Cryptorchidism / Undescended Testis

We know we must be vigilant! The constant search for clues for the covertly sick patient (ex, Leukemia in Neonates, Heart Failure, Pneumonia) has refined our vision and honed our intuition. That vigilance, however, can discover clues that we may not know what to do with completely. We know it is not an emergency, but it is still a problem. Let us take a minute to review what to do with one such finding: Cryptorchidism.

Cryptorchidism: Basics

Cryptorchidism = Undescended Testis [Shin, 2019]

  • It is the most common genitourinary disorder in male neonates.
  • Affects 1-4% of term and up to 45% of preterm male infants!
  • Can be present at birth, but can also occur after having already descended (1-2% of boys > 6 months of age)
  • Many cases will spontaneously descend by 3 months of age.
  • If the testes do not descend by 6 months of age, then the likelihood is low that it will.

Why it matters: [Shin, 2019]

  • Cryptorchidism can lead to infertility.
  • Cryptorchidism can lead to increased risk of cancer.

Risk Factors for Cryptorchidism: [Shin, 2019]

  • Prematurity (<37 weeks gestation)
    • Descent of the testis usually occurs between the 25th and 35th week of gestation.
  • Low Birth Weight (<2.5 kg)
  • Intrauterine Growth Restriction
  • Hormal disorders (ex, CAH)
  • Penile abnormalities (ex, hypospadias)
  • Abnormal Fetal growth (ex, Down Syndrome)
  • Family History of cryptorchidism (you can’t outrun your genes)

Classification: Palpation and Location [Shin, 2019]

  • The undescended testicle can be classified based on:
    • Palpable
    • Impalpable
  • The location is also factored in:
    • Palpable may be in:
      • Inguinal Canal
      • Supra-scotal and High Scrotal (retractile) areas
      • Ectopic areas (ex, inner thigh, femoral, pubic, perineal)
    • Impalpable may be in:
      • Inguinal Canal
      • Ectopic areas (same as above)
      • Intra-abdominal

Other considerations: [Shin, 2019]

  • The “retractile” testicle:
    • If it can be gently pulled into the bottom of the scrotum and then remains there for a while, then that can be normal.
  • Bilateral undescended testicles:
    • Can be associated with hormonal failure, posterior urethral valve, abdominal wall defects, or neural tube defects.
  • Testicular regression (“vanishing testis”):
    • May present with unilateral impalpable testis (“undescended testis”) with the palpable testis having compensatory hypertrophy.
    • An antenatal vascular event or torsion may cause failure of the testicle to develop as well.

Cryptorchidism: Management Considerations

Examination:

  • Position:
    • Supine and/or Frog position to start
    • If not palpable, try seated or squatting positions. [Shin, 2019]
  • Palpate everything!
    • The ectopic areas may be overlooked.
    • If you don’t find a testicle in the inguinal canal or the scrotum, look for it along the inner thigh and the femoral, public, perineal and penile regions. [Shin, 2019]

Imaging: [Shin, 2019]

  • Interesting, no imaging is recommended by the various international urologic associations.
    • Ultrasound is not accurate enough to rule-out intra-abdominal testis.
    • MRI is also not accurate enough.
  • Many still order ultrasound to evaluate the inguinal canal, but a testicle may not be able to be differentiated even in the canal.
  • Ultrasound results do not alter need for exploratory laparoscopy.

Surgical management: [Shin, 2019]

  • Timing of orchiopexy is an area of debate.
  • If a testicle is still undescended by 6 months, many recommend that the orchiopexy occur within the next 12-18 months.

Moral of the Morsel

  • Be thorough. Look (and feel) in regions that known to be ectopic locales.
  • Know natural history. An undescended testicle warrants follow-up, but let the family know that many will descend by 3 months of age.
  • Don’t need the images. I know… I know… I want to order an ultrasound intuitively, but know that the results will not change the management.

References

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Sean M. Fox
I enjoy taking care of patients and I finding it endlessly rewarding to help train others to do the same. I trained at the Combined Emergency Medicine and Pediatrics residency program at University of Maryland, where I had the tremendous fortune of learning from world renowned educators and clinicians. Now I have the unbelievable honor of working with an unbelievably gifted group of practitioners at Carolinas Medical Center. I strive every day to inspire my residents as much as they inspire me.
Articles: 548

2 Comments

  1. There is a Choosing Wisely statement that essentially support your recommendation to not perform ultrasound.

    From the American Urological Association
    Released February 21, 2013; sources updated May 9, 2016; updated May 26, 2017

    Don’t routinely perform ultrasound on boys with cryptorchidism.

    Ultrasound has been found to have poor diagnostic performance in the localization of testes that cannot be felt through physical examination. Studies have shown that the probability of locating testes was small when using ultrasound, and there was still a significant chance that testes were present even after a negative ultrasound result. Additionally, ultrasound results are complicated by the presence of surrounding tissue and bowel gas present in the abdomen.

    Matthieu

    PS. Thanks a lot for your weekly Peds EM Morsels. Great work.

    Matthieu Vincent
    MD, FRCPC
    Emergency medicine and Pediatric emergency medicine specialist
    Adjunct professor in the department of Paediatrics, Faculty of Medicine, McGill University
    Clinical assistant professor, Faculty of Medicine, Sherbrooke University
    Emergency department, Charles Lemoyne hospital, Quebec, Canada
    Emergency department, CHU St-Justine, Quebec, Canada

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