What is the recommended management for undescended testes by 6 months?

Management of Undescended Testes by 6 Months of Age

Infants with undescended testes who do not have spontaneous testicular descent by six months (corrected for gestational age) should be referred to an appropriate surgical specialist for timely evaluation and management. 1

Diagnosis and Evaluation

• Gestational history: Critical to obtain at initial evaluation as premature infants have higher rates of cryptorchidism (15-30% vs 1-3% in full-term) 1
• Physical examination: Primary care providers should palpate testes for quality and position at each well-child visit 1
• Spontaneous descent: Most likely to occur within the first 6 months of life; testes that remain undescended after 6 months (corrected for gestational age) are unlikely to descend spontaneously 1
• Imaging: Ultrasound is NOT recommended prior to referral due to poor sensitivity (45%) and specificity (78%) for non-palpable testes 2

Management Algorithm

1. Birth to 6 months: Monitor for spontaneous descent during well-child visits

   • Document testicular position at each visit
   • Approximately 70% of undescended testes are palpable 1

2. At 6 months (corrected for gestational age):

   • If testes have descended: Continue routine monitoring
   • If testes remain undescended: Refer to pediatric urologist or other qualified surgical specialist 1

3. Special circumstances requiring immediate specialist consultation:

   • All phenotypic male newborns with bilateral, nonpalpable testes (to evaluate for possible disorder of sex development) 1
   • Any child with both hypospadias and an undescended testis 3

Treatment Options

1. Surgical Management (Preferred):

   • Orchidopexy is the standard of treatment in the United States 1
   • Should be performed promptly after referral (ideally between 6-18 months of age) 4
   • Surgical approach depends on testicular position:
     • Palpable testes: Standard inguinal or prescrotal approach 4
     • Non-palpable testes: Diagnostic laparoscopy followed by appropriate surgical technique 4

2. Hormonal Therapy:

   • Not recommended as primary treatment due to low response rates (6-38%) and lack of evidence for long-term efficacy 2
   • Shows poor results compared to surgical intervention 1, 5

Rationale for Early Intervention

• Fertility preservation: After 15-18 months of age, some cryptorchid boys begin to lack germ cells in the testes, with approximately 40% of bilateral cryptorchid boys lacking germ cells by 8-11 years 2
• Cancer risk reduction: Early orchidopexy may reduce the risk of testicular malignancy 4, 3
• Improved surgical success: Earlier intervention is associated with higher rates of successful outcomes 6

Common Pitfalls to Avoid

1. Delayed referral: Waiting beyond 6 months (corrected for gestational age) can lead to irreversible testicular damage 1
2. Misdiagnosing retractile testes: These are normal testes that can be manipulated into the scrotum and do not require surgical intervention, but should be monitored as they have a 2-45% risk of secondary ascent 2
3. Unnecessary imaging: Routine ultrasound before specialist referral is not recommended and may delay appropriate treatment 2
4. Observation beyond 1 year: This approach is not supported by evidence and may impair spermatogenesis 3

Early diagnosis and timely referral by 6 months of age are crucial for optimal management of undescended testes to preserve fertility potential and reduce long-term complications.