Cryptorchidism

• Cryptorchidism is a congenital absence of one or both testes in the scrotum due to a failure of the testes to descend during development.

  It is found in 6% of newborns but drops to less than 3% of males at 3 months
• Classified as:

  • True undescended testis: where testis is absent from the scrotum but lies along the line of testicular descent
  • Ectopic testis: where the testis is found away from the normal path of decent
  • Ascending testis: where a testis previously identified in the scrotum undergoes a secondary ascent out of the scrotum.
  • Retractile - cremasteric reflex draws testis out of scrotum - seen in young boys 7-9 years but usually settles during puberty
  • Absent - caused by antenatal intrabdominal torsion (rare)
  • Atrophic - secondary to trauma/iatrogenic
• Pathophysiology:

  • In normal embryological development the testis descends from the abdomen to the scrotum (pulled by the gubernaculum) within the processes vaginalis
  • This process is incomplete in the context of true undescended testis, or tracks to an abnormal position in ectopic testis
  • Hormonal causes such as androgen insensitivity syndrome or disorder of sex development must be excluded (especially bilateral)
• Risk factors:

  • Prematurity
  • Low birth weight
  • Having other abnormalities of genitalia (e.g. hypospadias)
  • Family history - first degree relative
• History:

  • Clarify if the testis has ever been seen or palpated within the scrotum
  • Some parents may note the testicle in the scrotum in certain situations, such as in a warm bath (retractile testicle)
• Examination:

  • Feel along the normal decent of the testis - inguinal canal to the pubic symphysis
  • If the testis can be milked down into the base of the scrotum
  • If found within the inguinal canal - inguinal undescended testis
  • If impalpable - ectopic, intra-abdominal, absent or atrophic
• If disorder of sex development, undescended testis associated with ambiguous genitalia or hypospadias, or bilateral undescended testis are found = urgent referral to paediatrician within 24 hours

  • This may be a presentation of congenital adrenal hyperplasia
  • Adrenal glands produce sex hormones such as DHEA-S, testosterone and androgens
  • Need urgent review as risk of adrenal crisis
• No imaging modality has been shown to be of benefit in the diagnosis of undescended testis
• Management:

  • Found at birth - review at 6-8 weeks
  • At 6-8 weeks - review again at 3 months if not descended
  • At 3 months - if tested retractile, annual follow up (due to risk of ascending testis), if undescended refer to paediatric surgery/urology
  • Intervention should occur between the ages 6 months - 1 year
• Surgical management:

  • If the testis is palpable - open orchidopexy
  • If the testes is not palpable - examination under anaesthesia followed by laparoscopy. Then a Fowler-Stephens procedure is done to bring the testis into the scrotum
  • If atrophic testis are found they should be removed
• Complications:

  • Impaired fertility - increased intra-abdominal temperature can effect spermatogenesis. Risk increases with delayed correction
  • Testicular cancer - 2-3 more common with a history of undescended testis, and risk doubles if correction is undertaken after puberty
  • Torsion