What is the recommended treatment for a patient with cryptorchidism?

Treatment of Cryptorchidism

Surgical orchiopexy is the recommended treatment for cryptorchidism and should be performed between 6 and 12 months of age to optimize fertility potential and reduce the risk of testicular cancer. 1

Diagnosis and Evaluation

Cryptorchidism (undescended testis) is the most common genital disorder identified at birth, affecting 1-8% of full-term male newborns and up to 45% of preterm newborns 2. Proper evaluation includes:

• Gestational history: Essential at initial evaluation as prematurity is strongly associated with cryptorchidism 1
• Physical examination: Careful examination to distinguish true cryptorchidism from retractile testes
• No imaging recommended: Imaging studies are not recommended prior to specialist referral 1

Treatment Algorithm

1. Observation period (0-6 months):

   • Monitor for spontaneous descent, which commonly occurs in the first few months of life 3
   • Referral to specialist should occur by 6 months of age if no descent 1

2. Surgical management (preferred approach):

   • Timing: Orchiopexy between 6-12 months of age 1, 3
   • Procedure: Surgical repositioning of the testis within the scrotal sac
   • Benefits: Optimizes fertility potential and may reduce risk of testicular cancer 3

3. Hormonal therapy (not recommended as primary treatment):

   • The AUA guideline clearly states that hormonal therapy is not recommended as primary treatment 1
   • Human Chorionic Gonadotropin (hCG) has low success rates for inducing testicular descent 4
   • FDA labeling for hCG notes it "may help predict whether orchiopexy will be needed" but acknowledges that in most cases, any response is temporary 5

Rationale for Early Surgical Intervention

1. Fertility preservation:

   • Cryptorchidism impairs long-term Sertoli cell function 4
   • Germ cell loss is proportional to the duration of the condition 4
   • Fertility potential is greatest when orchiopexy is performed before 1 year of age 3

2. Cancer risk reduction:

   • Cryptorchidism is associated with increased risk of testicular germ cell tumors 4
   • Orchiopexy before 10-11 years may protect against this increased risk 3

3. Prevention of testicular torsion:

   • Undescended testes have a higher risk of torsion 1

Post-Treatment Follow-up

• Annual clinical examination until puberty for unilateral cases 6
• Lifelong surveillance for patients with history of cryptorchidism 6
• Patient education regarding self-examination techniques for early detection of testicular cancer 6

Special Considerations

• Bilateral nonpalpable undescended testicles warrant endocrinologic evaluation for disorders of sexual development 6
• Retractile testicles should be monitored annually until puberty 6
• Even with successful treatment, patients should be counseled that cryptorchidism is associated with:
  • Increased risk of testicular cancer
  • Potential fertility issues
  • Need for long-term follow-up

Common Pitfalls to Avoid

1. Delayed referral: Waiting beyond 6 months of age for spontaneous descent can compromise outcomes
2. Relying on hormonal therapy: Low success rates make this an ineffective primary treatment
3. Inadequate follow-up: Lifelong surveillance is necessary due to persistent cancer risk
4. Failure to distinguish retractile from truly undescended testes: Retractile testes do not require surgical intervention

In summary, early surgical intervention via orchiopexy between 6-12 months of age represents the standard of care for cryptorchidism, with the best outcomes for fertility preservation and reduction of cancer risk 1, 3.