What is the appropriate evaluation and management for an 8-month-old male infant with testicular retraction?

Management of Testicular Retraction in an 8-Month-Old

An 8-month-old with testicular retraction requires careful physical examination to distinguish between retractile testes (which can be manipulated into the scrotum and remain there without traction) versus true cryptorchidism, followed by annual monitoring if retractile, as no immediate intervention is needed at this age. 1

Initial Evaluation

Physical Examination Technique

• Examine the infant in a warm room with warm hands to minimize cremasteric reflex activation 2, 1
• Attempt to manipulate each testis into the scrotum and observe whether it remains there without traction 1
• If the testis can be manipulated into the scrotum and stays there without tension, this is a retractile testis 2, 1
• If the testis cannot be manipulated into the scrotum or immediately retracts despite gentle traction, this represents true cryptorchidism requiring different management 1

Critical Distinction: Bilateral Nonpalpable Testes

• If both testes are completely nonpalpable, immediate specialist consultation is mandatory to rule out disorders of sex development, particularly life-threatening congenital adrenal hyperplasia 2, 3
• A phenotypic male with bilateral nonpalpable gonads may be a genetic female (46 XX) with congenital adrenal hyperplasia until proven otherwise 2

Imaging Is Not Indicated

• Do not order ultrasound or other imaging studies, as they rarely assist in decision-making and have poor sensitivity (45%) and specificity (78%) for nonpalpable testes 2, 4

Management Based on Findings

If Retractile Testes Are Confirmed

• No immediate intervention is required at 8 months of age 1
• Institute annual monitoring at well-child visits to assess for secondary ascent (acquired cryptorchidism) 2, 1
• The risk of secondary ascent ranges from 2-45% during childhood, mechanistically related to hyperactive cremasteric reflex, foreshortened patent processus vaginalis, or entrapping adhesions 2, 1, 5, 6, 7, 8
• Research shows younger age at diagnosis (mean 1.3 years) is associated with higher risk of requiring eventual orchiopexy compared to older children (mean 4.3 years) 6

If True Cryptorchidism Is Present

• Refer to pediatric urology or pediatric surgery if the testis cannot be manipulated into the scrotum and kept there without traction 1, 3
• For cryptorchidism detected at birth, referral should occur by 6 months (corrected for gestational age) if spontaneous descent has not occurred 3
• Orchiopexy should ideally be performed by 18 months to preserve fertility potential, as germ cell damage begins after 15-18 months 1, 3

Monitoring Protocol for Retractile Testes

Annual Assessment Should Include:

• Testicular position: Can each testis be manipulated into the scrotum and remain there? 2, 1
• Testicular size: Compare both testes for symmetry 6, 8
• Spermatic cord characteristics: A taut or inelastic cord increases risk of ascent (56% vs 32% overall) 8
• Presence of inguinal hernia: Associated hernias increase orchiopexy risk to 68.8% compared to 9.2% without hernia 5

Red Flags Requiring Surgical Referral:

• Testis that previously could be manipulated into scrotum now cannot (secondary ascent) 1, 6, 8
• Testis cannot be kept in scrotum without traction at 15 months of age 1
• Decreasing testicular size on serial examinations 5, 6

Treatment Considerations

What NOT to Do:

• Do not use hormonal therapy (hCG or GnRH) as evidence shows low response rates (6-38%) and lack of long-term efficacy 2, 1
• Do not perform imaging studies prior to specialist referral 2, 4

Long-Term Outcomes:

• Most retractile testes (77.3%) have spontaneously favorable evolution and do not require surgery by age 14 5
• Research shows 30-45% of retractile testes eventually descend and become nonretractile, 32-40% remain retractile, and 14-32% ascend requiring orchiopexy 5, 6, 8
• Even if testes descend normally, lifelong surveillance for testicular cancer is recommended, as one case of testicular carcinoma has been reported in a patient with previously retractile testis 5

Common Pitfalls to Avoid

• Failing to distinguish retractile from truly undescended testes leads to unnecessary imaging and delayed appropriate management 2, 1
• Assuming retractile testes are benign without instituting annual monitoring misses 14-32% who develop secondary ascent 6, 8
• Ordering ultrasound wastes resources and provides no actionable information in most cases 2, 4
• Missing bilateral nonpalpable testes as a potential disorder of sex development can result in life-threatening adrenal crisis 2, 3