Undescended Testis in Children

Introduction to Undescended Testis in Children

Undescended testis, also known as cryptorchidism, is a common congenital anomaly in which one or both testes fail to descend into the scrotum by birth or within the first few months of life.

Epidemiology

Incidence: 3-5% in full-term newborns, up to 30% in premature infants
Bilateral in 10-20% of cases
Spontaneous descent occurs in many cases within the first 3-6 months of life
By 1 year of age, incidence decreases to 1%

Normal Testicular Descent

Testicular descent occurs in two phases:

Transabdominal phase: 8-15 weeks gestation
Inguinoscrotal phase: 25-35 weeks gestation

Classification

Palpable testes: 80% of cases
Non-palpable testes: 20% of cases

Etiology of Undescended Testis

The exact cause of cryptorchidism is often multifactorial and not fully understood. Several factors contribute to its development:

Hormonal Factors

Inadequate hypothalamic-pituitary-gonadal axis function
Insufficient testosterone or anti-Müllerian hormone production
Androgen receptor defects

Genetic Factors

Associated with various syndromes (e.g., Klinefelter, Prader-Willi)
Mutations in INSL3 gene or its receptor RXFP2

Mechanical Factors

Defects in gubernaculum development or function
Abdominal wall defects
Inguinal hernia

Environmental Factors

Maternal exposure to endocrine disruptors
Intrauterine growth restriction
Maternal smoking or alcohol consumption during pregnancy

Diagnosis of Undescended Testis

Diagnosis of undescended testis is primarily clinical, based on physical examination and history.

Clinical Assessment

History: Gestational age, birth weight, family history
Physical examination:
- Performed in warm environment with relaxed patient
- Assess for presence of testes in scrotum, inguinal canal, and abdomen
- Differentiate from retractile testis

Imaging Studies

Ultrasonography:
- Limited utility in diagnosis
- May be helpful in locating non-palpable testes
MRI: May be used for non-palpable testes, but not routinely recommended

Hormonal Evaluation

Not routinely performed for unilateral cases
Consider in bilateral cases or suspicion of endocrine disorders:
- FSH, LH, Testosterone levels
- hCG stimulation test

Diagnostic Laparoscopy

Gold standard for diagnosis and management of non-palpable testes

Management of Undescended Testis

The primary goal of treatment is to bring the testis into a normal scrotal position to preserve fertility and reduce the risk of malignancy.

Timing of Intervention

Current recommendations: surgical correction between 6-18 months of age
Earlier intervention associated with better outcomes

Hormonal Therapy

GnRH analogs or hCG:
- Limited success rate (15-20%)
- May be used in selected cases or as adjunct to surgery

Surgical Management

Orchiopexy: Standard surgical approach
- Open inguinal approach for palpable testes
- Success rate: 70-90%
Laparoscopic approach: For non-palpable testes
- Diagnostic and potentially therapeutic
- May involve one or two-stage Fowler-Stephens procedure

Post-operative Care

Pain management
Wound care
Follow-up examinations to assess testicular position and growth

Complications of Undescended Testis

Untreated or delayed treatment of undescended testis can lead to several complications:

Fertility Issues

Impaired spermatogenesis due to higher testicular temperature
Bilateral cases have higher risk of infertility
Earlier treatment associated with better fertility outcomes

Testicular Cancer

4-10 times increased risk compared to general population
Most common type: seminoma
Risk remains elevated even after orchiopexy

Testicular Torsion

Higher incidence in undescended testes
Can lead to testicular loss if not promptly treated

Psychological Impact

Body image concerns
Potential psychological distress, especially in older children

Inguinal Hernia

Associated with patent processus vaginalis
Higher incidence in children with undescended testis