What is the recommended management for a 9-month-old male with bilateral retractile testicles that can be manually pushed into the scrotum but retract back into the inguinal canals, with normal testicular vascularity and no other complications?

Management of Bilateral Retractile Testicles in a 9-Month-Old

This 9-month-old with bilateral retractile testicles requires close clinical monitoring with annual examinations until resolution, but does not need immediate surgical referral or intervention at this time. 1

Key Distinction: Retractile vs. Undescended Testicles

• Retractile testicles are fundamentally different from truly undescended testicles and do not require the same urgent surgical management that would be indicated for cryptorchidism at this age 1
• The ultrasound findings confirm both testicles can be manually positioned into the scrotum with normal vascularity and no complications, which definitively establishes this as retractile rather than undescended 1
• True undescended testicles that remain cryptorchid at 6 months corrected age require surgical referral for orchiopexy by 18 months, but this child does not meet that criterion 1

Natural History and Risk of Ascent

The primary concern with retractile testicles is the risk of secondary testicular ascent (acquired cryptorchidism):

• Studies report a broad range of ascent risk from 2-45%, with more rigorous studies showing approximately 3-32% of retractile testes ultimately require orchiopexy 1, 2, 3
• The mechanism involves hyperactive cremasteric reflex, foreshortened patent processus vaginalis, or entrapping adhesions 1
• Risk factors for ascent include younger age (higher risk under 7 years), presence of a taut or inelastic spermatic cord (56% ascent rate), and associated inguinal hernia 4, 3

Recommended Management Algorithm

Immediate Management (Age 9 Months)

• No surgical intervention is indicated at this time 1, 4
• Document current testicular position, size, and consistency in the medical record 1
• Reassure parents that retractile testicles are common and most resolve spontaneously 4, 2

Ongoing Surveillance Protocol

• Examine testicles for quality and position at each well-child visit (at minimum annually) 1
• Perform examinations in a warm environment with the child relaxed to minimize cremasteric reflex 5
• Specifically assess for:
  • Ability to manually bring testicles into mid-to-lower scrotum without tension 2, 3
  • Testicular size and any asymmetry suggesting atrophy 5, 3
  • Presence of taut or inelastic spermatic cord (high-risk feature) 3
  • Development of inguinal hernia (significantly increases surgical need to 68.8%) 4

Indications for Surgical Referral

Refer to pediatric urology/surgical specialist if any of the following develop during follow-up:

• Testicles ascend and can no longer be manipulated into the scrotum (acquired cryptorchidism) 1
• Progressive decrease in testicular size suggesting atrophy 4, 3
• Development of associated inguinal hernia 6, 4
• Persistent retractile pattern beyond puberty 1, 4

Critical Pitfalls to Avoid

• Do not dismiss retractile testicles as a benign variant requiring no follow-up—approximately one-third may ascend and require surgery 1, 3
• Do not confuse retractile testicles with true undescended testicles—the former can be brought to mid-scrotum without tension, while the latter cannot 2, 3
• Do not delay surgical referral if secondary ascent occurs—these testicles undergo the same progressive germ cell loss as primary undescended testicles after 15-18 months of age 1, 5
• Do not use hormonal therapy (hCG or GnRH)—this is ineffective for retractile testicles and shows poor long-term efficacy even for true cryptorchidism 1

Long-Term Considerations

• Most retractile testicles (approximately 77%) resolve spontaneously by adolescence without surgery 4
• Boys with bilateral involvement who ultimately require orchiopexy face increased infertility risk (38% vs 6% in general population) 1
• Even after spontaneous descent, one case of testicular carcinoma has been reported in a patient with history of retractile testis, suggesting lifelong self-examination after puberty may be prudent 4
• Continue monitoring until clear resolution with stable scrotal position through puberty 1