When Undescended Testicles Become a Concern in Infants
Undescended testicles become a concern at 6 months of corrected age—this is when referral to a pediatric urologist or surgical specialist must occur, as spontaneous descent after this point is highly unlikely and continued damage to the testes is probable. 1
Critical Age Thresholds
Birth to 6 Months: Observation Period
- Spontaneous testicular descent commonly occurs during the first 6 months of life, particularly in premature infants 1
- Testes that remain undescended beyond 6 months (corrected for gestational age) are unlikely to descend spontaneously 1
- Primary care providers must palpate testes for quality and position at every well-child visit during this period 1
6 Months: The Referral Threshold
- Infants with undescended testes detected at birth who lack spontaneous descent by 6 months (corrected for gestational age) require referral to a surgical specialist 1, 2
- The rationale for this timing is twofold: extremely low probability of spontaneous descent after 6 months and ongoing testicular damage in non-scrotal locations 1
- Corrected gestational age is critical—premature infants need age adjustment based on their due date, not birth date 1
6-18 Months: Surgical Window
- Orchiopexy should be performed between 6-18 months of age, with 18 months being the absolute latest recommended time 2
- After 15-18 months of age, cryptorchid boys begin losing germ cells in the testes 2
- By 8-11 years of age, approximately 40% of bilateral cryptorchid boys have no germ cells remaining in testicular biopsies 2
Immediate Emergency Situations
Bilateral Nonpalpable Testes in Newborns
- This is a medical emergency requiring immediate specialist consultation—do not circumcise the infant until evaluation is complete 1, 2
- A phenotypic male newborn with bilateral nonpalpable testes could be a genetic female (46 XX) with congenital adrenal hyperplasia, a life-threatening condition causing shock, hyponatremia, and hyperkalemia 1, 2
- Failure to diagnose congenital adrenal hyperplasia can result in serious harm or death 1
Acquired Cryptorchidism After 6 Months
- Boys with newly diagnosed undescended testes after 6 months (previously descended testes that ascended) require referral to a surgical specialist 1
- This represents a distinct clinical entity from congenital cryptorchidism and carries similar risks of germ cell loss 1
Risk Stratification by Gestational History
Premature Infants
- 15-30% of premature male infants have undescended testes at birth compared to 1-3% of full-term infants 1, 3
- Nearly 100% of extremely low birth weight infants (<900g) have undescended testes at birth 1, 2
- Spontaneous postnatal descent may be lower in small-for-gestational-age boys compared to those with normal birth weight 1
Full-Term Infants
- 1-3% of full-term male infants have undescended testes at birth 1, 2
- Prevalence decreases to approximately 1% by one year of age 3
Common Pitfalls to Avoid
Do Not Order Imaging Studies
- Ultrasound or other imaging modalities should not be performed prior to referral, as these studies rarely assist in decision-making and should not delay specialist evaluation 1, 2
- More than 70% of cryptorchid testes are palpable on examination by an experienced provider 1
Do Not Delay Referral Beyond 6 Months
- Delaying referral beyond 6 months of corrected age is the most critical error, as it increases the risk of infertility and testicular cancer 2
- Prepubertal orchiopexy results in a two- to six-fold reduction in testicular cancer risk compared with postpubertal orchiopexy 2
Do Not Confuse Retractile Testes with True Cryptorchidism
- Retractile testes can be manipulated into the scrotum and remain there without tension—these do not require surgical intervention 4
- True undescended testes cannot be manipulated into a stable scrotal position 1
Long-Term Consequences of Delayed Treatment
Fertility Impact
- Patients with unilateral undescended testis have infertility rates up to 10% 5
- Bilateral undescended testes, intra-abdominal location, or delayed orchiopexy significantly increase infertility risk 5
- By 8-11 years, approximately 40% of bilateral cryptorchid boys have complete germ cell loss 2