Undescended Testicle

Aka: Undescended Testicle, Undescended Testes, Undescended Testis, Cryptorchidism

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II. Definitions

  1. Cryptorchidism
    1. Undescended Testicle
    2. Derived from greek, "Hidden Testicle"

III. Pathophysiology

  1. See Male Gonadal Development

IV. Epidemiology: Incidence

  1. Preterm Newborn: 30 to 45% Incidence
  2. Term Newborn: 2.7 to 5.9% Incidence
  3. Age 6 months: 0.8% persistent Undescended Testicle
  4. Unilateral in 90% of cases
    1. Right Testicle most often affected
    2. Bilateral Undescended Testes in 10-20% of cases

V. Risk Factors

  1. Birth weight <2500 g
  2. Intrauterine Growth Restriction
  3. Preterm birth
  4. Perinatal asphyxia
  5. Cryptorchidism Family History
  6. Hormonal disorders
  7. Penile abnormalities
  8. Pregnancy related complications
    1. Maternal Obesity
    2. Advanced maternal age
    3. Cesarean Section
    4. Placental insufficiency

VI. History

  1. Review risk factors above
  2. Gestational age at birth
  3. Birth weight
  4. Testicle position history (has the Testicle previously been located within the Scrotum?)

VII. Exam: General

  1. See Genitourinary Examination in Infants
  2. Perform exam with infant supine
  3. Palpate the Scrotum and Inguinal Canal path
  4. Evaluate for other abnormalities
    1. Inguinal Hernia
    2. Hydrocele
  5. Perform serial exams
    1. Half of Undescended Testicles will descend by 3 months of age
    2. Testicles may also ascend (acquired Cryptorchidism) in age >6 years in up to 1 to 2%
    3. After Puberty, testicular size increase maintains Testicle in Scrotum

VIII. Exam: Cryptorchidism Type

  1. Nonpalpable Testicle
  2. Palpable Testicle (80% of cases)
    1. Retractile
      1. Testicle in upper Scrotum or lower Inguinal Canal
      2. Testicle can be pulled into Scrotum with mild tension
    2. Undescended
      1. Testicle not in the Scrotum (but at least halfway below midpoint of descent path)
      2. Testicle can be pulled into upper Scrotum with constant tension (but immediately rises out of Scrotum on release)
    3. Acquired undescended (Ascended Testicle)
      1. Testicle not in the Scrotum (but at least halfway below midpoint of descent path)
      2. Previously palpated in the Scrotum, and in correct position
    4. Ectopic undescended
      1. Testicle not in the typical path of Embryologic descent
      2. Testicle distal to External Inguinal Ring
        1. Most often in the superficial inguinal pouch
        2. May rarely be located in the prepubic, femoral, perianal or contralateral Scrotum
  3. References
    1. Mau (2017) Can Fam Physician 63(6): 432-5 [PubMed]

IX. Differential Diagnosis: Bilateral Undescended Testicle (Bilateral Crytorchidism)

  1. Congenital Adrenal Hyperplasia (female Virilization)
  2. Associated disorders of Sexual Development
    1. Hypospadias
    2. Micropenis
    3. Ambiguous Genitalia

X. Diagnostics: Bilateral Crytorchidism

  1. Start with urology evaluation
  2. Consider endocrinology Consultation
  3. Tests to consider in Bilateral Crytorchidism (consult endocrinology)
    1. Karyotype (Congenital Adrenal Hyperplasia)
    2. Serum Testosterone
    3. Luteinizing Hormone (LH)
    4. Follicle Stimulating Hormone (FSH)
    5. Thyroid Stimulating Hormone
    6. 17-Hydroxyprogesterone
    7. Mullerian-Inhibiting Substance
    8. Serum Cortisol

XI. Imaging

  1. No initial imaging is indicated (including Scrotal Ultrasound)
    1. Ultrasound has low efficacy for Testicle localization in nonpalpable Testicle
    2. Taslan (2011) Pediatrics 127(1): 119-28 [PubMed]
    3. Hartigan (2014) Transl Androl Urol 3(4): 359-64 [PubMed]
  2. Start with pediatric urology referral
  3. Bilateral Crytorchidism may warrant imaging after urology Consultation
    1. Pelvic Ultrasound (Congenital Adrenal Hyperplasia)

