Evaluation and Management of High Riding Testicles in a 9-Month-Old
This 9-month-old requires immediate physical examination in a warm room to determine if the testes can be manipulated into the scrotum and remain there without traction—if they cannot, refer immediately to a pediatric urologist for orchiopexy by 18 months of age. 1, 2
Immediate Clinical Assessment
Perform a careful physical examination in a warm environment with the child relaxed to distinguish between three possibilities 1, 3:
- Retractile testes: Can be easily manipulated into the scrotum and remain there without traction—this represents a hyperactive cremasteric reflex 1
- True undescended testes (cryptorchidism): Cannot be manipulated into the scrotum or do not remain there without traction 1
- Acquired cryptorchidism: Previously descended testes that have ascended and cannot be manipulated back 1
Key examination findings that predict true undescended testes include history of undescended testes at birth, prematurity, and scrotal asymmetry. 3
Critical Timing Considerations
At 9 months of age, this child is approaching the critical window for intervention 2:
- Spontaneous descent is unlikely after 6 months of corrected age, so waiting is not appropriate 2, 4
- Germ cell damage begins after 15-18 months, making timely referral essential 1, 2
- Referral should occur by 6 months if testes remain undescended, meaning this child is already past the ideal referral window 5, 2
- Orchiopexy must be performed between 6-18 months of age, with 18 months being the absolute latest to preserve fertility potential 2
Management Algorithm
If Testes Are Retractile (Can Be Manipulated and Stay in Scrotum):
- Establish annual monitoring through well-child visits 1
- Retractile testes carry a 2-45% risk of becoming truly undescended during childhood (secondary ascent) 1
- Reassess testicular position at least annually to monitor for secondary ascent 1
If Testes Cannot Be Manipulated Into Scrotum or Won't Stay There:
- Refer immediately to pediatric urologist or pediatric surgeon 1, 2
- Do not delay referral for imaging studies 5, 1
- Orchiopexy should be performed before 18 months to prevent irreversible germ cell loss 2
- Success rates for surgical intervention exceed 96% 2
What NOT to Do
Do not order imaging studies (ultrasound or other modalities) prior to referral—the American Urological Association explicitly states these rarely assist in decision-making and should not delay specialist evaluation 5, 1, 2, 3
Long-Term Counseling Points
Even with successful orchiopexy, counsel parents about 1, 2:
- Lifelong surveillance for testicular cancer is required, with relative risk 2.75-8 times higher than normal 1
- Prepubertal orchiopexy reduces cancer risk 2-6 fold compared to postpubertal surgery 1, 2
- Fertility may still be impaired despite successful surgery 5, 6
Common Pitfalls to Avoid
- Delaying referral beyond 6 months of age—this child at 9 months needs urgent evaluation 2
- Ordering unnecessary imaging that delays surgical referral 5, 1
- Assuming "high riding" testes will spontaneously descend after 6 months—they will not 2, 4
- Failing to examine in optimal conditions (warm room, relaxed child), leading to misdiagnosis of retractile testes as undescended 3