Undescended Testicle

Approximately 30% of preterm male infants have an undescended testis. Spontaneous descent into the scrotum usually occurs in the ensuing 3 to 6 postnatal months. Orchiopexy, a surgical procedure to place a testis in the scrotum, is indicated for a testis that fails to descend by 6 months of age and usually is performed at 9 to 15 months of age. Histologic changes representing degeneration of the seminiferous tubules that decreases the quality and quantity of spermatogenesis can be seen at 6 to 12 months of age and are progressive. The longer the testis remains in a location other than the scrotum, the greater the fertility impairment. Accordingly, observation until age 2 years is not appropriate. Orchiopexy improves fertility but does not change the malignancy risk. Ten percent of all testicular tumors occur in patients who have an undescended testicle. The relocated testis continues to have a malignancy potential that is 35 to 48 times greater than a normal testis. However, the contralateral testis in these patients also has an increased malignancy risk. Orchiopexy places the testis in a location that facilitates examination and early detection of a mass or torsion. Counseling should include recommendations to obtain immediate medical assessment of acute testicular pain. Parents or older patients should be instructed to perform monthly examination of both testes.

Neither human chorionic gonadotropin nor testosterone has been effective in treating undescended testes. A radionuclide scan of the testis has nothing to offer in the assessment and management of a palpable or nonpalpable undescended testis. Imaging studies are frequently not successful in localizing a nonpalpable testis. Laparoscopy is the most reliable method.

Retractile testes that result from a brisk cremasteric reflex most often are bilateral and may be found in children older than l year of age (most commonly between ages 5 and 6 years). Frequently, these testes can be reduced gently by milking the retracted testes into the scrotum. Placing the patient in a relaxed, frog-leg position in a warm room enhances the success of the procedure. The examiner places gentle pressure on the upper inguinal canal with the thumb and finger of one hand and uses the other hand to manipulate the testes.

Virilization of the female infant associated with the absence of testes suggests congenital adrenal hyperplasia. Palpation of inguinal masses in a female infant suggests testicular feminization syndrome.

The finding of cryptorchidism with a midpenile proximal hypospadias suggests an intersex disorder and the need for karyotyping. Karyotyping should be considered in any infant who has ambiguous genitalia.
Elder JS. Disorders and anomalies of the scrotal contents. In: Behrman RE, Kliegman RM, Jenson HB, eds. Nelson Textbook of Pediatrics. 16th ed. Philadelphia, Pa: WB Saunders Co; 2000:1650-1651
Pillai SB, Besner GE. Pediatric testicular problems. Pediatr Clin North Am. 1998;45:813-830