Primary Treatment for Cryptorchidism
The primary treatment for cryptorchidism is surgical orchiopexy (surgical repositioning of the undescended testis into the scrotum), which should be performed by 6-12 months of age to optimize fertility outcomes and reduce cancer risk. 1, 2
Treatment Algorithm
Timing of Intervention
- Infants with cryptorchidism detected at birth: Refer to a surgical specialist by 6 months of age (corrected for gestational age) if spontaneous descent has not occurred 1, 2
- Newly diagnosed cryptorchidism after 6 months: Immediate referral to a surgical specialist is indicated 1, 2
- Testes that remain undescended by 6 months are unlikely to descend spontaneously and continued damage occurs to testes remaining in a non-scrotal location 1, 2
Surgical Approach
- Open orchiopexy achieves success rates greater than 96% (range 89-100%) with testicular atrophy rates less than 2% 3
- For palpable low-lying testes, single-incision scrotal orchiopexy is a viable option 3
- Laparoscopic orchiopexy is equally safe and effective for palpable cryptorchidism, with comparable redo-orchiopexy rates, complication rates, and testicular atrophy rates to open surgery 4
- For non-palpable testes, surgical exploration must identify the status of testicular vessels to determine the next course of action 3
Special Surgical Considerations
Orchiectomy (removal) may be indicated in boys with a normal contralateral testis when any of the following are present 3:
- Very short testicular vessels and vas deferens
- Dysmorphic or very hypoplastic testis
- Postpubertal age at presentation
- Prepubertal orchiopexy results in a two- to six-fold reduction in cancer risk compared with postpubertal orchiopexy 3
What NOT to Do
Hormonal Therapy is NOT Recommended
- Hormonal therapy alone (hCG or GnRH) is not recommended as primary treatment for cryptorchidism 1, 2
- While hCG is FDA-approved for prepubertal cryptorchidism not due to anatomical obstruction, hormonal treatments have low success rates and are not recommended by current guidelines 5, 6
- HCG may help predict whether orchiopexy will be needed, but in most cases any response is temporary 5
Imaging is NOT Helpful
- Do not obtain ultrasound or other imaging studies prior to referral, as these rarely assist in decision-making 1, 2
Critical Red Flags Requiring Immediate Action
Bilateral nonpalpable testes in a phenotypic male newborn requires immediate specialist consultation to evaluate for disorders of sex development, particularly life-threatening congenital adrenal hyperplasia 1, 2, 7
- Do not circumcise until workup is complete 1, 2
- When cryptorchidism is present with phallic anomalies (hypospadias or micropenis), evaluation for disorders of sex development should be considered 1, 2, 7
Rationale for Early Surgical Treatment
The benefits of early orchiopexy include 1, 8:
- Reduced risk of impaired fertility potential - formerly bilateral cryptorchid men have greatly reduced fertility 3
- Decreased testicular cancer risk - prepubertal orchiopexy reduces cancer risk compared to postpubertal surgery, though the overall relative risk remains 2.75-fold elevated 3
- Prevention of testicular torsion 1
- Treatment of associated inguinal hernia (present in >90% of pediatric inguinal hernias occurring in boys) 1, 7
Important Caveats
- Successful orchiopexy reduces but does not eliminate long-term risks of infertility and testicular cancer 1
- All patients with a history of cryptorchidism require lifelong counseling regarding potential long-term risks, cancer surveillance, and fertility implications 3, 1, 8
- Boys should be taught monthly testicular self-examination after puberty to facilitate early cancer detection 3, 8
- Germ cell loss in the cryptorchid testis is proportional to the duration of the condition, reinforcing the importance of early intervention 6