Management of Bilateral Undescended Testis
For bilateral undescended testes, referral to a surgical specialist for orchiopexy is recommended between 6-12 months of age to preserve fertility potential and reduce malignancy risk. 1, 2
Initial Evaluation
- For newborns with bilateral nonpalpable testes, immediate specialist consultation is mandatory to evaluate for possible disorders of sex development (DSD), particularly congenital adrenal hyperplasia 3, 1
- Do not circumcise newborns with bilateral nonpalpable testes until after complete workup 3
- Primary care providers should palpate testes for quality and position at every well-child visit 3, 1
- Ultrasound or other imaging modalities should not be performed prior to referral as they rarely assist in decision making 3, 1
- In boys with bilateral nonpalpable testes who do not have congenital adrenal hyperplasia, measurement of müllerian inhibiting substance/anti-müllerian hormone and additional hormone testing should be considered to evaluate for anorchia 3
Timing of Referral
- Infants with cryptorchidism detected at birth who do not have spontaneous testicular descent by 6 months (corrected for gestational age) should be referred to a surgical specialist 3, 1
- Boys with newly diagnosed (acquired) cryptorchidism after 6 months should also be promptly referred to a surgical specialist 3, 2
- Premature infants have higher rates of cryptorchidism (15-30% vs 1-3% in full-term), so gestational age history is important for determining appropriate referral timing 3, 1
Treatment Options
Surgical Management
- Orchiopexy is the standard treatment for bilateral undescended testes 2, 4
- Surgery should be performed between 6-12 months of age to maximize fertility potential and reduce malignancy risk 1, 2
- For palpable testes, standard orchiopexy via scrotal or inguinal approach is recommended 4, 5
- For nonpalpable testes, diagnostic laparoscopy with simultaneous treatment is the procedure of choice 4, 5
- If standard orchiopexy would be inadequate due to short vascular pedicle, autotransplantation with microsurgical techniques may be necessary 5
Hormonal Therapy
- Routine hormonal therapy with human chorionic gonadotropin (hCG) is not recommended as primary treatment for bilateral undescended testes 2, 4
- hCG may be used in selected cases to help predict whether orchiopexy will be needed, but the response is usually temporary 6
- hCG stimulates the interstitial cells of the testis to produce androgens, which may induce testicular descent when no anatomical impediment is present 6
Follow-up and Long-term Considerations
- Adequate follow-up should be conducted in the first postoperative year to detect re-ascensus and/or insufficient growth 4
- Patients with bilateral undescended testes have higher infertility rates than those with unilateral cases 2, 7
- Regular testicular self-examination should be taught and encouraged after puberty (from age 15) for early detection of testicular malignancy 2, 4
- Bilateral undescended testes are associated with a threefold increased risk of testicular cancer compared to the general population 2, 7
Common Pitfalls
- Failure to recognize the urgency of referral for bilateral nonpalpable testes can lead to delayed diagnosis of potentially life-threatening conditions 1
- Observation beyond 6 months of age is not recommended as it delays treatment, lowers surgical success rates, and likely impairs spermatogenesis 2, 8
- Mistaking an inguinal undescended testis for an inguinal hernia can lead to inappropriate management 2
- Delayed orchiopexy (beyond 12-18 months) increases risks of infertility and malignancy 1, 2