What is the management of undescended testes?

Management of Undescended Testes

The management of undescended testes is primarily surgical via orchidopexy, which should be performed by 18 months of age in children, while adult management depends on testicular function with orchidectomy recommended for unilateral cases with normal contralateral function, and hormonal therapy is not recommended at any age. 1, 2

Pediatric Management (Birth to 18 Months)

Initial Evaluation and Timing

• Infants with cryptorchidism at birth should be observed until 6 months of age, as spontaneous descent may occur during this period 3, 4
• Immediate referral to a surgical specialist is required if no spontaneous descent occurs by 6 months, as testes that remain undescended beyond this point are unlikely to descend spontaneously 3, 4
• Boys diagnosed with cryptorchidism after 6 months of age should be promptly referred without delay 3
• Imaging studies (ultrasound, CT, MRI) are not recommended prior to referral, as they rarely assist in decision-making and do not change management 3

Critical Red Flags

• Bilateral nonpalpable testes in a phenotypic male newborn requires immediate specialist consultation to evaluate for disorders of sex development 3
• Do not circumcise newborns with bilateral nonpalpable gonads until workup is complete 3
• Cryptorchidism with phallic anomalies warrants evaluation for disorders of sex development 3

Surgical Intervention

• Orchidopexy should be performed by 18 months of age at the latest to preserve fertility potential and reduce cancer risk 1, 4
• The optimal timing is by 18 months because progressive histologic damage occurs to undescended testes, particularly after the first year of life 1
• Standard inguinal orchidopexy is indicated for most palpable undescended testes 1
• Laparoscopic orchidopexy is indicated for non-palpable testes, allowing for diagnosis and treatment in the same procedure 1
• The overall success rate for open surgical intervention exceeds 96%, with testicular atrophy risk less than 2% 1

Hormonal Therapy in Children

• Hormonal therapy (hCG or GnRH) is not recommended as primary treatment for cryptorchidism due to poor success rates 3, 2
• The FDA label for hCG states it may induce testicular descent in situations where descent would have occurred at puberty, but in most cases the response is temporary 5

Adult Management (Post-Pubertal)

Assessment-Based Algorithm

The management strategy depends on hormonal and spermatogenic evaluation of the contralateral testis 2:

Scenario 1: Unilateral Undescended Testis with Normal Contralateral Function

• Orchidectomy should be offered to adult men with unilateral undescended testis and normal hormonal function/spermatogenesis (strong recommendation) 2
• This approach eliminates the cancer risk from the undescended testis while preserving fertility and hormonal function through the normal contralateral testis 2

Scenario 2: Unilateral or Bilateral Undescended Testis with Impaired Contralateral Function

• Orchidopexy may be offered if the patient has biochemical hypogonadism and/or spermatogenic failure (infertility) to preserve androgen production and fertility 2
• Multiple biopsies of the undescended testis are mandatory at the time of orchidopexy to exclude germ cell neoplasia in situ (GCNIS) as a prognostic indicator of future testicular cancer 2

Hormonal Therapy in Adults

• Do not use hormonal treatment for cryptorchidism in postpubertal men (strong recommendation) 2

Cancer Surveillance Protocol

• Perform simultaneous testicular biopsy for detection of intratubular germ cell neoplasia in situ if undescended testes are corrected in adulthood (strong recommendation) 2
• At the time of orchidectomy for testicular cancer, biopsy the contralateral testis in high-risk patients: those with history of cryptorchidism, testicular volume <12 ml, or hypospermatogenesis 2, 6
• All men with cryptorchidism should perform regular testicular self-examinations, as they have a 3.6-7.4 times higher risk of germ cell tumors compared to the general population 2

Long-Term Outcomes and Counseling

Fertility Prognosis

• Men with unilateral cryptorchidism have paternity rates nearly equivalent to men without cryptorchidism 2
• Men with bilateral cryptorchidism have significantly reduced paternity rates of 35-53% and should be counseled accordingly 2
• Unilateral cryptorchidism carries an infertility rate up to 10%, while bilateral cases have even higher rates 4

Cancer Risk

• Men with cryptorchidism have a 2-6% lifetime risk of developing testicular tumors 2
• Orchidopexy performed before puberty reduces testicular cancer risk by 2-6 fold compared to postpubertal surgery 1
• Even men who undergo early orchidopexy harbor a higher cancer risk than men without cryptorchidism, necessitating lifelong surveillance 2

Hypogonadism Risk

• Men with cryptorchidism are at higher risk of hypogonadism and should be monitored for biochemical evidence of testosterone deficiency 2

Post-Operative Follow-Up

• Regular monitoring of testicular position and development is necessary throughout childhood and adolescence 1, 3
• Patient education must include counseling on long-term risks of infertility and cancer, even after successful orchidopexy 1, 3
• Annual follow-up after surgery is recommended to identify testicular tumors early 7

Common Pitfalls to Avoid

• Do not delay referral waiting for imaging studies – they do not change management and delay definitive treatment 3
• Do not perform orchidopexy after 18 months in children – this increases the risk of infertility and does not fully mitigate cancer risk 1, 4
• Do not offer hormonal therapy as primary treatment – it has poor success rates and is not recommended by current guidelines 2, 3
• Do not perform orchidopexy in adults without concurrent testicular biopsy – this misses the opportunity to detect GCNIS 2
• Do not assume successful orchidopexy eliminates cancer risk – lifelong surveillance is required 2, 1