In a term male infant with non‑palpable testes in the scrotum, how should the evaluation be performed?

Evaluation of Non-Palpable Testes in a Term Male Infant

The evaluation of non-palpable testes in a term male infant requires only a thorough physical examination with careful palpation—imaging studies should NOT be performed as they do not assist in clinical decision-making. 1, 2

Initial Clinical Assessment

Key History Elements

Obtain the following specific information 2:

• Gestational age at birth (critical for determining timing of referral)
• Birth weight for gestational age
• Presence of any penile anomalies (hypospadias, micropenis)
• Family history of cryptorchidism

Physical Examination Technique

Perform a careful bimanual examination to classify the testes as either palpable or non-palpable 1:

• Examine in a warm room with warm hands
• Palpate from the external inguinal ring down to the scrotum
• Use one hand to "milk" from the abdomen downward while the other hand palpates the inguinal canal and scrotum
• Check for ectopic locations (perineum, femoral triangle, contralateral scrotum)
• Document whether each testis is palpable or truly non-palpable

Critical distinction: Approximately 70% of undescended testes are palpable on careful examination 2. For non-palpable testes, approximately 30% will be in the inguinal-scrotal area, 55% intra-abdominal, and 15% absent/vanishing 2.

Imaging: What NOT to Do

Do not order ultrasound, CT, or MRI prior to surgical referral 2. The 2014 AUA guidelines explicitly state that imaging modalities "rarely assist in decision making" and the most recent 2025 EAU/ESPU guidelines confirm that "localisation studies using different imaging modalities usually provide no additional benefit" 1. This recommendation was even included in the Choosing Wisely Canada campaign 3.

Special Consideration: Bilateral Non-Palpable Testes

If both testes are non-palpable, this is a medical emergency requiring immediate specialist consultation 2. This presentation may represent:

• Congenital adrenal hyperplasia in a 46,XX infant (life-threatening)
• Disorder of sexual development
• Bilateral anorchia

Do NOT circumcise until the workup is complete, even with a normal-appearing penis 2.

Referral Timing

Refer to a pediatric urologist or appropriate surgical specialist by 6 months of corrected gestational age 1, 2. The rationale is clear:

• Spontaneous descent after 6 months is rare 1
• Surgery should be completed by 12 months of age (18 months at the absolute latest) 1
• Histological damage (progressive loss of germ cells and Leydig cells) is already evident by 12-18 months 1
• Early intervention optimizes fertility outcomes and reduces malignancy risk

What Happens After Referral

The surgical specialist will 1:

1. Re-examine under general anesthesia (a previously non-palpable testis may become palpable, changing the surgical approach)
2. Perform diagnostic laparoscopy if the testis remains non-palpable—this is the gold standard for locating intra-abdominal testes 1
3. Proceed with appropriate surgical management based on findings

Common Pitfalls to Avoid

• Do not wait beyond 6 months hoping for spontaneous descent
• Do not order imaging thinking it will help—it won't change management and delays appropriate referral
• Do not miss bilateral non-palpable testes—this requires urgent evaluation for life-threatening conditions
• Do not confuse retractile testes (which can be manipulated into the scrotum and stay there) with truly undescended testes

The evidence strongly supports that clinical examination alone is sufficient for diagnosis and triage, with definitive anatomic localization reserved for the operating room via laparoscopy when needed 1, 2, 4.