What are the potential causes and management options for a physically active male of reproductive age with a right testicle that ascends to the pelvic floor during activity?

Management of Testis Ascending to Pelvic Floor During Activity

This patient has acquired cryptorchidism (secondary ascent), which requires urgent surgical referral for orchiopexy to prevent irreversible germ cell damage, preserve fertility potential, and reduce cancer risk. 1

Understanding the Condition

This is not a retractile testis—a truly retractile testis can be easily manipulated into the scrotum and remains there without traction. 1 Your patient's testis ascends to the pelvic floor and cannot be kept in the scrotum, which defines acquired cryptorchidism (secondary ascent). 1 This represents a previously descended testis that has now become truly undescended, mechanistically related to hyperactive cremasteric reflex, foreshortened patent processus vaginalis, or entrapping adhesions. 1

Immediate Action Required

Refer immediately to a pediatric urologist or pediatric surgeon for orchiopexy. 1, 2 The American Academy of Pediatrics is clear: if the testis cannot be manipulated into the scrotum and kept there without traction, surgical referral is mandatory. 1

Critical Timing

• Orchiopexy should be performed by 18 months of age to preserve fertility potential and reduce cancer risk. 3, 1, 2, 4
• Germ cell damage begins after 15-18 months, with progressive loss of fertility potential thereafter. 1
• Imaging studies (ultrasound, CT, MRI) should NOT be ordered prior to referral—they rarely assist in decision-making and delay definitive treatment. 1, 2

Long-Term Risks Without Treatment

Fertility Impact

• Even unilateral cryptorchidism affects the contralateral descended testis, causing smaller volume, softer consistency, and reduced markers of future fertility potential. 3
• Paternity rates with unilateral cryptorchidism approach normal if treated appropriately, but bilateral cases have only 35-53% paternity rates. 3

Cancer Risk

• Men with cryptorchidism have a 3.6-7.4 times higher risk of germ cell tumors compared to the general population. 3
• Lifetime risk of testicular tumor is 2-6%. 3, 2
• Orchiopexy performed before puberty reduces testicular cancer risk 2-6 fold compared to postpubertal surgery, though risk remains elevated even after early surgery. 3, 2

Additional Complications

• Increased risk of testicular torsion. 3
• Higher risk of hypogonadism in adulthood. 3
• Associated inguinal hernia. 3

Surgical Approach

• Standard inguinal orchiopexy is the definitive treatment with the highest success rate. 3, 2
• For low inguinal testes, a prescrotal approach may be effective with reduced surgical time and equivalent success rates. 4
• Hormonal therapy with hCG or GnRH is NOT recommended—meta-analyses show poor success rates (6-38%) and lack of long-term efficacy. 3, 1

Post-Operative Surveillance

Even after successful orchiopexy, lifelong surveillance is mandatory: 1, 2

• Regular monitoring of testicular position and development throughout childhood and adolescence. 2
• Patient education on testicular self-examination due to persistently elevated cancer risk. 3, 2
• Counseling regarding potential fertility implications, particularly if bilateral involvement. 3, 2

Common Pitfall to Avoid

Do not adopt a "wait and see" approach hoping for spontaneous descent—data do not support monitoring until adolescence. 4 Retractile testes carry a 2-45% risk of becoming truly undescended during childhood, and once secondary ascent occurs, prompt orchiopexy is required. 1 The window for preventing irreversible germ cell damage closes rapidly after 18 months. 1, 4