Lecture
2-week-old with empty scrotum
Patient will present as → a one-year-old child who is brought to your office for his 12-month visit. You note that the boy's testicles are inappreciable on the exam. The medical record reports that the child's testicles had been examined at two previous visits. The mother is concerned and asks if her son will need surgery.
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Cryptorchidism is the failure of testes to descend - undescended testicle - (one or both)
- ↑ Risk in premature infants 30% vs. 5% in full-term infants
- Cryptorchidism is most common in the right testicle
- If not descended by 4-6 months and before he is 12 months old, surgery (orchiopexy) should be performed
- Complications of undescended testes are testicular cancer (in both descended and undescended testes) or infertility (which occurs in up to 75% of male children with bilateral cryptorchidism and in 50% of male children with unilateral cryptorchidism)
Thorough GU exam, including an attempt to "milk" inguinally located testes into the scrotum
- If one or both testes are palpable in the scrotum or inguinal canal, re-examine at the next well-child exam
- If neither testes are palpable at birth, obtain an ultrasound and karyotype promptly
Undescended testes can be monitored for spontaneous descent over the first 4-6 months of life
- If still non-palpable at 4-6 mo well-child exam, refer to urology/surgery for evaluation and possible orchiopexy
- For absent testes, strongly consider a consultation with a specialist regarding labs for CAH
- Complications of undescended testes include malignancy, subfertility, and testicular torsion. Therefore, the American Urologic Association suggests that these patients should perform monthly testicular self-examinations during adolescence
Surgical correction of cryptorchidism, or orchiopexy, is ideally performed between 4 to 12 months of age to optimize testicular growth, fertility potential, and reduce the risk of complications like testicular cancer and torsion. Spontaneous descent is rare after four months, and earlier intervention improves outcomes. Surgery should be completed by two years of age if not performed earlier. – UpToDate
Testicles after undescended testicle surgery
Question 1 |
A 6-month-old boy is brought to the pediatrician for a well-child visit. Physical examination fails to palpate testes in the scrotum. Which of the following is the most appropriate next step in the management of this patient?
Immediate surgical referral for orchiopexy Hint: Indicated after confirming the presence and location of the testes, especially if they are palpable or identified on ultrasound. | |
Observation until the child reaches puberty Hint: Inappropriate, as delayed treatment can lead to impaired fertility and increased risk of malignancy. | |
Hormonal therapy with human chorionic gonadotropin (hCG) Hint: May be considered in some cases to induce testicular descent but is not the first-line approach. | |
Ultrasound of the inguinal region and abdomen | |
Reassurance and discharge without further action Hint: Inappropriate due to the potential complications associated with untreated cryptorchidism. |
Question 1 Explanation:
Ultrasound of the inguinal region and abdomen is the most appropriate next step for a child with non-palpable testes. This imaging can help locate the testes, distinguishing between cryptorchidism and anorchia (absence of testes), and guide further management.
Question 2 |
What is the recommended age for surgical intervention in a child with palpable, undescended testes?
Soon after birth Hint: While early diagnosis is important, immediate surgery is not typically performed to allow time for possible spontaneous descent in the first few months of life. | |
By 6 months of age Hint: Just before this age is when intervention is considered, with the optimal window being shortly thereafter. | |
Between 6 to 12 months of age | |
Between 12 to 18 months of age Hint: Waiting beyond the first year of life may increase the risk of subfertility and malignancy. | |
After 2 years of age Hint: Delayed correction of cryptorchidism is associated with a higher risk of infertility and malignancy. |
Question 2 Explanation:
Surgical intervention for cryptorchidism, typically an orchiopexy, is recommended between 6 to 12 months of age. This timing balances the risk of anesthesia in very young infants with the benefits of early surgery for normal testicular development, reduced risk of infertility, and reduced risk of testicular cancer.
Question 3 |
Which of the following is a known risk factor for cryptorchidism?
Advanced maternal age Hint: Advanced maternal age is not a recognized risk factor for cryptorchidism. | |
Gestational diabetes Hint: Gestational diabetes has not been found to increase the risk of cryptorchidism. | |
Low birth weight Hint: Low birth weight in isolation does not increase cryptorchidism risk. | |
Multiparity Hint: Multiparity does not increase the risk of cryptorchidism compared to nulliparity. | |
Preterm birth |
Question 3 Explanation:
Preterm birth is a known risk factor for cryptorchidism in newborn males (30% vs. 5% in full-term infants). The shorter gestation may interrupt normal testicular descent.
There are 3 questions to complete.
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References: Merck Manual · UpToDate