Where is the testis normally located and how should an undescended (cryptorchid) testis be managed?

Normal Testicular Location and Management of Cryptorchidism

The normal testis is located in the scrotum, and an undescended testis should be surgically corrected (orchidopexy) by 18 months of age at the latest—optimally by 12 months—to reduce risks of infertility and testicular cancer. 1

Normal Testicular Anatomy

The testis normally completes its descent into the scrotum before birth, with the critical androgen-dependent phase occurring between 25-30 weeks gestation. 1 An undescended testis (cryptorchid testis) may be located anywhere along the path of descent:

• Abdomen (retroperitoneum along the psoas)
• Inguinal canal (most common location)
• Superficial inguinal pouch
• Upper scrotum
• Ectopic locations (perineum, contralateral scrotum, femoral region—rare)

Approximately 70% of undescended testes are palpable on examination. 1

Initial Evaluation and Referral Timing

At Birth and Early Infancy

• Palpate testes at every well-child visit to assess quality and position 1
• Spontaneous descent may occur in the first 6 months of life (corrected for gestational age) 1
• Testes that remain undescended after 6 months (corrected age) are unlikely to descend spontaneously 1

Critical Referral Points

Refer infants to a surgical specialist by 6 months (corrected for gestational age) if the testis has not descended spontaneously. 1 This early referral allows timely surgical planning to meet the 12-18 month surgical window.

For acquired cryptorchidism (testis that previously descended but later ascended), refer immediately upon diagnosis regardless of age. 1

Emergency Consultation

Immediately consult a specialist for any phenotypic male newborn with bilateral nonpalpable testes to evaluate for disorders of sex development, particularly congenital adrenal hyperplasia. Do not circumcise until evaluation is complete. 1

Surgical Management

Timing of Surgery

Perform orchidopexy between 6-18 months of age, with 12 months being optimal. 1, 2 The evidence strongly supports this window:

• Progressive germ cell loss begins by 6-9 months of age 3
• Up to 40% of retained testes lose their entire germ cell pool by age 2 years 3
• Prepubertal orchidopexy reduces testicular cancer risk 2- to 6-fold compared to postpubertal surgery 1
• Recent data show orchidopexy at 6-18 months produces significantly better testicular catch-up growth compared to surgery at 19-30 months 4

Surgical Approach by Testicular Location

For Palpable Testes:

• Perform scrotal or inguinal orchidopexy 1
• Single-incision scrotal approach is viable for low-lying palpable testes 1
• Success rate exceeds 96% (range 89-100%) 1
• Testicular atrophy occurs in less than 2% of cases 1

For Nonpalpable Testes:

• Re-examine under general anesthesia—previously nonpalpable testes may become identifiable 2
• Diagnostic laparoscopy is the gold standard for locating intra-abdominal testes 2
• Identify testicular vessel status to guide next steps 1

Laparoscopic findings and management: 2

• Spermatic vessels entering inguinal canal (40%): proceed with standard orchidopexy
• Intra-abdominal testis (40%): laparoscopic or staged orchidopexy (Fowler-Stephens or Shehata technique)
• Peeping testis at internal ring (10%): laparoscopic orchidopexy
• Blind-ending vessels (10%): confirms vanishing testis, no further intervention needed

Postpubertal Management

In postpubertal boys with cryptorchidism, consider orchiectomy or biopsy rather than orchidopexy, particularly if: 1

• Normal contralateral testis is present
• Very short testicular vessels and vas deferens
• Dysmorphic or severely hypoplastic testis
• Intra-abdominal location

The rationale: spermatogenic damage is often irreversible by this age, and malignancy risk remains elevated. 5 Recent evidence shows postpubertal orchiopexy yields poor functional outcomes, with 43.3% showing severe spermatogenic impairment and anatomical success of only 80%. 5

Long-Term Risks and Counseling

Fertility Impact

Counsel all patients and families about fertility risks: 1

• Bilateral cryptorchidism: 62% paternity rate (38% infertile) versus 94% in controls—a 6-fold increased infertility risk 1
• Unilateral cryptorchidism: 89.5% paternity rate, similar to general population 1
• Time to pregnancy is significantly prolonged in bilateral cases (33.9 months versus 11.1 months) 1

Malignancy Risk

The relative risk of testicular cancer is 2.75-8 times higher than in the general population (earlier estimates of 10-40 times were likely overestimated). 1

• Risk is highest with intra-abdominal testes
• Prepubertal orchidopexy reduces cancer risk 2- to 6-fold compared to postpubertal surgery 1
• Even the contralateral descended testis in unilateral cryptorchidism has increased cancer risk (OR 2.0) 6
• Teach monthly testicular self-examination starting at puberty 1
• Long-term surveillance is essential—malignancy can occur years after orchidopexy 5

Common Pitfalls to Avoid

1. Delaying referral beyond 6 months: This compromises the ability to operate within the optimal 12-18 month window
2. Relying on imaging for nonpalpable testes: Ultrasound has only 45% sensitivity and 78% specificity for intra-abdominal testes 3—proceed directly to laparoscopy
3. Using hormonal therapy as primary treatment: Success rates are only 10% above placebo, far inferior to surgery's 96% success rate 3
4. Assuming orchidopexy eliminates cancer risk: It reduces but does not eliminate risk; lifelong surveillance is required
5. Circumcising newborns with bilateral nonpalpable testes before evaluation: This may delay diagnosis of life-threatening congenital adrenal hyperplasia 1