XII. Management

  1. Initial Referral Indications
    1. Bilateral Undescended Testes
    2. Associated genitourinary abnormalities
    3. Refer persistent Cryptorchidism (except retractile Testicle) to urology by 6 months of corrected Gestational age
  2. Unilateral retracted Testicle
    1. Testicle may be brought down into Scrotum
    2. Parents pull Testis into Scrotum per diaper change
    3. Follow-up examinations in the clinic
    4. Resolves spontaneously in 70 to 75% of cases
      1. Transition to acquired Undescended Testicle occurs more often in age <7 years
  3. Unilateral palpable ectopic or Undescended Testicle
    1. Observe for descent
    2. Spontaneous descent is unlikely after 6 months of corrected Gestational age
    3. Surgical correction at 6 month to 1 year of corrected Gestational age
      1. Best surgical outcomes for fertility if repaired by 12 months age
      2. Orchiopexy recommended before 18 months of age
  4. Unilateral nonpalpable Testicle (15% of cases)
    1. Laparoscopy at 6 months to 1 year of corrected Gestational age for evaluation
      1. Best surgical outcomes for fertility if repaired by 12 months age
      2. Orchiopexy recommended before 18 months of age
    2. Testicle found on laparoscopy in 50% of cases
    3. Orchiopexy brings Testis into Scrotum (98% efficacy)
  5. Other management
    1. Hormonal therapy (hcg, LHRH) is NOT recommended

XIII. Complications: Cryptorchidism

  1. Testicular Cancer (Seminoma) at age 15 to 45 years
    1. Early surgical intervention reduces cancer risk (before age 13 years)
    2. Overall cancer risk 3% (RR 5-10)
      1. Risk 2% if repaired age <13 years
      2. Risk 5% if repaired age >13 years
  2. Infertility
    1. Repaired unilateral Cryptorchidism
      1. Unilateral Cryptorchidism does not appear to increase Infertility risk regardless of original Testicle location
      2. Lee (2000) J Urol 164(5): 1697-701 [PubMed]
    2. Repaired bilateral Cryptorchidism: 85% fertile
      1. Infertility risk is 6 fold higher than the 1 to 2% seen in males without Cryptorchidism
    3. Best outcomes for fertility are with Orchiopexy by 12 months of age
      1. Gates (2022) J Pediatr Surg 57(7): 1293-1308 [PubMed]
  3. Other complications
    1. Indirect Inguinal Hernia (often present)
    2. Testicular Torsion (of cryptorchid Testicle)

XIV. Complications: Orchiopexy

  1. Overall Orchiopexy complication rate <1%
  2. Early complications
    1. Ilioinguinal nerve injury
    2. Vas deferens injury
  3. Late Complications
    1. Testicular atrophy
      1. Urology will typically follow with annual exams and Ultrasound (testicular volume, testicular atrophy index)
      2. In some cases, hormonal testing, Semen Analysis or testicular biopsy may be needed
    2. Acquired Undescended Testicle (recurrent Cryptorchidism)
    3. Testicular Torsion

XV. Prevention

  1. Testicular Self-Exam
    1. Males with Cryptorchidism history are at increased risk of Testicular Cancer (even with early repair)

XVI. References

  1. Behrman (2000) Nelson Pediatrics, Saunders, p. 1650-1
  2. Docimo (2000) Am Fam Physician 62(9):2037-48 [PubMed]
  3. Fuloria (2002) Am Fam Physician 65(2):265-70 [PubMed]
  4. Nguyen (2023) Am Fam Physician 108(4): 378-85 [PubMed]

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Ontology: Cryptorchidism (C0010417)

