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What is undescended testicle (or cryptorchidism)?
During development of the male fetus, the testicles (testes) are located in the abdomen by the lower poles of the kidneys. During the seventh month of pregnancy, they gradually migrate down the abdomen, along the groin and, finally, into the scrotum. When they descend, they pass through a small passageway that runs along the abdomen near the groin called the inguinal canal. Once they are through this canal, the testes reside in the scrotal sac. Since the scrotal sac is several degrees cooler than body temperature, it is the ideal location for the testicles because they function better at this lower temperature.
Undescended testis (plural – testes) 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 approximately 3% of all newborn males and up to as much as 20% in premature male newborns. Nearly three-quarters of these will 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 (involving 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 comfortably into the scrotal sac, even if it retracts again upon release, it is a retractile testis. A reflex involving muscle (cremaster) 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 any treatment other than reassurance for the family. Under increasing hormonal influence, these testicles will eventually spend a progressively greater amount of time within the scrotum.
How is the diagnosis of undescended testicle(s) made?
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 and inguinal canal). Occasionally, the exam demonstrates an inguinal hernia (a weakened area in the lower abdominal wall or inguinal canal where the intestines may protrude) as well. In some instances, imaging studies (such as ultrasound, CT scan and/or MRI may be recommended by your son’s doctor to determine the position, or even the existence, of his testicle(s).
What is the cause of undescended testicle(s)?
It is unknown why some testicles fail to descend. It may have been because the testicles were never normal during their 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 or in abnormal proportions to stimulate the testicular descent normally. In most cases, it is probable that a combination of these and other factors were involved.
What are the signs & symptoms of undescended testicle(s)?
The uncomplicated undescended testicle does not cause pain. An exception to this is when the testicle undergoes torsion [see Complications], or a twisting of its blood supply which can ultimately decrease or completely interrupt blood flow to the affected testicle, leading to testicular pain, infarction (gangrene) and, unless emergency surgical intervention is performed rapidly, loss of the testis.
The scrotal sac may look smoother, smaller or flatter than the unaffected side.
What are the complications of undescended testicle(s)?
If an undescended testicle is not corrected, the following complications may occur as the male child grows and matures:
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.
An undescended testicle increases the risk of testicular cancer in adulthood, often as early as the second or third decade of life. While the correction of the undescended testicle does not decrease this cancer risk, it allows for the testicle to be properly examined in the future and facilitates easier and earlier detection of cancer should it develop.
A testicle that is trapped in abnormal position is more likely to be injured from trauma during ordinary or exertional activity.
Testicular torsion is a very painful condition whereby the testicle and its blood supply can twist and decrease its blood flow, eventually leading to testicular loss. This will occur more often in an undescended testicle than in the normally descended one.
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 may be smaller than the unaffected side. If a testicle is absent or requires removal, placement of a prosthesis during adolescence is possible and usually desired by the young man.
What is the treatment for undesended testicle(s)?
There are two treatment options, hormonal and surgical.
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 intramuscular (IM) 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 about 10-15% of the time. Later, surgery may still be indicated. Therefore, most parents prefer surgical treatment.
There are several possible procedures to correct this condition depending upon the location of the testicle and the distance to the scrotal sac.
- The Orchidopexy is an outpatient (patient does not need to stay overnight after surgery in the 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, repositioned and anchored in the scrotum. The passage way is then stitched closed to prevent reascent.
- A Laparoscopic Orchidopexy procedure is frequently performed when the testicle(s) is (are) nonpalpable (cannot be felt on physical exam). The testicle may be: 1) located in the abdomen, 2) absent or 3) very small (atrophic). 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.
- 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 sufficiently elastic enough to allow delivery to, and placement of the testicle in, 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 should I call the doctor after surgery?
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 times, inability to keep liquids down
- Extreme pain, not relieved by pain medication
What is the postoperative care after 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 5-7 days post op, though 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.
Are there any special instructions after recovery from surgery?
It is recommended that, as a teenager, these patients have regular physician physical examinations and be reminded to perform monthly testicular self-examinations.