What is an undescended testis (cryptorchidism)?
During the unborn male's development, the testicles (testes) are located in the abdomen and gradually move down into the scrotum during the seventh month of pregnancy. When they descend, they pass through a small passageway that runs along the abdomen near the groin called the inguinal canal. Once through the inguinal canal, the testes reside in the scrotal sac. Since the scrotal sac is cooler than the body temperature, it is the ideal location for the testicles because they function better at this cooler temperature.
Undescended testis (testes –plural) and cryptorchidism refer to a condition in which the testicle has not descended and cannot be brought into the scrotum with external manipulation. This occurs in 3% of newborn males and up to 21% in premature male newborns. Nearly three quarters of these move down on their own by the child's first birthday.
The undescended testis can be located in the abdomen, the inguinal canal or other more unusual locations, but most are located in the inguinal canal (80%). About 10-15% of all cases are bilateral (involve both testicles).
There is a genetic association with this condition. About 14% of boys with this condition come from families in which another male is affected also. Six percent of fathers of males with undescended testis have also had this problem.
It is very important to clarify that "retractile testicles" are not undescended testicles. If a testicle can be brought down into the scrotal sac, even if it retracts again upon release, it is a retractile testis. A reflex pulls the testicle up to protect it when the boy is cold or frightened. These retractile testicles are in the scrotum at other times and do not require treatment.
Diagnosis
The discovery of an undescended testicle can be done by parents or by a pediatrician during a physical examination. Often, no testicle can be felt; this condition is called a non-palpable testicle(unable to be felt on examination of the scrotal sac). Frequently, the exam shows an inguinal hernia (a weakened area in the lower abdominal wall or inguinal canal where the intestines may protrude) as well.
Cause
It is unknown why the testicles failed to descend. It may have been because the testicles were never normal at development, or that there was a mechanical problem that lead the testicles in the wrong direction or that the infant's hormones may have been insufficient to stimulate the testicles normally.
Symptoms
The undescended testicle does not cause pain. The scrotal sac may look smoother, smaller or more flat than the unaffected side.
Complications
If an undescended testicle is not corrected, the following complications may occur as the male child grows and matures:
Infertility
The exposure of the testicle to the higher temperature of the body, when it is not in the scrotum, may impair the sperm production. This is the most important concern and this risk increases when both testicles are undescended.
Malignancy
An undescended testicle increases the risk of testicular cancer in adulthood. While the correction of the undescended testicle does not decrease the risk of cancer, it allows for the testicle to be properly examined in the future and early detection of cancer if it develops.
Trauma
A testicle that is trapped in abnormal position is more likely to be injured from trauma during ordinary activity.
Testicular Torsion
Testicular torsion is a painful condition where the testicle can twist and decrease its blood supply and eventually lead to testicular loss. This can occur more often in an undescended testicle.
Psychological Consideration
Once the male child becomes a teenager and becomes more aware of his body, the empty scrotum may cause considerable concern. Usually, surgery results in the normal appearance of the scrotum; occasionally, the testicle is smaller than the unaffected side.
Treatment
There are two treatment options hormonal and surgical.
Hormonal
In cases in which both sides are undescended, hormonal treatment may aid the testicles' descent into the scrotum. The hormone human chorionic gonadotropin (hcg) is given as injections over several weeks. Although it is safe and successful in proving that retractile testes are down in the scrotum, it only cures undescended testes 10-15% of the time. Later, surgery may still be indicated. Therefore, most parents prefer surgical treatment.
Surgery
There are several possible procedures to correct this condition depending upon the location of the testicle and the distance to the scrotal sac.
1. The Orchidopexy is an outpatient (patient does not need to stay in hospital) procedure which requires general anesthesia. This is performed when the surgeon can palpate (feel) the testicle in the groin. A small incision (cut) is made in the groin (area where the leg attaches to the body); the testicle is located, freed from restrictive tissues, positioned and anchored in the scrotum. The passage way is then stitched closed to prevent re-ascent.
2. A Laparoscopic Orchidopexy procedure is frequently performed when the testicle is nonpalpable (cannot be felt on physical exam). The testicle may be located in the abdomen, may be absent or very small (atrophic). First, the surgeon determines if the testicle is present and functional.
Occasionally, the testicle is too severely malformed to be saved. It may have twisted sometime prior to the child's birth and lost its blood supply. The remaining non-functional tissue is removed. The opposite testicle is secured in its scrotal sac to prevent testicular torsion of that testicle. If the malformed testicle is removed, a prosthesis (an artificial replacement) can be placed in the scrotum after puberty.
Depending on its location, a functional testicle will be brought down into the scrotal sac and secured.
3. A Testicular Auto-transplant is indicated when the testicle is located very high in the abdomen and the blood vessels and other necessary structures are neither ample nor elastic enough to be stretched to the scrotum. The testicle must be "auto transplanted" into the scrotum with all the necessary blood vessels and structures first cut and then reconnected (anastomosed).
When to Call the Doctor
After surgery call the doctor for the following situations:
- Inability to urinate after 8 hours following surgery
- Temperature of 101 degrees or above following surgery
- A green or yellowish discharge from the suture lines along with increased redness, swelling and pain
- Vomiting more than 3 time, inability to keep liquids down
- Extreme pain, not relieved by pain medication
Special Instructions
It is recommended that, as a teenager, these patients have regular physical examinations and be reminded to perform monthly testicular self-examinations.
After Care
After surgery care for the Orchidopexy and the Laparoscopic Orchidopexy
- For pain control, over the counter Tylenol" can be given every four hours, but do not exceed 5 doses in 24 hours. Patients that are at least 4 years old may be given a prescription for a stronger pain medicine. Use this prescription only for significant discomfort and administer as directed.
- We advise the patient to receive pain medication on schedule for the first 24 hours after surgery. After that time, only administer medicine if needed.
- Your surgeon will direct you on the care of the bandage/dressing and surgery site.
- No tub baths for five days post op, showering may be permitted. A sponge bath is okay.
- For 2-3 weeks, do not place your child in an exercise saucer or a walker, and refrain from carrying the child across your hip bone. It is fine to place the child in a car seat and high chair. For the older child, avoid riding a bike, climbing jungle gym or participating in gym class.
- Your child may return to school or daycare when comfortable and not requiring prescription pain medicine, usually in 2-5 days.
After surgery care for Testicular Auto Transplant will be given by the surgeon.
Rev. 9/07