Definition (NCI_NCI-GLOSS) A condition in which one or both testicles fail to move from the abdomen, where they develop before birth, into the scrotum. Undescended testicles may increase the risk for development of testicular cancer.
Definition (NCI) The failure of one or both testes of a male fetus to descend from the abdomen into the scrotum during the late part of pregnancy. If not surgically corrected in early childhood, males may be at increased risk for testicular cancer later in life.
Definition (CSP) failure of testes to descend into scrotum.
Definition (MSH) A developmental defect in which a TESTIS or both TESTES failed to descend from high in the ABDOMEN to the bottom of the SCROTUM. Testicular descent is essential to normal SPERMATOGENESIS which requires temperature lower than the BODY TEMPERATURE. Cryptorchidism can be subclassified by the location of the maldescended testis.
Concepts Congenital Abnormality (T019)
MSH D003456
ICD9 752.51
ICD10 Q53 , Q53.9
SnomedCT 367721002, 204879009, 156967003, 37501009, 268226005, 204882004, 204878001
English Cryptorchism, Testis, Undescended, Testes, Undescended, Undescended Testes, CRYPTORCHISM, Cryptorchidism, UNDESCENDED TESTICLE, Undescended testicle NOS, Cryptorchidism NOS, Undescended testicle, unspecified, UNDESCENDED TESTIS, Cryptorchidism (unilateral or bilateral), CRYPTORCHIDISM, UNILATERAL OR BILATERAL, IDT - Imperf descended testis, testes cryptorchism, undescended testicle, cryptorchidism, cryptorchism, undescended testicle (diagnosis), cryptorchidism (physical finding), cryptorchism was observed, Maldescended testis, Maldescended testicle, Testicle maldescended, Testicle undescended, Cryptorchism NOS, Cryptorchidism [Disease/Finding], maldescent of testis, undescend testicle, undescended testis, testicle undescended, testes undescend, maldescended testis, testicles undescended, undescended testes, Cryptorchidism, Unilateral Or Bilateral, Undescended Testis, Undescended testis (disorder), Undescended testicle NOS (disorder), Cryptorchism (disorder), Cryptorchidism NOS (disorder), Retained testicle, Cryptorchid, undescended testicles, Undescended Testicle, Undescended testis, Undescended testicle, Imperfectly descended testis, Maldescent of testis, IDT - Imperfectly descended testis, UDT - Undescended testes, Undescended testicle (disorder), maldescent; testis, nondescent; testicle, testicle; nondescent, Undescended testis (disorder) [Ambiguous], Undescended testis (body structure)
French CRYPTORCHIDIE, Ectopie testiculaire, Testicule mal descendue, Testicule non descendue, Cryptochirdie d'un testicule, Testicule mal descendu, ECTOPIE TESTICULAIRE, Cryptorchidie unilatérale ou bilatérale, Cryptorchisme, Cryptorchidie, Testicule non descendu
German KRYPTORCHISMUS, Maldescensus testis, Hoden nicht abgestiegen, gestoerter Hodenabstieg, Hodenabstieg gestoert, nicht abgestiegener Hoden, HODENHOCHSTAND, Nondescensus testis, nicht naeher bezeichnet, Nondescensus testis, Hodenhochstand, Kryptorchismus
Dutch niet-ingedaalde testikels, cryptorchidisme, slecht ingedaalde testikel, slecht ingedaalde testis, niet-ingedaalde testis, niet-ingedaalde testikel, Niet ingedaalde testis, maldescensus; testis, niet indalen; testis, testis; niet indalen, Niet ingedaalde testis, niet gespecificeerd, cryptorchisme, Cryptorchisme, Testis, niet ingedaalde
Italian Testicolo non disceso e retrattile, Testicolo ritenuto, Testicoli ritenuti, Criptorchismo, Criptorchidismo
Portuguese Testículo mal descido, Criptorquidia, Testículo não descido, CRIPTORQUIDIA, ECTOPIA TESTICULAR, Testículo Abdominal, Testículo não Descido, Testículo Inguinal, Criptorquismo, Criptorquidismo, Testículo Retido
Spanish Testículo mal descendido, Testículo inadecuadamente descendido, Descenso anómalo del testículo, Testículo no descendido, CRIPTORQUIDIA, criptorquidia, SAI (trastorno), criptorquidia (trastorno), criptorquidia, criptorquidia, SAI, falta de descenso testicular, SAI, falta de descenso testicular, SAI (trastorno), criptorquidia (concepto no activo), testículo no descendido (trastorno), testículo no descendido, Criptorquidia, testículo maldescendido, Criptorquidismo, Testículo no Descendido
Japanese 下降不良精巣, ﾃｲﾘｭｳｾｲｿｳ, ｶｺｳﾌﾘｮｳｾｲｿｳ, 高位睾丸, 停留精巣, 停留睾丸, 潜伏睾丸, 潜伏睾丸症, 潜伏精巣, 潜在睾丸, 潜在睾丸症, 潜在精巣, 潜在精巣症, 睾丸下降不全, 鼠径睾丸, 鼠径精巣, 睾丸-停留, 精巣-停留
Swedish Kryptorkism
Czech kryptorchismus, Nesestouplé varle, Nedokonale sestouplé varle, Kryptorchismus, nesestouplé varle
Finnish Piilokiveksisyys
Russian KRIPTORKHIZM, KRIPTORKHIDIZM, IAICHKO NEOPUSTIVSHEESIA, КРИПТОРХИДИЗМ, КРИПТОРХИЗМ, ЯИЧКО НЕОПУСТИВШЕЕСЯ
Korean 정류 고환, 상세불명의 정류 고환
Croatian KRIPTORHIZAM
Polish Wnętrostwo, Jądro niezstąpione
Hungarian Cryptorchismus, Retentio testis, Maldescendus here, Testis maldescendus, Helytelenül leszállt here, Le nem szállt testis, Rejtettheréjűség, Le nem szállt here
Norwegian Testikkelretensjon, Testisretensjon, Kryptorkisme
Derived from the NIH UMLS (Unified Medical Language System)

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