What is the treatment approach for a toddler with an undescended testicle versus a retractable testicle?

Undescended vs Retractable Testicle in Toddler

Critical Distinction

The key difference is that a retractable testicle can be manually manipulated into the scrotum and stays there temporarily, while a true undescended testicle cannot be brought down into the scrotum—retractile testes require no treatment, whereas undescended testes require surgical referral by 6 months of age. 1

Retractile Testicle

Clinical Characteristics

• The testicle can be manually brought down into the scrotum during examination and will remain there at least temporarily 1
• This is a normal variant caused by an overactive cremasteric reflex 1
• The testicle moves up and down between the scrotum and groin area 1

Management Approach

• No surgical intervention is needed 1
• Annual follow-up by the primary care provider is recommended, as retractile testes can occasionally become acquired undescended testes (ascending testes) later in childhood 2
• Careful palpation at each well-child visit is essential to detect any change in testicular position 1
• Peak age for acquired cryptorchidism is around 8 years 1

Important Caveat

• Many cases initially diagnosed as "retractile" are actually low-lying undescended testes that are difficult to distinguish clinically 2
• If there is any doubt about whether the testis truly descends and remains in the scrotum, refer to a pediatric urologist 1

Undescended Testicle (Cryptorchidism)

Clinical Characteristics

• The testicle cannot be manipulated into the scrotum, or if it can be brought down, it immediately retracts back up 1
• May be palpable (70% of cases) in the inguinal canal or upper scrotum, or non-palpable (30%) 1
• Can be congenital (present from birth) or acquired (previously descended but later ascended) 1

Timing of Referral and Surgery

Refer to pediatric urology/surgical specialist by 6 months of corrected age if the testicle remains undescended 1, 3

Surgery (orchiopexy) should be performed between 6-18 months of age, ideally before 18 months 3

Rationale for Early Intervention

• Spontaneous descent after 6 months of corrected age is highly unlikely 1, 3
• Germ cell loss begins after 15-18 months of age 3
• By 8-11 years, approximately 40% of boys with bilateral undescended testes have no germ cells on biopsy 3
• Early orchiopexy (before 18 months) reduces testicular cancer risk by 2-6 fold compared to postpubertal surgery 3
• Fertility rates are impaired even with successful orchiopexy (75% for unilateral, 50% for bilateral), but earlier surgery may improve outcomes 4

Special Considerations for Toddlers

Gestational History Matters

• Premature infants have 15-30% prevalence of undescended testes at birth versus 1-3% in full-term infants 1, 3
• Corrected gestational age must be used when determining the 6-month referral threshold 1

Bilateral Non-Palpable Testes = Emergency

• Immediate specialist consultation is required to rule out disorders of sex development, particularly congenital adrenal hyperplasia, which can be life-threatening 1, 3
• Do not circumcise until evaluation is complete 1

What NOT to Do

• Do not order ultrasound or other imaging studies before referral—they rarely assist in decision-making and should not delay specialist evaluation 1, 3
• Do not wait beyond 6 months of corrected age to refer 1, 3

Surgical Success Rates

• Open orchiopexy has >96% success rate for palpable testes 3
• Testicular atrophy occurs in <2% of cases 3
• For non-palpable testes, laparoscopic exploration is necessary to locate the testis and determine the surgical approach 1, 3

Hormonal Therapy (Generally Not Recommended)

• HCG (human chorionic gonadotropin) is FDA-approved for prepubertal cryptorchidism in children ages 4-9 years 5
• However, HCG is effective in causing descent in only a small percentage of cases and is not useful for non-palpable testes 4
• Most responses to HCG are temporary rather than permanent 5
• Current guidelines prioritize surgical intervention over hormonal therapy 1, 3

Long-Term Counseling

• Parents should be counseled about increased risks of infertility and testicular cancer, even with successful orchiopexy 3
• The contralateral descended testis also has increased cancer risk 4
• Lifelong testicular self-examination should be taught at an appropriate age 3

Acquired (Ascending) Cryptorchidism

Recognition

• A previously documented descended testis that later ascends and cannot be manipulated back into the scrotum 1
• Prevalence is 1-7%, peaking around age 8 years 1
• Has the same adverse histologic features (germ cell loss) as congenital undescended testes 1, 2

Management

• Refer to surgical specialist for evaluation 1
• Some evidence suggests spontaneous descent may occur at puberty in a subset of cases (84% in one study), but this remains controversial and should not delay referral in toddlers 6
• The same surgical principles apply as for congenital undescended testes 1, 2