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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