In a newborn or infant a few months old with a palpable undescended testis in the inguinal canal, should immediate orchiopexy be performed or can surgery be delayed until age 2 years?

Management of Palpable Undescended Testis in Newborns and Infants

Do not perform immediate surgery; wait until 6 months of age to allow for spontaneous descent, then refer for orchiopexy to be performed between 6-18 months of age, ideally before 18 months. 1

Initial Management Strategy (Birth to 6 Months)

Observation is appropriate during the first 6 months of life because spontaneous testicular descent can occur during this period, though it becomes unlikely after 6 months of corrected gestational age. 1 This waiting period is particularly important for premature infants, who have much higher rates of undescended testes (15-30% versus 1-3% in full-term infants) and greater potential for spontaneous descent. 1

Key Actions During Observation Period:

• Examine the infant in a warm room with warm hands to minimize cremasteric reflex activation 2
• Palpate testes for quality and position at each well-child visit 1
• Correct for gestational age when determining the 6-month timeline 1
• Do not order imaging studies (ultrasound or other modalities) as they have poor sensitivity (45%) and specificity (78%) and rarely assist in decision-making 2, 3

Timing of Surgical Referral and Intervention

Refer to a pediatric urologist or pediatric surgeon by 6 months of corrected age if the testis remains undescended, as spontaneous descent after this point is highly unlikely. 1 The rationale for this early referral is to facilitate timely surgical intervention while minimizing continued testicular damage. 1

Orchiopexy should be performed between 6-18 months of age, with 18 months being the absolute latest recommended time. 1 This timing is critical because:

• Germ cell damage begins after 15-18 months of age 1, 2
• By 8-11 years, approximately 40% of bilateral cryptorchid boys have no germ cells in testicular biopsies 1
• Prepubertal orchiopexy results in a 2- to 6-fold reduction in testicular cancer risk compared with postpubertal surgery 1, 2

Why Waiting Until Age 2 Years Is Inappropriate

Delaying surgery until 2 years of age is outdated and harmful because irreversible germ cell loss begins at 15-18 months. 1, 2 This delay compromises both fertility potential and increases long-term cancer risk. The evidence overwhelmingly supports intervention before 18 months, making a 2-year timeline unacceptable by current standards. 1, 4, 5, 6

Surgical Approach for Palpable Inguinal Testis

For a palpable testis in the inguinal canal, scrotal or inguinal orchiopexy should be performed with success rates exceeding 96% and testicular atrophy occurring in less than 2% of cases. 1 Some surgeons advocate for a prescrotal approach for low inguinal testes, which reduces surgical time and patient discomfort with equivalent success rates. 4

Concurrent Hernia Repair:

More than 90% of boys with undescended testes have a patent processus vaginalis, creating both the pathway for inguinal hernia and arrested testicular descent. 7 All inguinal hernias require concurrent surgical repair during orchiopexy to prevent bowel incarceration and gonadal infarction. 7

Critical Pitfalls to Avoid

• Never delay referral beyond 6 months of corrected age 1
• Never order unnecessary imaging studies prior to specialist referral 1, 2, 3
• Never use hormonal therapy (hCG or GnRH) as evidence shows low success rates (6-38%) and lack of long-term efficacy 2, 3
• Never wait until age 2 years as this exceeds the window for optimal fertility preservation 1, 2

Special Emergency Consideration

If both testes are nonpalpable, this requires immediate specialist consultation to rule out disorders of sex development, particularly life-threatening congenital adrenal hyperplasia. 1, 3 A baby with bilateral nonpalpable testes could be a genetic female (46,XX) with congenital adrenal hyperplasia, which can cause shock and life-threatening electrolyte abnormalities. 1

Long-term Counseling

Parents should be counseled that even with successful orchiopexy performed at the optimal time, the child will require lifelong surveillance for testicular cancer, with a relative risk 2.75-8 times higher than the general population. 2 After puberty, monthly testicular self-examination should be taught. 2