At what age should a baby with undescended testes (cryptorchidism) be referred to urology?

From the Guidelines

Babies with undescended testes (cryptorchidism) should be referred to urology by 6 months of age if the testes have not descended spontaneously, as recommended by the American Urological Association (AUA) guideline 1. This timeline is crucial because spontaneous descent typically occurs within the first 3-6 months of life, particularly during the first 3 months. Early referral is vital because surgical correction (orchiopexy) is recommended between 6-18 months of age, with optimal timing being 6-12 months, as stated in the AUA guideline 1. Delaying treatment beyond this window increases risks of infertility and testicular cancer later in life. The undescended testis is exposed to higher temperatures than normal, which can damage the developing germ cells and affect future sperm production. Additionally, early intervention allows for identification of any associated conditions or anatomical abnormalities. Primary care providers should document the position of testes at each well-child visit until resolution, and any child with previously descended testes that later ascend (acquired cryptorchidism) should also be referred to urology promptly, as emphasized in the AUA guideline 1. Some key points to consider include:

• Gestational age is critical in determining the likelihood of spontaneous descent, with premature boys having a higher prevalence of cryptorchidism 1.
• Low birth weight for gestational age is also associated with a higher prevalence of cryptorchidism, with approximately 100% of infants under 900g being affected 1.
• Imaging for cryptorchidism is not recommended prior to referral, which should occur by 6 months of age, as stated in the AUA guideline 1.
• Orchidopexy is the most successful therapy to relocate the testis into the scrotum, while hormonal therapy is not recommended, according to the AUA guideline 1.
• Successful scrotal repositioning of the testis may reduce but does not prevent the potential long-term issues of infertility and testis cancer, highlighting the importance of timely referral and treatment 1.

From the Research

Referral to Urology for Undescended Testes

The age at which a baby with undescended testes (cryptorchidism) should be referred to urology is a crucial consideration for timely management and prevention of potential complications.

• According to 2, if the testes do not descend by 6 months of age, the probability of spontaneous descent thereafter is low, and a surgical specialist referral is recommended.
• Similarly, 3 suggests that if a testis is found to be undescended at any age after 6 months, the patient should be referred for surgery, preferably to pediatric surgeons/urologists if the boy is less than 1 year old.
• 4 and 5 also support the idea that referral should be considered around the age of 6 months if the testes have not descended, with the recommendation for orchiopexy by 18 months of age to maximize potential for fertility and reduce the risk of testicular carcinoma.

Considerations for Referral

It's essential to consider the following:

• The likelihood of spontaneous descent decreases significantly after 6 months of age 2.
• Early referral and surgical intervention (orchiopexy) between 6 and 18 months of age are recommended to protect fertility potential and decrease the risk of malignant changes 2, 4, 5.
• The mode of treatment may vary depending on whether the testis is palpable or non-palpable, with different surgical approaches applicable in each case 4.

Importance of Timely Referral

Timely referral to a urologist or surgical specialist is critical for:

• Reducing the risk of infertility and testicular cancer later in life 2, 6.
• Preventing degenerative changes in the testes that can occur as early as 1 to 2 years of age 6.
• Ensuring the best possible outcomes for children with undescended testes through appropriate and timely management.