What is the diagnosis and management for a 2-year-old male with cryptorchidism (undescended testes)?

From the Guidelines

For a 2-year-old boy with undescended testes, referral to pediatric urology is recommended for surgical correction (orchiopexy) as soon as possible. This recommendation is based on the American Urological Association (AUA) guideline, which suggests that surgery should be performed before age 18 months, but since this child is already 2 years old, prompt intervention is important to minimize risks of infertility and testicular cancer 1. The procedure involves bringing the undescended testis into the scrotum and fixing it in place. Prior to surgery, physical examination should be performed to locate the undescended testis, as more than 70% of cryptorchid testes are palpable by physical examination and need no imaging 1. If the testis cannot be palpated, laparoscopy may be needed during surgery to locate it.

Key Points to Consider

• Hormonal therapy with human chorionic gonadotropin (hCG) or gonadotropin-releasing hormone (GnRH) is generally not recommended as primary treatment but may be used in specific cases, as evidence shows low response rates and lack of evidence for long-term efficacy 1.
• Early surgical correction is crucial because undescended testes are associated with increased risks of testicular cancer, infertility, and testicular torsion.
• The higher temperature outside the scrotum can damage the developing testicular tissue, affecting future sperm production.
• Parents should be counseled about the importance of regular follow-up after surgery to monitor testicular development and position.

Important Considerations for Management

• Providers should not use hormonal therapy to induce testicular descent as evidence shows low response rates and lack of evidence for long-term efficacy 1.
• Providers should not perform ultrasound or other imaging modalities in the evaluation of boys with cryptorchidism prior to referral, as these studies rarely assist in decision making 1.
• Orchidopexy in the first 18 months of life is recommended to preserve available fertility potential, and since this child is already 2 years old, prompt intervention is important to minimize risks of infertility and testicular cancer 1.

From the FDA Drug Label

Prepubertal cryptorchidism not due to anatomical obstruction. In general, HCG is thought to induce testicular descent in situations when descent would have occurred at puberty. HCG thus may help predict whether or not orchiopexy will be needed in the future. Although, in some cases, descent following HCG administration is permanent, in most cases, the response is temporary Therapy is usually instituted in children between the ages of 4 and 9.

For a 2-year-old boy with undescended testes, the use of human chorionic gonadotropin (HCG) may be considered, but it is essential to note that therapy is usually instituted in children between the ages of 4 and 9. The effectiveness of HCG in inducing permanent testicular descent at this age is not explicitly stated in the label.

• Key points:
  • HCG may help predict the need for orchiopexy.
  • The response to HCG is temporary in most cases. Given the age of the child is below the usual treatment age range, caution should be exercised, and the decision to use HCG should be made on a case-by-case basis, considering the individual circumstances of the patient 2.

From the Research

Undescended Testes in a 2-Year-Old Boy

• The condition of undescended testes, also known as cryptorchidism, occurs in 1-3% of male term infant births 3.
• At least two-thirds of undescended testes will descend spontaneously, typically during the first 6 months of life 3.
• If the testes do not descend by 6 months of age, the probability of spontaneous descent thereafter is low, with about 1%-2% of boys older than 6 months having undescended testes after their early postnatal descent 4.

Treatment and Management

• Orchiopexy performed prior to puberty may significantly reduce the malignant potential by up to 4-fold 3.
• Neoadjuvant hormonal therapy starting at 6 months of life has been shown to potentially improve the testicle's fertility index and should be part of the therapeutic concept 3.
• However, the use of hormonal treatment and HCG beyond the first year of life is to be challenged given a potentially negative impact on testicular function 3.
• Laparoscopic exploration and therapy is the method of choice for non-palpable testes 3.
• Ideally, surgical repair of the undescended testis should be completed by the age of 1 year 3, and orchiopexy is recommended between 6 and 18 months at the latest to protect the fertility potential and decrease the risk of malignant changes 4.

Risks and Complications

• Undescended testes are associated with loss of spermatogenic potential and testicular malignancy in the long term 3.
• Patients with undescended testis have a threefold increased risk of testicular cancer later in life compared to the general population 4.
• Unilateral undescended testis have an infertility rate of up to 10%, and this rate is even higher in patients with bilateral undescended testes, with intra-abdominal undescended testis, or who underwent delayed orchiopexy 4.
• Self-examination after puberty is recommended to facilitate early cancer detection 4.

Diagnosis and Referral

• International guidelines do not recommend ultrasonography or other diagnostic imaging because they cannot add diagnostic accuracy or change treatment 4.
• A surgical specialist referral is recommended if descent does not occur by 6 months, undescended testis is newly diagnosed after 6 months of age, or testicular torsion is suspected 4.