Treatment of Partial Undescended Testis in Pediatric Patients
Surgical orchidopexy performed between 6-18 months of age is the definitive treatment for partial undescended testis, with referral to a pediatric urologist or pediatric surgeon by 6 months (corrected for gestational age) if the testis remains undescended. 1
Optimal Timing for Surgical Intervention
The critical window for surgical correction is narrow and evidence-based:
- Orchidopexy must be performed between 6-18 months of age, with 18 months being the absolute latest recommended time to preserve fertility potential and reduce cancer risk 1
- Referral to a surgical specialist should occur by 6 months of corrected gestational age if the testis has not descended spontaneously 1
- After 6 months of age, spontaneous descent is highly unlikely and continued delay causes progressive testicular damage 1
Why Early Intervention Matters
The rationale for this timing is based on irreversible pathological changes:
- Germ cell degeneration begins after 15-18 months of age in cryptorchid testes 1, 2
- By 8-11 years of age, approximately 40% of bilateral cryptorchid boys have complete absence of germ cells on testicular biopsy 1
- Prepubertal orchidopexy reduces testicular cancer risk by 2-6 fold compared to postpubertal surgery 1, 2
- Even early orchidopexy does not eliminate cancer risk entirely—these patients still have 2.75-8 times higher risk than the general population 2
Surgical Approach
Surgery is the only effective treatment—medical therapy with hormones should not be used. 3
Surgical Technique Based on Testicular Position
- For palpable testes: Scrotal or inguinal orchidopexy should be performed, with success rates exceeding 96% and testicular atrophy occurring in less than 2% of cases 1
- For non-palpable testes: Surgical exploration with identification of testicular vessels is necessary to determine the appropriate intervention 1
Why Hormonal Therapy Fails
Meta-analyses demonstrate that medical treatment with gonadotropin-releasing hormone (GnRH) and human chorionic gonadotropin (hCG) have poor success rates of only 6-38% with no long-term efficacy 3, 2. The European Association of Urology guidelines explicitly state that surgical treatment is the most effective approach 3.
Important Clinical Considerations
What NOT to Do
- Do not order ultrasound or other imaging studies prior to specialist referral—these rarely assist in decision-making and only delay appropriate surgical intervention 1, 2
- Do not attempt hormonal therapy—the evidence clearly shows it is ineffective 3, 2
- Do not delay referral beyond 6 months of age—this is a critical error that compromises fertility outcomes 1
Bilateral Non-Palpable Testes: A Medical Emergency
If both testes are completely non-palpable in a newborn, this requires immediate specialist consultation to evaluate for disorders of sex development, particularly life-threatening congenital adrenal hyperplasia 1, 2. A genetic female (46,XX) with congenital adrenal hyperplasia can present with male-appearing genitalia and bilateral non-palpable testes, and without rapid diagnosis can develop shock with dangerously abnormal electrolytes 1.
Long-Term Counseling Requirements
Parents and patients must understand the lifelong implications:
- Paternity rates: Men with unilateral cryptorchidism have near-normal paternity rates, but those with bilateral cryptorchidism have only 35-53% paternity rates 3
- Cancer risk: The risk of testicular cancer is 3.6-7.4 times higher than the general population, with 2-6% of men with cryptorchidism history developing testicular tumors 3
- Lifelong surveillance: Even after successful orchidopexy, these patients require regular testicular self-examinations and monitoring for malignancy 3, 2
- Hypogonadism risk: Men with cryptorchidism may be at higher risk of testosterone deficiency 3
Contralateral Testis Considerations
Even in unilateral cryptorchidism, the contralateral descended testis may have structural abnormalities including smaller volume, softer consistency, and impaired fertility markers 3. This implies that unilateral cryptorchidism may represent a bilateral testicular disorder, and counseling should reflect this 3.
Special Situations
Postpubertal Presentation
For postpubertal males with cryptorchidism and a normal contralateral testis, orchiectomy may be more appropriate than orchidopexy due to the high risk of germ cell neoplasia in situ (GCNIS) 3, 1. Multiple biopsies should be performed at the time of any orchidopexy in adults to exclude GCNIS 3.
Associated Conditions
Examine for inguinal hernia, which is one of the main reasons for treatment alongside fertility and cancer concerns 4. The presence of hypospadias or other phallic anomalies with cryptorchidism should prompt evaluation for disorders of sex development 4.