In a 19‑month‑old boy with a non‑palpable right testicle and a mobile left testicle, ultrasound shows normal testicular echotexture with both testes able to slide into the scrotum, what is the recommended management?

Management of Retractile Testes in a 19-Month-Old

This child has retractile testes (not cryptorchidism) and requires annual monitoring only—no surgery is indicated at this time. 1

Clinical Reasoning Based on Examination and Ultrasound Findings

The ultrasound findings are diagnostic and reassuring:

• Both testes demonstrate normal echotexture 2
• Both testes were visualized sliding up and down the lower inguinal canal region 2
• Final images showed both testes side-by-side in the scrotal area 2
• The left testis is palpable and mobile on examination 1

These findings confirm retractile testes, not true cryptorchidism. 1 The key distinguishing feature is that retractile testes can be manipulated into the scrotum and remain there without traction, which is exactly what the ultrasound demonstrated when both testes were visualized in the scrotal area. 1, 3

Why Surgery Is Not Indicated Now

True cryptorchidism requires surgical referral when the testis cannot be manipulated into the scrotum and kept there without traction at 15 months of age. 1 However, this child's ultrasound definitively shows both testes can descend into the scrotum spontaneously. 2, 3

The ultrasound was actually unnecessary according to guidelines—the American Urological Association recommends against ordering imaging studies as they rarely assist in decision-making and have only 45% sensitivity and 78% specificity for localizing non-palpable testes. 2, 3 However, since it was already performed for another indication (liver lesion follow-up), the findings are helpful in confirming the diagnosis.

Required Management: Annual Monitoring

The American Urological Association mandates annual assessment of testicular position at well-child visits to monitor for secondary ascent (acquired cryptorchidism). 2, 1 This is critical because:

• Retractile testes carry a 2-45% risk of becoming truly undescended during childhood (secondary ascent) 1
• This risk is mechanistically related to hyperactive cremasteric reflex, foreshortened patent processus vaginalis, or entrapping adhesions 2, 1
• Germ cell damage begins after 15-18 months if true cryptorchidism develops 1

What to Monitor at Each Annual Visit

At each well-child visit, perform examination in a warm room with warm hands to minimize cremasteric reflex activation: 3

• Examine the child in multiple positions (supine, sitting, squatting) 3
• Attempt to manipulate each testis into the scrotum 3
• Observe whether each testis remains in the scrotum without traction 1, 3

If at any future visit the testis cannot be manipulated into the scrotum and kept there without traction, immediately refer to pediatric urology/surgical specialist for orchiopexy. 1, 3

Timing of Intervention If Secondary Ascent Occurs

If secondary ascent is detected during monitoring, surgery should be performed by 18 months of age (or as soon as possible if detected after 18 months) to preserve fertility potential and reduce cancer risk. 1, 4 Orchiopexy performed before puberty decreases the risk of testicular cancer 2-6 fold compared to postpubertal surgery. 2, 1

What NOT to Do

Do not use hormonal therapy (hCG or GnRH). 2, 1 Evidence shows low response rates (6-38% success) and lack of long-term efficacy. 2, 1

Do not order repeat ultrasounds for monitoring. 2, 3 Clinical examination is sufficient and more reliable than imaging for detecting secondary ascent. 2, 3

Long-Term Counseling Points for Parents

Even though surgery is not needed now, counsel the parents that: 2

• Annual monitoring must continue throughout childhood until puberty 2, 1
• If secondary ascent occurs and requires surgery, the child will need lifelong surveillance for testicular cancer with relative risk 2.75-8 times higher than the general population 1
• After puberty, teach the child monthly testicular self-examination for early cancer detection 2

Common Pitfall to Avoid

Failing to distinguish retractile from truly undescended testes leads to unnecessary surgery. 3 The ultrasound in this case definitively confirmed retractile testes by visualizing both testes in the scrotum, which would not occur with true cryptorchidism. 2, 3