Undescended testicle (cryptorchi­dism)

What is an undescended testicle?

Before birth, the testicles develop inside the abdomen and, in the last months of pregnancy, pass through the inguinal canal and come down into the scrotum. If one or both testicles are not in the scrotum at birth, this is called an undescended testicle or cryptorchidism.

It occurs in about 1–3% of full-term boys and in up to 30% of premature boys. In some of these children the testicle comes down on its own in the first months, but after 6 months of age descent almost never happens.

Types

• Palpable testicle (about 80%): the testicle can be felt in the inguinal canal or at its opening but does not come down into the scrotum.
• Nonpalpable testicle (about 20%): the testicle may be inside the abdomen, underdeveloped, or may have disappeared before birth.
• Ectopic testicle: the testicle has come down off the normal path, for example to another spot on the thigh or groin.
• Ascending (acquired) testicle: a testicle that used to be in the scrotum moves up as the child grows.

A retractile testicle is a separate condition: the testicle pulls up in the cold or when touched, but can be brought down into the scrotum easily and stays there.

Why should it be treated?

• Fertility. The temperature in the scrotum is 2–3 degrees lower than body temperature. In a testicle outside the scrotum, the sperm-forming cells start to be damaged from the first year.
• Cancer risk. The risk is somewhat higher in an undescended testicle. When the testicle is in the scrotum, changes can be felt in time.
• Risk of torsion and injury. A testicle in the groin twists and gets injured more easily.
• Inguinal hernia is often present as well.
• Psychological reasons: an empty scrotum can cause the child distress.

Diagnosis

The diagnosis is made by examination by an experienced doctor. Ultrasound adds no information either for finding the testicle or for choosing treatment and is not routinely recommended.

For a nonpalpable testicle, the most reliable way to find it is diagnostic laparoscopy: the inside of the abdomen is viewed with a camera, and treatment is done in the same operation.

Treatment

Timing of surgery

Surgery is recommended at 6–12 months, at the latest by 18 months. Children diagnosed at an older age have surgery as soon as possible after diagnosis.

Surgery

• For a palpable testicle, the testicle is freed through a small incision in the groin or scrotum and stitched into the scrotum (orchiopexy). The child often goes home the same day.
• For a nonpalpable testicle, laparoscopy is done first. If the testicle is in the abdomen, laparoscopic orchiopexy is chosen, or a one- or two-stage (Fowler-Stephens) method if it is very high. If the testicle has not developed, the remnant tissue is removed.

Hormone treatment

Hormone injections (hCG, GnRH) are not effective for bringing the testicle into the scrotum and are not routinely recommended.

After surgery

After surgery, the testicle is checked over several months and during adolescence. The testicle moving back up or shrinking happens rarely. In adolescence, a boy should learn to check his testicles himself.