Management of Retractile Testes in a 9-Month-Old
For a 9-month-old with retractile testes (testes that can be easily manipulated into the scrotum and remain there without traction), no surgical intervention is needed at this time—only annual monitoring is required to detect secondary ascent. 1, 2
Immediate Assessment
First, confirm the diagnosis through proper examination:
- Examine in a warm room with warm hands to minimize cremasteric reflex activation 3
- The key distinguishing feature: A retractile testis can be easily manipulated into the scrotum and stays there without traction, unlike true undescended testes 3
- If the testis cannot be manipulated into the scrotum or immediately retracts when released, this is true cryptorchidism requiring urgent referral 2, 3
Why Retractile Testes Don't Need Immediate Surgery
At 9 months of age, retractile testes represent a hyperactive cremasteric reflex pulling the testis upward, not arrested testicular descent 3. The critical germ cell damage that occurs with true cryptorchidism begins after 15-18 months of age 1, 2, so there is no urgency for intervention in truly retractile testes at this age.
Required Monitoring Protocol
Annual assessment is mandatory because retractile testes carry a 2-45% risk of secondary ascent (becoming truly undescended) during childhood 1, 3. This ascent is mechanistically related to hyperactive cremasteric reflex, foreshortened patent processus vaginalis, or entrapping adhesions 1, 3.
At each annual well-child visit:
- Assess whether the testis can still be manipulated into the scrotum and remains there without traction 1, 3
- If at 15 months or later the testis cannot be manipulated into the scrotum and kept there without traction, immediate surgical referral is required 3
When to Refer for Surgery
Refer immediately to a pediatric urologist or pediatric surgeon if:
- The testis cannot be manipulated into the scrotum at any examination 2, 3
- The testis retracts immediately when released (cannot stay in scrotum without traction) 3
- Secondary ascent is detected at any follow-up visit 3
Timing of orchiopexy if secondary ascent occurs: Surgery should be performed by 18 months of age to preserve fertility potential and reduce cancer risk 2, 3
Common Pitfalls to Avoid
- Do not order imaging studies (ultrasound or other modalities)—they rarely assist in decision-making and should not delay referral if true cryptorchidism is suspected 2, 3
- Do not use hormonal therapy (hCG or GnRH)—evidence shows low response rates (6-38% success) and lack of long-term efficacy 1
- Do not assume retractile testes are benign and stop monitoring—the 2-45% risk of secondary ascent requires lifelong surveillance through childhood 1, 3
- Do not delay referral if the testis becomes truly undescended—germ cell damage begins after 15-18 months, with 40% of bilateral cryptorchid boys lacking germ cells by 8-11 years of age 1, 2
Long-term Considerations
Even if the testis remains retractile and never requires surgery, boys with a history of retractile testes who develop secondary ascent and undergo orchiopexy will need lifelong surveillance for testicular cancer, with a relative risk 2.75-8 times higher than the general population (though prepubertal orchiopexy reduces this risk 2-6 fold compared to postpubertal surgery) 3.