Latest Guidelines for Treatment of Undescended Testis
Surgical orchidopexy performed by 18 months of age is the standard treatment for cryptorchidism, with referral to a surgical specialist by 6 months if spontaneous descent has not occurred. 1, 2
Timing of Referral and Treatment
Infants with cryptorchidism at birth should be referred to a surgical specialist if no spontaneous descent occurs by 6 months of age (corrected for gestational age). 2, 3
Boys diagnosed with cryptorchidism after 6 months should receive prompt referral to a surgical specialist, as testes remaining undescended beyond this point are unlikely to descend spontaneously. 2, 3
The optimal surgical timing is by 18 months of age, as progressive histologic damage occurs to undescended testes particularly after the first year of life. 1
This early timing maximizes fertility preservation potential and may reduce testicular cancer risk compared to later surgery. 1
Pre-Referral Management
Primary care providers should palpate testes for quality and position at each well-child visit. 3
Do not obtain ultrasound or other imaging studies prior to referral, as these rarely assist in decision making. 2, 3
Obtain gestational history, as premature infants have higher cryptorchidism rates (15-30% versus 1-3% in full-term infants). 3
Surgical Approach
Standard inguinal orchidopexy is indicated for most palpable undescended testes, with an overall success rate exceeding 96% and testicular atrophy risk below 2%. 1
Laparoscopic orchidopexy is indicated for non-palpable testes, allowing simultaneous diagnosis and treatment. 1
Orchiectomy may be appropriate when testicular vessels and vas deferens are very short, or when the testis is dysmorphic or hypoplastic. 1
Hormonal Therapy: Not Recommended
Hormonal therapy alone is not recommended as primary treatment for cryptorchidism. 2
While the FDA label indicates hCG may induce testicular descent in some cases, the response is typically temporary rather than permanent. 4
Evidence suggests hCG treatment may cause interstitial edema, inflammation-like changes, and adverse effects on germ cells through increased apoptosis. 5
Meta-analyses show only 15-20% of retained testes descend during hormonal treatment, with one-fifth re-ascending later. 6
Special Urgent Situations
For phenotypic male newborns with bilateral nonpalpable testes, immediate specialist consultation is required to evaluate for disorders of sex development, particularly life-threatening congenital adrenal hyperplasia. 2, 3
A newborn with bilateral nonpalpable gonads should not be circumcised until workup is complete. 2, 3
When cryptorchidism presents with phallic anomalies (hypospadias or micropenis), evaluation for disorders of sex development should be considered. 3
Long-Term Outcomes and Counseling
Cryptorchidism increases testicular cancer risk by 2.75-8 times, but prepubertal orchidopexy reduces this risk by 2-6 fold compared to postpubertal surgery. 1
Successful scrotal repositioning reduces but does not completely eliminate long-term risks of infertility and testicular cancer. 2
Unilateral cryptorchidism has paternity rates similar to the general population, while bilateral cryptorchidism significantly reduces fertility. 1
Regular monitoring of testicular position and development is necessary throughout childhood and adolescence, with counseling on long-term risks. 1, 2
Common Pitfalls to Avoid
Failure to recognize urgency of bilateral nonpalpable testes can delay diagnosis of potentially life-threatening conditions. 3
Delaying surgery beyond 18 months increases risk of progressive testicular damage and reduced fertility potential. 1
Ordering unnecessary imaging studies delays appropriate surgical referral without adding clinical value. 2, 3