Treatment of Undescended Testis in a Boy
The most appropriate treatment is orchidopexy (Answer A), which should be performed promptly, ideally by 18 months of age, to preserve fertility potential and reduce testicular cancer risk. 1
Why Orchidopexy is the Standard of Care
Orchidopexy is the definitive surgical treatment for cryptorchidism and achieves success rates exceeding 96% with testicular atrophy risk below 2%. 1, 2 The American Urological Association and European Association of Urology both establish this as the standard surgical procedure for undescended testis. 1, 2
Critical Timing Considerations
- Surgery should be performed by 18 months of age because progressive germ cell degeneration begins after the first year of life and accelerates during the second year. 1
- Approximately 25% of cryptorchid boys are born with reduced germ cell numbers, and by 8-11 years of age, about 40% of bilateral cryptorchid boys lack germ cells entirely. 1
- Prepubertal orchidopexy reduces testicular cancer risk by 2-6 fold compared to postpubertal surgery. 1, 2
Why Other Options Are Incorrect
Option C (Wait Till Puberty) - Contraindicated
Waiting until puberty is explicitly not recommended as it results in irreversible testicular damage and increased cancer risk. 1, 2 While one older study suggested some acquired undescended testes might descend spontaneously at puberty 3, this contradicts current guideline recommendations that prioritize early intervention to prevent ongoing histologic damage. 1
Option D (Androgen Administration) - Ineffective
Hormonal therapy with hCG or GnRH is not recommended due to low response rates (6-38% in controlled studies) and lack of long-term efficacy. 1 The European Association of Urology explicitly states not to use hormonal treatment for cryptorchidism. 1 Meta-analyses demonstrate poor success rates for both gonadotropin-releasing hormone and human chorionic gonadotropin. 1
Option B (Orchidectomy) - Only for Specific Circumstances
Orchidectomy is reserved for postpubertal patients with very short testicular vessels and vas deferens, dysmorphic or severely hypoplastic testis, or when a normal contralateral testis is present. 2, 4 This is not appropriate for a prepubertal boy with a palpable inguinal testis.
Surgical Approach for This Case
- For a palpable testis in the inguinal canal, standard inguinal orchidopexy is the primary approach. 1, 2
- Single-incision scrotal orchidopexy is also viable for low-lying palpable testes and has been documented as equally effective. 1
Long-Term Counseling Requirements
- Testicular cancer risk remains elevated 2.75-8 times baseline despite orchidopexy, and patients should be taught monthly testicular self-examination after puberty. 1, 2
- Unilateral cryptorchidism has near-normal paternity rates, while bilateral cryptorchidism significantly reduces fertility to 35-53%. 1, 2
- The contralateral descended testis may also have structural abnormalities, affecting overall fertility potential. 1
Common Pitfall to Avoid
Do not delay referral or surgery based on the misconception that spontaneous descent might occur. 1, 5 Testes that remain undescended by 6 months are unlikely to descend spontaneously, and continued damage occurs to testes in non-scrotal locations. 5 Imaging is not recommended prior to referral as it rarely assists in decision-making. 1, 5