What are the treatment options for a pediatric or young adult patient with a retractile right testicle that can move into the pelvic floor?

Management of Retractile Testis

A retractile testis that can be manually brought into the scrotum but retracts requires annual monitoring until resolution, not immediate surgery, but carries a 3-14% risk of secondary ascent requiring orchiopexy—particularly if diagnosed before age 2 years or if an inguinal hernia is present. 1, 2

Distinguishing Retractile from True Cryptorchidism

The critical first step is confirming this is truly a retractile testis versus true cryptorchidism:

• A retractile testis can be easily manipulated into the mid-to-lower scrotum without tension and remains there briefly without traction, then retracts due to an overactive cremasteric reflex 3
• True cryptorchidism cannot be manipulated into the scrotum or immediately springs back with any release of traction 3
• Examine the patient in multiple positions (supine, sitting, squatting) with warm hands to minimize cremasteric reflex activation 3
• No imaging (ultrasound, CT, MRI) should be performed, as it provides no actionable information and delays appropriate management 1, 3

Management Strategy for Confirmed Retractile Testis

Observation Protocol

The majority (77-86%) of retractile testes will either remain retractile or spontaneously descend into normal scrotal position by adolescence and do not require surgery 4, 5:

• Annual physical examination by an experienced provider is mandatory to monitor for secondary ascent 1
• Follow-up must continue until the testis maintains stable scrotal position through puberty 2, 4
• Document testicular position and volume at each visit 2

Risk Factors for Secondary Ascent Requiring Surgery

Approximately 3-14% of retractile testes will ascend and require orchiopexy 2, 4, 5:

• Younger age at diagnosis (<2 years) carries significantly higher risk of requiring eventual orchiopexy (p=0.009) 2
• Presence of an associated inguinal hernia dramatically increases surgical risk to 68.8% versus 9.2% without hernia (p<0.001) 4
• A patent processus vaginalis is identified in 68% of cases requiring orchiopexy 5

Indications for Surgical Intervention

Proceed with orchiopexy if any of the following develop during monitoring 2, 4:

• The testis ascends and becomes truly undescended (cannot be manipulated into scrotum) 2, 4
• Progressive decrease in testicular size compared to contralateral testis 2, 4
• Testis remains persistently out of the scrotum despite manipulation 1

Critical Pitfalls and Rare Complications

Even post-pubertal males with a history of retractile testis can experience spontaneous transcanalicular translocation into the abdomen through a patent processus vaginalis, requiring emergency laparoscopic orchiopexy 6. This exceptional case underscores the importance of:

• Counseling patients and families that even resolved retractile testes may rarely ascend later 6
• Instructing patients to perform testicular self-examination after puberty 1
• Maintaining awareness that retractile testis carries a small but documented risk of testicular cancer, even after spontaneous descent 4

Long-Term Surveillance Requirements

All patients with a history of retractile testis require lifelong testicular cancer surveillance 1, 4:

• Men with cryptorchidism history have 3.6-7.4 times higher risk of testicular cancer than the general population 1
• One documented case of testicular carcinoma occurred in a patient with retractile testis after spontaneous descent 4
• Teach monthly testicular self-examination after puberty for early cancer detection 1

When to Refer to Pediatric Urology

Immediate referral is indicated if 1, 3:

• The testis cannot be manipulated into the scrotum (true cryptorchidism, not retractile) 3
• Secondary ascent occurs during monitoring 2, 4
• Testicular volume decreases 2, 4
• Associated inguinal hernia is present 4
• Patient is under 6 months of age with persistent abnormal testicular position 1, 3