Undescended testicle, or cryptorchidism, is a condition where one or both of a male infant’s testicles fail to descend into the scrotum. This common congenital anomaly affects approximately 1-4% of full-term male newborns and up to 30% of premature infants. While the condition often resolves spontaneously within the first few months of life, persistent cryptorchidism necessitates medical intervention due to its potential long-term complications, including infertility and increased risk of testicular cancer.
Anatomy and Physiology of Testicular Descent
The testicles develop in the abdomen of the male fetus and typically descend into the scrotum during the last few months of gestation. This descent is a complex process influenced by hormonal, anatomical, and genetic factors. Key hormones involved include testosterone and anti-Müllerian hormone (AMH), which guide the testicles through the inguinal canal into the scrotum.
Types of Undescended Testicle
Undescended testicles can be classified based on their location:
- Abdominal: The testicle is located within the abdomen.
- Inguinal: The testicle is situated in the inguinal canal. This is the most common location of an undescended testicle.
- Pre-scrotal: The testicle is near the scrotum but not fully descended.
- Ectopic: The testicle has deviated from the normal path of descent and is located in an abnormal position, such as the perineum or thigh.
Causes and Risk Factors
The etiology of cryptorchidism is multifactorial, involving genetic, environmental, and maternal factors. Some of the known risk factors include:
- Prematurity: Premature infants have a higher incidence of undescended testicles.
- Low Birth Weight: Infants with low birth weight are at increased risk.
- Family History: A family history of cryptorchidism or other genital anomalies.
- Maternal Health: Conditions such as diabetes or smoking during pregnancy can increase the risk.
- Hormonal Disorders: Hormonal imbalances during pregnancy can affect the descent process.
Diagnosis
Clinical Examination
The initial diagnosis of an undescended testicle is usually made through a physical examination. Pediatricians or pediatric urologists palpate the scrotum to determine the presence and position of the testicles. In some cases, the testicle may be retractile, meaning it can move back and forth between the scrotum and the groin. This is different from true cryptorchidism and often does not require treatment.
Imaging Studies
When a testicle is not palpable, imaging studies may be necessary. Ultrasonography is commonly used due to its non-invasive nature and ability to detect inguinal testicles. However, its effectiveness in locating abdominal testicles is limited. In these cases, an MRI can be useful to locate the testicle.
Hormonal Tests
In certain cases, hormonal tests might be indicated to evaluate testicular function and the presence of testicular tissue. Measurement of serum testosterone, luteinizing hormone (LH), and follicle-stimulating hormone (FSH) can be useful in ambiguous cases.
Laparoscopy
Laparoscopy is considered the gold standard for diagnosing non-palpable testicles. This minimally invasive procedure allows direct visualization of the abdominal cavity and identification of the testicle’s location. Laparoscopy can also be therapeutic, allowing for simultaneous surgical correction.
Treatment
Watchful Waiting
In neonates, there is a possibility of spontaneous descent within the first six months of life. Therefore, initial management may involve a period of watchful waiting, particularly in preterm infants.
Hormonal Therapy
Hormonal therapy, using human chorionic gonadotropin (hCG) or gonadotropin-releasing hormone (GnRH), has been explored as a treatment option. These hormones can stimulate testicular descent by mimicking the physiological hormonal surges that occur during normal testicular descent. However, the success rate of hormonal therapy is variable, and it is generally not the first-line treatment.
Surgical Intervention
Orchidopexy
Orchidopexy is the primary surgical treatment for undescended testicles. The procedure involves mobilizing the testicle and securing it within the scrotum. Orchidopexy is recommended between 6 and 18 months of age to optimize testicular function and reduce the risk of malignancy.
The surgical approach can vary depending on the location of the undescended testicle:
- Inguinal Orchidopexy: For inguinal and pre-scrotal testicles, an incision is made in the groin, and the testicle is mobilized and fixed in the scrotum.
- Laparoscopic Orchidopexy: For non-palpable testicles, laparoscopy is used to locate and mobilize the testicle. If the testicle is found in the abdomen, it is brought down into the scrotum in a staged procedure if necessary.
Fowler-Stephens Procedure
In cases where the testicle has a short spermatic cord, the Fowler-Stephens procedure may be used. This technique involves ligating the testicular vessels in a first stage to encourage collateral blood supply from the cremasteric artery and then, in a second stage, mobilizing the testicle to the scrotum.
Postoperative Care
Postoperative care involves monitoring for complications such as hematoma, infection, and testicular atrophy. Follow-up appointments are crucial to assess the position and size of the testicle and ensure normal development. Long-term follow-up into adulthood is recommended to monitor fertility potential and screen for testicular malignancies.
Complications and Long-Term Outcomes
Infertility
Undescended testicles are associated with impaired spermatogenesis, especially if left untreated beyond the recommended age for orchiopexy. This is because of exposure to excessive heat from the malposition of testes. Early surgical intervention can significantly improve fertility outcomes, but bilateral cryptorchidism poses a higher risk for infertility.
Testicular Cancer
Men with a history of undescended testicles have an increased risk of testicular cancer, particularly seminoma. The risk remains elevated even after surgical correction, underscoring the importance of regular self-examinations and follow-up with healthcare providers.
Psychological Impact
Cryptorchidism can have psychological effects due to concerns about body image and sexual development. Early diagnosis and treatment can help mitigate these effects and support normal psychosocial development.
Recent Advances and Research
Recent research has focused on the genetic and molecular mechanisms underlying cryptorchidism. Studies have identified various genetic mutations and polymorphisms associated with the condition, offering potential targets for future therapeutic interventions . Additionally, advances in minimally invasive surgical techniques, such as robot-assisted laparoscopy, are improving outcomes and reducing recovery times for patients .
Conclusion
Undescended testicle is a common congenital condition that requires timely diagnosis and appropriate management to prevent long-term complications. While the condition can sometimes resolve spontaneously, persistent cases necessitate intervention, typically through surgical orchiopexy. Early treatment not only improves fertility outcomes but also reduces the risk of malignancy. Ongoing research continues to enhance our understanding of the condition, paving the way for improved diagnostic and therapeutic strategies. Regular follow-up and patient education remain critical components of comprehensive care for individuals with a history of cryptorchidism.
Best Hospital for Undescended Testes Treatment in Jaipur, Rajasthan – Institute of Urology, C Scheme
The Institute of Urology stands at the forefront of urological care, distinguished by its cutting-edge
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minimally invasive surgical techniques, the Institute of Urology offers unparalleled medical
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We have also started the facility of online consultation so that you can discuss about your problems in detail with our experts from the comfort of your home. Please remember to keep ready all the investigations that you’ve had done so far so that it is helpful for the specialist to guide you precisely about the next course of action. At Institute of Urology, we strictly abide by the International protocols so that we keep up with the latest and best of what the advancements in the medical field has to offer.
Our doctors can be reached Monday to Saturday during working hours.
Dr. M. Roychowdhury – 9929513468/ 9829013468
Dr. Rajan Bansal – 8601539297
References
- Hutson, J. M., & Balic, A. (2008). Embryology of the human male descent of the testis: the gubernaculum and transabdominal descent. Early Human Development, 84(2), 81-89.
- Barthold, J. S., & González, R. (2003). The epidemiology of congenital cryptorchidism, testicular ascent and orchiopexy. The Journal of Urology, 170(6), 2396-2401.
- Braga, L. H., Lorenzo, A. J., & Salle, J. L. P. (2009). Laparoscopic versus open orchiopexy for non-palpable undescended testes: a prospective comparative study. Journal of Pediatric Urology, 5(4), 320-324.
