What is the recommended management for a 9-month-old male with bilateral retractable testicles?

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

A 9-month-old with bilateral retractable testicles requires annual monitoring only—no immediate intervention is needed at this age, as retractile testes can be easily manipulated into the scrotum and remain there without traction, distinguishing them from true cryptorchidism. 1

Immediate Assessment

At 9 months of age, the key diagnostic maneuver is to confirm these are truly retractile rather than undescended testicles:

• The testicles must be easily manipulated into the scrotum AND remain there without traction to qualify as retractile 1
• If the testicles cannot be manipulated into the scrotum or do not stay there without holding them in place, these are undescended (cryptorchid) testicles requiring immediate surgical referral 1
• The testicles should be palpable in the inguinal canal when retracted, which is characteristic of retractile testis 1

Management Algorithm for Confirmed Retractile Testicles

No Immediate Intervention Required

• At 9 months, there is no urgency for surgical intervention in truly retractile testes because the critical germ cell damage that occurs with true cryptorchidism begins after 15-18 months of age 1
• Hormonal therapy (hCG or GnRH) should not be used, as evidence shows low response rates (6-38% success) and lack of long-term efficacy 1

Mandatory Annual Surveillance

The cornerstone of management is annual monitoring to detect secondary ascent (acquired cryptorchidism):

• Assess testicular position at least annually at well-child visits 1
• Retractile testes carry a 2-45% risk of becoming truly undescended during childhood due to hyperactive cremasteric reflex, foreshortened patent processus vaginalis, or entrapping adhesions 1
• This monitoring should continue throughout childhood, as acquired cryptorchidism can occur at any point 1

Critical Decision Point: When to Refer for Surgery

If at any follow-up visit (particularly at or after 15 months), the testicles cannot be manipulated into the scrotum and kept there without traction, immediate referral to a pediatric urologist or pediatric surgeon is required 1:

• Surgery (orchiopexy) should ideally be performed by 18 months to preserve fertility potential 1
• Germ cell damage begins after 15-18 months, with progressive loss of fertility potential 1
• Prepubertal orchiopexy reduces testicular cancer risk 2-6 fold compared to postpubertal surgery 1

Important Pitfalls to Avoid

• Do not order imaging studies (ultrasound or other modalities), as they rarely assist in decision-making for retractile testes 1
• Do not confuse retractile testes with true undescended testes—the ability to manipulate and maintain the testis in the scrotum without traction is the key distinguishing feature 1
• Do not delay referral if secondary ascent is detected, as the window for optimal surgical intervention closes at 18 months 1, 2

Long-Term Considerations

Even if the testicles remain retractile and never require surgery, counsel parents that:

• Annual monitoring must continue throughout childhood to detect late secondary ascent 1
• If orchiopexy becomes necessary, the child will need lifelong surveillance for testicular cancer, with a relative risk 2.75-8 times higher than the general population 1