Undescended testis (cryptorchidism)

Clinical features

• Empty or underdeveloped hemiscrotum
  • Unilateral: one side of scrotum is poorly developed.
  • Bilateral: both testes absent from the scrotum.
• Testis not palpable in normal scrotal position.
• Palpable testis may be felt in:
  • superficial inguinal pouch
  • inguinal canal
  • near the external inguinal ring.
• Non-palpable testis may be intra-abdominal, atrophic, absent, or a vanishing testis.
• Usually painless and detected during routine newborn, infant, or child examination.
• Associated findings can include:
  • indirect inguinal hernia/patent processus vaginalis
  • hypospadias or other genital ambiguity
  • disorders/differences of sex development, particularly with bilateral non-palpable testes.

Complications

1. Subfertility or infertility
   • Higher intra-abdominal temperature progressively damages germ cells and seminiferous tubules.
   • Histological changes may begin by 6 months, with impaired spermatogenesis developing later.
   • Bilateral disease has a much poorer fertility and paternity outcome than unilateral disease. Sabiston Textbook of Surgery, p. 2697.
2. Testicular malignancy
   • Increased lifetime risk of testicular germ-cell tumour, especially seminoma.
   • Risk is particularly high with intra-abdominal testes.
   • Orchiopexy reduces risk when performed early, but does not return the risk fully to normal. It allows easier examination and earlier recognition of a tumour. The Developing Human, p. 762.
3. Torsion
   • An undescended testis is prone to torsion, which may present with groin or abdominal pain rather than scrotal pain.
4. Trauma
   • An inguinal testis is more exposed to external injury.
5. Associated inguinal hernia
6. Psychological/cosmetic concern, especially later in childhood or adolescence.

Management

1. Observation initially

• Spontaneous descent may occur during early infancy.
• If descent has not occurred by 6 months corrected age, spontaneous descent thereafter is unlikely.
• Refer to paediatric urology/paediatric surgery at 6 months.

2. Orchiopexy

• Aim to perform between 6 and 12 months of age, and no later than 18 months.
• Benefits:
  • improves preservation of testicular growth and future fertility potential
  • facilitates examination and cancer surveillance
  • reduces risk of torsion/trauma
  • corrects associated hernia where present.

• Inguinal exploration, mobilisation of spermatic cord, ligation of patent processus vaginalis if present, and scrotal orchiopexy.

• Examination under anaesthesia followed by diagnostic laparoscopy.
• Findings and treatment:
  • viable intra-abdominal testis: laparoscopic orchiopexy, either single-stage or staged Fowler-Stephens procedure for a high testis
  • vessels entering internal ring: inguinal exploration
  • blind-ending vessels/vanishing testis: no viable testis to preserve, possible removal of remnant depending on operative findings.

3. Hormonal therapy

• Not recommended routinely for inducing descent in unilateral undescended testis because success is limited and recurrence can occur.
• hCG or GnRH therapy is not a substitute for timely orchiopexy.
• In selected bilateral cases, paediatric endocrine input may be considered regarding fertility potential, but surgery remains central to management.

4. Bilateral non-palpable testes: urgent evaluation

• karyotype/genetic assessment where indicated
• serum electrolytes and endocrine assessment
• hormonal tests such as AMH, inhibin B, LH, FSH, and testosterone, tailored to age and clinical setting
• assessment for congenital adrenal hyperplasia or a disorder/difference of sex development if genital ambiguity or hyperpigmentation is present.

5. Long-term follow-up

• Counsel the patient/parents about residual cancer risk.
• Teach testicular self-examination from puberty.
• Prompt review for a new testicular lump, persistent groin/abdominal pain, or testicular asymmetry.