What are the next steps in managing a 9-month-old male with scrotal ultrasound (US) findings?

Management of 9-Month-Old Male with Scrotal Ultrasound

The next steps depend entirely on what the scrotal ultrasound revealed, but given this infant's age, the most critical consideration is whether cryptorchidism (undescended testis) was identified—if so, immediate referral to pediatric urology/surgery is mandatory, as spontaneous descent is unlikely after 6 months of corrected age and surgical intervention should occur promptly to prevent testicular damage. 1

Age-Specific Context for a 9-Month-Old

At 9 months of age, this infant is past the critical 6-month window for spontaneous testicular descent. 1 The AUA guidelines are explicit that:

• Spontaneous testicular descent is unlikely after 6 months of corrected gestational age 1
• Testes remaining undescended by 6 months require surgical referral to prevent continued testicular damage from the non-scrotal location 1
• Approximately 70% of undescended testes are palpable, while 30% are non-palpable (with 55% intra-abdominal, 30% inguinal-scrotal, and 15% absent/vanishing) 1

Clinical Decision Algorithm Based on Ultrasound Findings

If Ultrasound Shows Undescended Testis/Testes

Immediate action required:

• Refer urgently to pediatric urologist or appropriate surgical specialist for orchidopexy planning 1
• Obtain complete gestational history if not already documented (prematurity and low birth weight significantly increase cryptorchidism risk) 1
• Document whether unilateral or bilateral (bilateral non-palpable testes would require immediate specialist consultation to evaluate for disorder of sex development, though this should have been identified at birth) 1

The rationale: Continued testicular damage occurs in non-scrotal locations, and surgical correction (orchidopexy) should ideally be performed between 6-18 months of age to optimize fertility outcomes and reduce malignancy risk. 1

If Ultrasound Shows Acute Pathology (Torsion, Infection, Trauma)

For testicular torsion findings (absent/decreased blood flow, whirlpool sign, heterogeneous testis):

• Immediate surgical consultation—this is a surgical emergency 2, 3
• Testicular viability is compromised if not treated within 6-8 hours of symptom onset 2, 3
• In neonates/infants, torsion is typically extravaginal and may occur prenatally or perinatally 3
• Do not delay surgical exploration for additional imaging if clinical suspicion is high 2

For epididymitis/orchitis findings (enlarged epididymis with increased blood flow, scrotal wall thickening):

• Bed rest, scrotal elevation, and analgesics 2
• Age-appropriate antibiotic therapy if infectious etiology suspected 2
• Follow-up to ensure resolution 4, 5

If Ultrasound Shows Incidental/Benign Findings

For hydrocele, varicocele, or other benign findings:

• Most hydroceles in infants resolve spontaneously by 12-18 months 4, 6
• Document findings and plan routine follow-up 6
• Surgical referral only if persistent beyond 18-24 months or if symptomatic 4, 6

Critical Pitfalls to Avoid

• Do not assume normal testicular position without physical examination correlation—ultrasound should complement, not replace, careful physical examination 1
• Do not delay surgical referral for cryptorchidism past 6 months of corrected age—the window for spontaneous descent has closed 1
• In acute presentations, do not let normal or equivocal Doppler flow exclude torsion—false-negative rates can reach 30%, particularly with partial torsion 2, 7
• Always use the contralateral testis as an internal control when interpreting Doppler findings, as prepubertal testes normally have reduced flow 2, 7

Essential Physical Examination Correlation

Regardless of ultrasound findings, perform careful bilateral testicular palpation:

• Document position (scrotal, inguinal canal, non-palpable) 1
• Assess testicular size and consistency 1
• Evaluate cremasteric reflex if acute pathology suspected 7
• Note any scrotal skin changes, masses, or asymmetry 4, 5

The ultrasound report must be interpreted in the clinical context—if cryptorchidism is confirmed at 9 months of age, surgical referral should occur immediately to facilitate timely orchidopexy and prevent irreversible testicular damage. 1