Management of Testis in Superficial Inguinal Ring with Normal Testosterone and Semen Analysis
In an adult patient with a testis in the superficial inguinal ring who has normal testosterone levels and normal semen analysis, orchidectomy is the recommended treatment rather than orchidopexy. 1
Rationale for Orchidectomy Over Orchidopexy
The European Association of Urology provides a strong recommendation for orchidectomy in adult men with unilateral undescended testis who have normal hormonal function and spermatogenesis 1. This recommendation is based on several critical factors:
Why Orchidectomy is Preferred
Malignancy risk: Adults with undescended testes have a 3.7 to 7.5-fold increased risk of testicular cancer, with seminoma being the most common tumor type in undescended testes 2. The risk remains elevated even after orchidopexy 3.
Fertility preservation: Since the patient has normal semen analysis and normal testosterone, the contralateral descended testis is functioning adequately 1. Men with unilateral cryptorchidism who undergo orchidectomy (monorchidism) have paternity rates similar to those with unilateral cryptorchidism (89.5% vs 94% in controls), indicating no significant fertility disadvantage 3.
No functional benefit from orchidopexy: Attempting orchidopexy when orchidectomy is indicated provides no benefit and only increases the cancer surveillance burden 1. Post-pubertal undescended testes typically show severe degenerative changes with considerable loss of spermatogenesis 4.
Critical Procedures Required at Surgery
Simultaneous testicular biopsy must be performed at the time of orchidectomy to detect intratubular germ cell neoplasia (testicular intraepithelial neoplasia/TIN) 1. This is a strong recommendation because:
- 2-5% of testicular cancer patients have TIN in the contralateral testis 3
- The highest risk (≥34%) occurs with testicular atrophy (volume <12 ml) and age <40 years 3
- If untreated, invasive testicular tumor develops in 70% of TIN-positive testes within 7 years 3
Sperm cryopreservation should be offered before orchidectomy to preserve future fertility options, even though current semen analysis is normal 1, 3.
When Orchidopexy Would Be Considered Instead
Orchidopexy is only offered in adults with undescended testis when there is biochemical hypogonadism or spermatogenic failure, and only if technically feasible 1. Since your patient has normal testosterone and normal semen analysis, this does not apply.
Common Pitfalls to Avoid
- Do not attempt orchidopexy in this clinical scenario—it provides no benefit and increases cancer surveillance burden 1
- Do not omit testicular biopsy at the time of surgery, as this is the only opportunity to detect pre-malignant changes in the contralateral testis 1
- Do not consider hormonal treatment—the European Association of Urology strongly recommends against hormonal treatment for cryptorchidism in postpubertal men due to limited efficacy and potential risks 1
Surgical Approach
If orchidectomy is performed, use an inguinal approach with removal of the testis and spermatic cord at the level of the internal inguinal ring 3. Never use a scrotal approach for suspected pathology in undescended testes 5.