What is the evaluation and management approach for an infant with undescended testis (cryptorchidism)?

Evaluation and Management of Undescended Testis in Infants

Infants with undescended testes should be referred to a pediatric urologist if the condition persists at 6 months of corrected gestational age, with surgical intervention (orchiopexy) recommended between 6-12 months of age to maximize fertility potential and reduce cancer risk. 1

Epidemiology and Diagnosis

• Prevalence:

  • Full-term infants: 1-3%
  • Premature infants: 15-30% 1
  • Spontaneous descent possible until 6 months of age 2

• Physical Examination:

  • Must be performed in optimal conditions (warm room, relaxed child)
  • Examine with warm hands while the child is in supine and cross-legged positions
  • Palpate from the abdomen toward the scrotum along the path of descent
  • Avoid ultrasound prior to referral due to poor sensitivity (45%) and specificity (78%) 1

Classification and Location

• Palpable testes: Most common presentation, located in the inguinal canal

• Non-palpable testes: Distribution 1

  • 30% in inguinal-scrotal area
  • 55% intra-abdominal
  • 15% absent or vanishing

• Important distinctions:

  • Retractile testis: Normal variant that can be manually brought into scrotum and remains there temporarily
  • Ectopic testis: Testis that has deviated from normal path of descent
  • Ascending testis: Previously descended testis that has moved out of scrotum

Management Algorithm

1. Initial Assessment (Birth to 6 months):

   • Monitor for spontaneous descent
   • If bilateral non-palpable testes present at birth, consider earlier specialist referral 3

2. At 6 Months of Age:

   • If testes remain undescended, refer to pediatric urologist 1
   • Do not delay referral for ultrasound imaging 4

3. Treatment Options (6-12 months):

   • Surgical intervention (preferred): 1, 5

     • Palpable testes: Standard inguinal or prescrotal approach
     • Non-palpable testes: Diagnostic laparoscopy followed by appropriate surgical technique

   • Hormonal therapy (not recommended): 1, 5

     • Human chorionic gonadotropin (hCG) has poor overall success rates
     • May help predict whether orchiopexy will be needed but response is usually temporary 6
     • Potential long-term adverse effects on spermatogenesis 5

Surgical Approaches

• For palpable testes: 7

  • Standard inguinal approach
  • Prescrotal approach for low inguinal testes (reduces surgical time with equivalent success)

• For non-palpable testes: 7

  • Diagnostic laparoscopy to determine location
  • If abdominal and mobile: One-stage laparoscopic or open orchiopexy
  • If vessels are short: Two-stage Fowler-Stephens orchiopexy
  • If contralateral testicular hypertrophy present: Consider scrotal exploration

Outcomes and Follow-up

• Surgical success rate: >96% for open surgical intervention 1

• Complications:

  • Testicular atrophy: <2% after orchiopexy 1
  • Need for potential follow-up procedures if initial surgery unsuccessful

• Long-term monitoring:

  • Regular testicular self-examination after puberty for early cancer detection 1
  • Annual monitoring of retractile testes due to risk of secondary ascent 1

Rationale for Early Intervention

• Fertility preservation:

  • After 15-18 months, cryptorchid boys begin to lack germ cells
  • By 8-11 years, approximately 40% of bilateral cryptorchid boys have no germ cells 1

• Cancer risk reduction:

  • 2.75-8 times increased risk of testicular cancer compared to general population
  • Prepubertal orchiopexy results in 2-6 fold reduction in cancer risk compared to postpubertal intervention 1

Important Considerations

• Orchiopexy before one year should only be performed at centers with both pediatric surgeons/urologists and pediatric anesthesiologists 5
• Parents should be counseled about surgical risks, possibility of finding an abnormal testis requiring removal, and potential long-term risks of infertility and cancer 1
• Unilateral cryptorchidism typically has minimal impact on overall fertility, while bilateral cryptorchidism is associated with a paternity rate of 35-53% 1