Next Diagnostic Step for Suspected Cryptorchidism with One Palpable Testis
The next step is a careful repeat physical examination by an experienced provider to determine if the missing testis is truly non-palpable or simply retractile, and imaging studies should NOT be performed. 1
Immediate Clinical Assessment
The critical first step is distinguishing between three possibilities through physical examination:
- Retractile testis: Can be easily manipulated into the scrotum and remains there without traction—this is a normal variant requiring only annual monitoring 1, 2
- True cryptorchidism (palpable): Testis can be felt in the inguinal canal but cannot be manipulated into the scrotum or stay there without traction—requires surgical referral 1, 2
- Non-palpable testis: Cannot be felt anywhere on examination—requires surgical exploration, not imaging 1
The examination should be performed with the child in multiple positions (supine, sitting, squatting) and with warm hands to minimize cremasteric reflex activation. 1
Why Imaging is NOT Indicated
Ultrasound and other imaging modalities should NOT be performed prior to surgical referral, as these studies rarely assist in decision-making. 1 The evidence is clear:
- Ultrasound has only 45% sensitivity and 78% specificity for localizing non-palpable testes 1, 3
- More than 70% of cryptorchid testes are palpable by an experienced examiner, making imaging unnecessary 1
- No radiological test can conclude with 100% accuracy that a testis is absent 1
- Imaging delays appropriate surgical referral and adds no clinical value 1, 4
Referral Timing Based on Age
The management pathway depends critically on the child's age:
If the child is under 6 months (corrected for gestational age):
- Monitor for spontaneous descent, as this can occur in the first 6 months of life 4
- Refer to pediatric urology/surgical specialist by 6 months if the testis remains non-palpable or truly undescended 4
If the child is 6-18 months old:
- Immediate referral to pediatric urology/surgical specialist is indicated 4
- Spontaneous descent after 6 months is unlikely 4
- Surgery should ideally be performed by 18 months to preserve fertility potential 4
If the child is over 18 months:
- Urgent referral to pediatric urology/surgical specialist 4
- Germ cell damage begins after 15-18 months of age 4, 2
Critical Red Flag: Bilateral Non-Palpable Testes
If BOTH testes are non-palpable in a newborn, this is a medical emergency requiring immediate specialist consultation. 1, 4 This scenario requires:
- Urgent evaluation for disorder of sexual development (DSD), particularly congenital adrenal hyperplasia 1
- A phenotypic male with bilateral non-palpable testes could be a 46,XX individual with life-threatening congenital adrenal hyperplasia 1, 4
- Do NOT circumcise until the workup is complete 1
- Failure to diagnose congenital adrenal hyperplasia can result in shock, hyponatremia, and hyperkalemia 1
Definitive Diagnosis: Surgical Exploration
For truly non-palpable testes, diagnostic laparoscopy or open surgical exploration is the gold standard with nearly 100% sensitivity and specificity. 1, 3 The surgical objectives are:
- Identify the testicular vessels to determine if testicular tissue is present 1
- Locate the testis (intra-abdominal, inguinal canal, or absent) 1
- Perform orchiopexy if viable testis is found 1
Common Pitfalls to Avoid
- Ordering ultrasound or CT/MRI before referral—this delays appropriate care and provides no actionable information 1, 4
- Delaying referral beyond 6 months of age in infants with persistent undescended testis 4
- Mistaking a retractile testis for cryptorchidism—retractile testes can be manipulated into the scrotum and stay there 1, 2
- Missing bilateral non-palpable testes in a newborn, which requires emergency evaluation for DSD 1, 4
- Failing to correct for gestational age in premature infants when determining the 6-month referral timeline 4