Where to refer a 15-month-old child with non-palpable testes?

Referral for Non-Palpable Testes in a 15-Month-Old Child

A 15-month-old child with non-palpable testes should be referred immediately to a pediatric urologist for evaluation and management. 1

Rationale for Specialist Referral

• The American Urological Association (AUA) guidelines clearly state that infants with undescended testes who do not have spontaneous descent by six months (corrected for gestational age) should be referred to an appropriate surgical specialist for timely evaluation 1
• This 15-month-old child is well beyond the recommended referral timeframe, making immediate referral critical to prevent further complications

Why a Pediatric Urologist Specifically

• According to the American Academy of Pediatrics guidelines on referral to pediatric surgical specialists, a pediatric urologist is the most appropriate specialist for this condition 1
• Pediatric urologists have completed training in urology, are certified by the American Board of Urology, and have completed a 2-year pediatric urology fellowship 1
• They have specialized expertise in the evaluation and management of non-palpable testes, which require specialized diagnostic approaches and potential surgical intervention

Diagnostic Approach by the Specialist

• The specialist will perform a thorough physical examination under optimal conditions to confirm the non-palpable status of the testes 1
• Importantly, imaging studies such as ultrasound should NOT be performed prior to referral, as these rarely assist in decision making for non-palpable testes 1, 2
• For truly non-palpable testes, diagnostic laparoscopy is the gold standard for evaluation 1, 3

Urgency of Referral

• Immediate referral is critical because:
  • Delayed treatment increases the risk of impaired spermatogenesis and fertility 4
  • Untreated undescended testes have an increased risk of testicular malignancy 5, 4
  • The success rate of surgical intervention decreases with age 5

Special Considerations

• If the child has bilateral non-palpable testes, evaluation for disorders of sex development should be considered, particularly if there are any other genital anomalies 1
• In cases of bilateral non-palpable testes, the specialist may measure müllerian inhibiting substance or anti-müllerian hormone to evaluate for anorchia 1

Common Pitfalls to Avoid

• Delaying referral beyond 6 months of age (this child is already delayed at 15 months)
• Ordering ultrasound or other imaging studies prior to specialist referral
• Confusing retractile testes (which can be manipulated into the scrotum) with truly non-palpable testes 6
• Assuming spontaneous descent will occur (extremely unlikely after 6 months of age) 1, 4

Timely referral to a pediatric urologist is essential to optimize outcomes related to fertility preservation and to minimize the risk of future malignancy in this 15-month-old child with non-palpable testes.