How to manage undescended testes (testicles) that are within the inguinal canals?

Management of Undescended Testes in the Inguinal Canal

Surgical correction (orchiopexy) should be performed between 6-18 months of age for undescended testes that remain in the inguinal canals to maximize fertility potential and reduce the risk of testicular cancer. 1

Diagnosis and Initial Evaluation

• Gestational history: Critical to obtain at initial evaluation as premature infants have higher rates of cryptorchidism (15-30%) compared to full-term infants (1-3%) 1, 2
• Physical examination: Palpate testes for quality and position at each well-child visit 1
  • Approximately 70% of undescended testes are palpable 1, 2
  • For testes that are not palpable, about 30% will be found in the inguinal-scrotal area, 55% will be intra-abdominal, and 15% will be absent or vanishing 1
• Timing of spontaneous descent: Most undescended testes will descend spontaneously within the first 6 months of life 1, 3
• Imaging: Ultrasound is NOT recommended prior to referral due to poor sensitivity (45%) and specificity (78%) for non-palpable testes 1, 2

Referral Timing

• Refer infants with undescended testes to a surgical specialist (pediatric urologist) if:
  • Testes remain undescended at 6 months of corrected gestational age 1, 2
  • Undescended testes are newly diagnosed after 6 months of age 3
  • Bilateral non-palpable testes are present at birth (requires immediate referral to evaluate for possible disorder of sex development) 2

Treatment Options

Surgical Management (Recommended)

• Orchiopexy: Standard of treatment in the United States 1, 2
  • For palpable testes in the inguinal canal: Standard inguinal approach 4
  • For low inguinal testes: Prescrotal approach may be effective 4
  • Success rate is greater than 96% (range 89-100%) for open surgical intervention 1
  • Subsequent testicular atrophy is uncommon (<2%) 1

Hormonal Therapy (Not Recommended)

• Human chorionic gonadotropin (hCG) has poor success rates (6-38%) 2
• Meta-analyses have demonstrated poor overall success rates with hormonal therapy 1
• FDA labeling for hCG indicates it may help predict whether orchiopexy will be needed but typically produces only temporary descent 5

Timing of Intervention

• Optimal timing: Between 6-18 months of age 1, 2, 3
• Rationale for early intervention:
  • After 15-18 months of age, some cryptorchid boys begin to lack germ cells in the testes 2
  • By 8-11 years, approximately 40% of bilateral cryptorchid boys have no germ cells 2
  • Early intervention preserves fertility potential 1, 4
  • Reduces risk of testicular malignancy 1, 3

Special Considerations

• Non-palpable testes: Require identification of testicular vessels during exploration to determine next course of action 1
• Normal contralateral testis: Orchiectomy may be considered if the undescended testis has very short vessels and vas deferens, is dysmorphic/hypoplastic, or the patient is postpubertal 1
• Retractile testes: Require annual monitoring due to risk of secondary ascent 2

Long-term Risks and Counseling

• Fertility:

  • Unilateral cryptorchidism: Paternity rates nearly equivalent to men without cryptorchidism 1
  • Bilateral cryptorchidism: Paternity rate of 35-53% 1

• Testicular cancer:

  • 2.75-8 times increased relative risk compared to general population 1, 3
  • Early orchiopexy (prepubertal) results in 2-6 fold reduction in relative risk compared to postpubertal orchiopexy 1
  • Regular testicular self-examination after puberty is recommended 1, 3

• Hypogonadism: Men with cryptorchidism may be at higher risk 1

Follow-up

• Patients should be counseled regarding potential long-term risks of infertility and cancer 1
• Regular testicular self-examination after puberty should be taught to facilitate early cancer detection 3

Proper management of undescended testes in the inguinal canal requires timely referral to a surgical specialist and surgical correction between 6-18 months of age to optimize outcomes related to fertility and cancer risk.