The Undescended Testicle (Cryptorchidism)
What is an undescended testicle?

Undescended testis is a condition when the testis cant be found in its normal location inside the scrotum. Undescended testis is one of the most common abnormalities seen in newborn babies. Medically it is also known as ‘Cryptorchidism’ (crypt- hidden, orchid- testis). 

The testicle (testis) is responsible for the production of male hormone and also sperm. In the developing baby, the testes develop inside the belly near the kidney. The testes drop down to scrotum in 8-9 months of pregnancy. Before the child is born the testicle migrates down from high in the abdomen and passes through abdominal wall and groin to take its normal position in the scrotum.

 
How common is Undescended Testis?

At birth almost 3-5% of the boys have undescended testis and a large majority of these may come down to normal position in first 3-4 months of life, last by 6 months. At 1 year of life, about 1- 1.5% of the boys have undescended testis.

When a testicle is not in the normal scrotal location several possibilities exist:
  • There may never have been a testicle (congenital absence).
  • The testicle may have atrophied (withered away) before birth due to torsion (twist) or blockage of the testicular blood vessels.
  • The testicle may have descended incompletely and may lie within the inguinal canal (just above the scrotum).
  • The testicle may have not descended properly, but remains within the abdominal cavity.
  • In some children the testes may be found in the groin, but can be brought down into the scrotum during examination. These 'retractile' testicles also will be seen to descend when the child is in the bathtub. Retractile testicles are due to hyperactive muscles that temporarily pull the testicle into the groin. However, retractile testicles are not believed to injure the testicles and require no treatment.
 
Why should an undescended testicle be treated?
  • The scrotal location keeps the testes cooler than the core body temperature, this is  important for the development of the testicle and production of normal sperm.
  • There is an increased risk of infertility in men with a history of undescended testicles. Relocating the testicle into the scrotum may decrease the risk of fertility problems, particularly if done at an early age.
  • The undescended testis in an abnormal location is more prone to injury and torsion (twisting of blood supply).
  • Undescended testicles are at increased risk for cancer.  Testicular cancer has been shown to be almost 35 times more common when compared to the normal population and it usually occurs at a later age in thirties. This risk can be minimized if the corrective surgery is done in early age.Testicular carcinoma is highly curable, when detected early, and the best way to do this is monthly self-examination, which can only be done if the testicles are within the scrotum.
  • Any abnormality related to sex organs arouses tremendous social and cultural issues and it is imperative that the kids with this common problem receive the best and timely therapy.
 
How is an undescended testicle treated and at what age?

We recommend treatment of the undescended testicle before one year of age, preferably between 6-9 months of age. The most effective treatment is surgery, which can be performed as an outpatient.

 
What is the surgery for undescended testis and how it is done?

Surgery for bringing the testis down to the normal position is called Orchiopexy.

Conventional Orchiopexy: When a testis is felt in the groin area we usually explore the area through a small incision. Most undescended testes are associated with a hernia that must be repaired. After this is done, the testis is brought down into the scrotum and anchored in a space created in the scrotum (orchiopexy).
Laparoscopic Orchiopexy: When a testis is not palpable on physical exam by an experienced pediatric urologist, its presence/absence location must be determined. Ultrasound/ CT/MRI are not 100% reliable in this assessment. In the present era – Diagnostic Laparoscopy is considered to be the “Gold Standard” for ascertaining the presence/absence of testis and its location. For Diagnostic Laparoscopy, a small telescope is placed into the belly through a small incision below the 'belly button' to look in the abdomen at the time of surgery.

  • If the testis is absent (20%)- Most of these children probably had torsion or twisting of the testis on its blood supply prior to birth that led to disappearance of the testis. When a boy is left with a single functioning testis we recommend anchoring it to minimize chances of losing it to torsion later in life.
  • If the testis is found in the abdomen and located low enough – a single stage laparoscopic orchipexy is done.
  • If the testis is located high up in the tummy, a staged surgery is required to bring the testis out to its normal location.
  • A small number of children will be found to have very small abnormal gonads for which removal (orchiectomy) is a better option.
 
Cases Case 2
 
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