What is the recommended treatment for a newborn with an undescended testicle (cryptorchidism)?

Management of Undescended Testicle in a Newborn

For a newborn with an undescended testicle, observe until 6 months of corrected age, then refer to a pediatric urologist or surgical specialist if the testis has not descended spontaneously, as surgery should be performed between 6-18 months of age to preserve fertility and reduce cancer risk. 1, 2

Immediate Assessment at Birth

Critical Red Flag: Bilateral Nonpalpable Testes

• If both testicles are nonpalpable in a phenotypic male newborn, this is a medical emergency requiring immediate specialist consultation to rule out congenital adrenal hyperplasia, a life-threatening condition 1, 2
• A masculinized infant with bilateral nonpalpable gonads could be a genetic female (46 XX) with congenital adrenal hyperplasia, which can cause shock, hyponatremia, and hyperkalemia 1, 2
• Do not circumcise until the workup is complete 1

Initial Physical Examination

• Palpate for testicular position at every well-child visit throughout infancy 1, 2
• Distinguish between truly undescended testes and retractile testes (which require no treatment) 3
• Examine in a warm environment with the patient relaxed to avoid mistaking a retracted testis for true cryptorchidism 4

Observation Period (Birth to 6 Months)

Expected Natural History

• Spontaneous testicular descent commonly occurs in the first 6 months of life, particularly in the first 3 months 1, 2, 5
• After 6 months of corrected age, spontaneous descent is highly unlikely 1, 2, 5
• Premature infants have much higher rates (15-30%) compared to full-term infants (1-3%), so corrected gestational age must be used 2

What NOT to Do During Observation

• Do not order ultrasound or other imaging studies - they rarely assist in decision-making and should not delay referral 1, 2
• Do not extend observation beyond 6 months of corrected age, as this delays treatment and impairs outcomes 6

Referral Timing (At 6 Months)

Refer to a pediatric urologist or surgical specialist by 6 months of corrected age if the testis remains undescended 1, 2

Rationale for 6-Month Referral Deadline

• Testes that remain undescended by 6 months are unlikely to descend spontaneously 1, 2
• Continued non-scrotal position causes progressive testicular damage 1
• Germ cell loss begins after 15-18 months of age 2, 4
• By 8-11 years, approximately 40% of bilateral cryptorchid boys have no germ cells in testicular biopsies 2

Surgical Treatment (6-18 Months of Age)

Optimal Timing Window

• Orchiopexy should be performed between 6-18 months of age, with 18 months being the absolute latest 2, 5, 7
• Earlier surgery (before 18 months) maximizes fertility potential 2, 7
• Prepubertal orchidopexy reduces testicular cancer risk by 2-6 fold compared to postpubertal surgery 2

Surgical Approach Based on Examination

• For palpable testes: Standard scrotal or inguinal orchiopexy with success rates exceeding 96% 2
• For nonpalpable testes: Diagnostic laparoscopy to locate the testis and determine surgical approach 2, 7
• Testicular atrophy occurs in less than 2% of cases with modern surgical techniques 2

Hormonal Therapy: Not Recommended

Routine hormonal therapy with hCG is NOT recommended as primary treatment 5, 8

Why Hormones Are Not First-Line

• The FDA label for hCG states it may help predict whether orchiopexy will be needed, but in most cases the response is temporary 9
• hCG is effective in causing descent in only a small percentage of children 3
• International guidelines do not recommend routine hormonal therapy due to lack of evidence 5
• Early surgery is the key to treatment, not hormonal manipulation 8

Long-Term Counseling for Parents

Fertility Risks

• Unilateral undescended testis: up to 10% infertility rate 5
• Bilateral undescended testes: even higher infertility rates 5
• Delayed orchiopexy worsens fertility outcomes 5

Cancer Risk

• Three-fold increased risk of testicular cancer compared to general population 5
• Risk affects both the undescended testis AND the contralateral descended testis 3
• Self-examination after puberty is recommended for early cancer detection 5

Common Pitfalls to Avoid

• Delaying referral beyond 6 months - this is the most critical error, as it reduces surgical success and impairs fertility 1, 2, 6
• Ordering unnecessary imaging before referral - ultrasound does not change management 1, 2, 5
• Mistaking retractile testes for true cryptorchidism - retractile testes require no treatment 3
• Missing bilateral nonpalpable testes as a medical emergency requiring immediate evaluation 1, 2
• Attempting hormonal therapy as primary treatment instead of timely surgical referral 5, 8