High Riding Testes
High riding testes refer to testicles that are positioned abnormally high in the scrotum or at the external inguinal ring, rather than at the base of the scrotum where they should normally reside. This term encompasses several related conditions that exist on a spectrum from normal to pathological positioning.
Clinical Spectrum and Definitions
High riding testes can represent different clinical entities depending on their behavior and mobility:
Retractile Testis
- The testis can be easily manipulated into the scrotum and remains there without traction, representing a hyperactive cremasteric reflex pulling the testis upward 1
- The testis is palpable in the inguinal canal but can be brought down to a normal scrotal position 1
- This is generally considered a benign variant but requires monitoring 1
Gliding Testis
- The testis is located below the external ring and can be manipulated to the upper scrotum but tends to ascend back to its original high position 2
- This represents a minor degree of true undescended testis with characteristic anatomical findings: absence of the gubernaculum and a partially patent processus vaginalis from the upper scrotum to the mid groin area 2
- These testes are smaller than the contralateral testis in 24% of boys and histologic changes can be detected by 7 years of age 2
Acquired Cryptorchidism (Secondary Ascent)
- A previously descended testis that has ascended and cannot be manipulated back into the scrotum 1
- Retractile testes carry a 2-45% risk of becoming truly undescended during childhood through secondary ascent, mechanistically related to hyperactive cremasteric reflex, foreshortened patent processus vaginalis, or entrapping adhesions 1
- These testes share the same histopathology and germ cell damage as congenital undescended testes 3
Clinical Significance and Risks
The critical distinction is whether the testis can be manipulated into the scrotum and kept there without traction—this determines whether surgical intervention is needed.
Fertility Implications
- Germ cell damage begins after 15-18 months of age, with progressive loss of fertility potential 1
- High riding testes that cannot remain in the scrotum face the same fertility risks as congenital undescended testes 1
- Testicular ascent is associated with more depressed spermatogenesis in infertile men, even without a history of cryptorchidism 4
Malignancy Risk
- Even with successful orchiopexy, lifelong surveillance for testicular cancer is required, with relative risk 2.75-8 times higher than normal 1
- Prepubertal orchiopexy reduces cancer risk 2-6 fold compared to postpubertal surgery 1, 5
Management Algorithm
At 15 Months of Age (Corrected for Gestational Age)
- If the testis cannot be manipulated into the scrotum and kept there without traction, immediate referral to a pediatric urologist or pediatric surgeon for orchiopexy is required 1
- Orchiopexy should ideally be performed by 18 months to preserve fertility potential 1, 5
For Retractile Testes
- Annual monitoring is required because these carry risk of becoming truly undescended during childhood 1
- Assess testicular position at least annually at well-child visits to monitor for secondary ascent 1
- Do not order imaging studies, as they rarely assist in decision-making 1
For Gliding Testes
- These typically require surgical intervention given their anatomical abnormalities and risk of histologic changes 2
- Hormonal therapy may provide transient benefit but most require orchiopexy 2
Common Pitfalls to Avoid
- Confusing retractile testes with true undescended or gliding testes—the key is whether the testis remains in the scrotum without traction 1
- Delaying referral beyond 6 months of age when testes remain undescended 5
- Failing to monitor retractile testes annually for secondary ascent 1
- Ordering unnecessary imaging studies prior to specialist referral 1, 5
- Missing bilateral nonpalpable testes in newborns, which requires immediate specialist consultation to evaluate for disorders of sex development 5