CRYPTOCHIDISM: SIGNS AND SYMPTOMS

Cryptorchidism means "concealed testicle." It occurs when one or both testicles get stuck at some point in fetal descent.

Ectopic maldescent means one or both testicles have strayed from the normal path of descent. The usual place for a missing testicle is the groin.

Both these conditions are often called undescended testicles.

Description of Cryptorchidism (Undescended testicles)



The testes start to develop 40 days after conception. They grow inside the fetal abdomen. Near the end of the eighth month, they travel down the inguinal canal and through the abdomen wall. They reach their low-hanging position in the scrotum a few days before birth. A post-birth check ensures that they have safely descended.
Cryptorchidism is a congenital disorder when one or both of a newborn's testicles fail to descend into the scrotum. Although this condition may occur on both sides, it more commonly affects the right testis.

Because the testicles normally descend into the scrotum during the eighth month of gestation, undescended testicles most commonly affect newborns. In about 80 percent of affected infants, testicles descend spontaneously during the first year; in the rest, the testicles may or may not descend later.

Of full-term babies, 3.4 percent are born with undescended testicles. Of these, 50 percent descend in the first month of life.

Of premature babies, 30 percent have undescended testicles. Of these, 80 percent are safely down by the first month.

In most cases, the natural history of an undescended testis is spontaneous descent, usually occurring within the first year of life and, in most cases, within the first three months of life. If no descent is observed in the first 1 to 3 months, urologic consultation is indicated. If the bilateral condition persists untreated into adolescence, it may result in sterility, make the testicles more vulnerable to injury, and significantly increase the risk of testicular cancer and infertility.

Cryptorchidism on both sides can rarely be a sign of an inter-sex disorder. In particular, babies with absent testes on both sides and hypospadius (opening of the penis is located not at the tip but lower down on or toward the shaft) may rarely be genetic females. In any case where there is a double abnormality, expert consultation should be obtained before a baby is assigned a gender.

Retractile testicles is a related condition where the testes can be at times found within the scrotum and at times not. In more than half of all cases, this resolves without intervention. However, nearly 40% of boys with this condition will need intervention. They should be followed closely. A urologist can decide with the pediatrician when and if a procedure is needed.

Treatment of Cryptorchidism (Undescended testicles)
Treatment for cryptorchidsm includes both medical (hormonal) and surgical approach separately or in combination with one another. Procedures are usually completed between 6 and 24 for months of age for the best outcomes.

Medical Treatment:
Increasing the level of the male sex hormone testosterone can increase the likelihood that undescended testicles will move into the scrotum. This is done by either giving injections of human chorionic gonadotropin (hCG) or gonadotropin releasing analog (not approved in the United States). Both cause the testes to produce testosterone. The approach is most likely to work if the testes are already low and are not blocked or actually just retractile. Retractile testicles are sometimes in the scrotum or sometimes in the inguinal canal. This approach results in descent of 5-25% with about 25% of those for whom the treatment work relapsing.

Surgical Treatment:
The first step is to confirm the location of the testes (often can be felt in the inguinal canal). If a boy has non-palpable testicles, he may need exploratory surgery to determine if testes are present. In some cases, testes are completely absents (about 1/10 boys with undescended testicles). Consequently, diagnostic laparoscopy is often used first in these boys confirm the presence of testes before a full inguinal incision is made for the full orchiopexy. Once the location of the testes in confirmed, surgeons will perform the full procedure.

Orchiopexy is a surgical procedure that secures the proper position of a testicle in the scrotum. When successful, orchiopexy decreases the risk of sterility, testicular cancer, and testicular injury from abnormal positioning. If a testicle is missing or must be removed, a prosthesis is inserted to achieve a normal appearance and to foster the person's positive body image. Orchiopexy for correction of an undescended testicle is usually performed in children ages 1 to 6.

Orchiopexy is performed when other treatments such a hormonal therapy fail. It is performed under general anesthesia. If there is testicular torsion (twisting), the surgeon makes an incision in the scrotal skin and attempts to untwist and stabilize the spermatic cord. To treat an undescended testicle, the surgeon makes an incision in the groin or lower abdomen to expose the testicle and a small incision to open the scrotum. He or she then frees the testicle, lowers it into the scrotal sac, and secures it with stitches. If both testicles are undescended this procedure is repeated for the other testicle.

In two-stage orchiopexy, an alternative procedure, the surgeon brings the testicle down into the scrotal sac and stitches it to the thigh; then, 2 to 3 months later, she embeds it in the scrotal sac. If the spermatic cord is too short to accommodate repositioning the testicle, the surgeon may sever the spermatic cord before replacing the testicle in the scrotal sac. After completing the procedure, the surgeon closes the incision and applies a dressing. Complications of the procedure are uncommon but include hemorrhage, infection, and painful urination.