology: I. A neworchidometer and its clinical application. Fertil Steril 1983; 39:836-40.

11. Behre HM, Nashan D, Nieschlag E. Objective measurement oftesticular volume by ultrasonography: evaluation of the tech-nique and comparison with orchidometer estimates. Int J Androl1989; 12:395.

12. Chipkevitch E, Nishimura RT, Tu DGS, Galea-Rojas M. Clinicalmeasurement of testicular volume in adolescents: Comparison ofthe reliability of 5 methods. J Urol 1996; 156:2050-3.


attaining a volume of four ml or more is an indication of G2;this is an example of how measurement of testicular volumecan help to carry out pubertal staging. A testicular volumeof three ml is generally prognostic of puberty, for anestimated 80% chance of starting within the following sixmonths.7 Eleven to 12-year old boys with small testes (oneto two ml) are probably affected by delay of pubertaldevelopment (usually constitutional).

Measuring testicular volume is also important for theassessment of diagnosis of certain pathologies; for example,cases of Klinefelter syndrome (small testes) or of Fragile-X syndrome (possible macro-orchidism). The follow-upmeasurement of testicular volume is important in postsurgicalfollow-up of orchipexy (to check whether ectopy, twistingand/or surgical handling has affected testicular development)or of varicocele (that presents risk for testicular hypertrophyand subfertility).

Most adolescents have similar left- and right-hand sidetesticular volumes; however, it is common for the left-handside testicle to have a slightly lower volume than the right-hand side one. In cases of significant differences (20%), itis important to examine the patient for factors that may beinterfering in growth of the smaller testis (varicocele,previous surgery, orchitis, twisting, etc).

Testicular volume is significantly correlated with thetesticular function. Some authors consider a testicular volumeof 12 ml, attained, in average, around 13 to 14 years of ageand during maximum growth velocity, the minimum volumecompatible with fertility; in this sense, attainment of thisvolume is comparable to menarche as a reference for malesexual maturity.1

The average testicular volume of Brazilian adolescentsis four ml for G2, nine ml for G3, 16 ml for G4, and 20 mlfor G5. However, there can be significant variations in thesevalues. Consequently, a specific testicular volume cannotbe used to define stage of sexual maturation. Adult testes,for example, can vary from 12 to 30 ml in volume.7

References1. Chipkevitch E. Puberdade e adolescência: aspectos biológicos,

clínicos e psicossociais. São Paulo: Roca; 1995.

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Clinical assessment of sexual maturation in adolescentsjped.com.br/conteudo/01-77-S135/ing.pdf · 2002. 3. 7. · 1). Stage 1 (Tanner 1) corresponds to the prepubertal phase and stage