Is it possible for testes (testicles) to be palpable at 12 months and then not palpable at 15 months?

Testicular Ascent After Initial Palpability: Secondary Cryptorchidism

Yes, it is possible for testes to be palpable at 12 months and then become non-palpable at 15 months due to a condition called testicular ascent or acquired cryptorchidism. 1

Understanding Testicular Ascent

Testicular ascent is a well-documented phenomenon where previously descended testes move out of the scrotum. This occurs most commonly with retractile testes, which have an increased risk of secondary ascent.

The American Urological Association (AUA) guidelines specifically note:

• Studies report an extremely broad range (2-45%) of testicular ascent in boys with retractile testes 1
• Retractile testes are at increased risk for secondary ascent due to:
  • Hyperactive cremasteric reflex
  • Foreshortened patent processus vaginalis
  • Entrapping adhesions 1

Clinical Implications and Management

When a previously palpable testis becomes non-palpable, this requires prompt evaluation:

1. Annual monitoring: Boys with retractile testes should have their testicular position assessed at least annually to monitor for secondary ascent (Grade B evidence) 1

2. Specialist referral: If ascent is detected, referral to a pediatric urologist is recommended 2

3. Surgical intervention: Secondary cryptorchidism typically requires orchiopexy, as spontaneous re-descent is unlikely 1

4. Timing is critical: Orchiopexy should be performed promptly after diagnosis of ascent to preserve fertility potential 1

Diagnostic Considerations

When evaluating a case of testicular ascent:

• Avoid unnecessary imaging: Ultrasound has poor sensitivity (45%) and specificity (78%) for non-palpable testes and is not recommended prior to specialist referral 1, 2

• Physical examination technique: The examination should be performed in a warm room with warm hands, with the child in both sitting and supine positions 3

• Specialist evaluation: A pediatric urologist will perform examination under optimal conditions to confirm the non-palpable status 2

Fertility Implications

The timing of intervention is crucial for fertility preservation:

• After 15-18 months of age, some cryptorchid boys begin to lack germ cells in the testes 1
• The number of boys without germ cells increases with age, reaching about 40% in bilateral cryptorchid boys by 8-11 years 1
• Early intervention (before 18 months) is recommended to preserve fertility potential 1

Common Pitfalls to Avoid

1. Delaying referral: Assuming spontaneous descent will occur after 6 months of age is unlikely 2

2. Ordering unnecessary ultrasound: Imaging rarely assists in decision-making for non-palpable testes 1, 2

3. Hormonal therapy: Hormonal treatment shows low response rates (6-38% in controlled studies) and lacks evidence for long-term efficacy 1

4. Confusing retractile with truly ascended testes: Retractile testes can be manipulated into the scrotum, while truly ascended testes cannot 2

In summary, testicular ascent is a recognized clinical entity that requires vigilant monitoring and timely intervention to preserve fertility and reduce the risk of future complications.