Undescended testis - MITR

Undescended Testis

Undescended testis is a condition where the testis is not in its normal position in the scrotum but somewhere up.

The testis (testicle) has two major functions – production of male hormones and sperms. Before the child is born the testicle initially develops in the abdomen and then it migrates down through abdominal wall and groin to take its normal position below in the scrotum. Undescended testicles are one of the most common anomalies. They may be present in 3-4% of boys at birth, and there is an even higher incidence in premature infants. 50%-60% of these undescended testicles will come to normal location within the first 3-4 months of life.

When a testicle is not present in the normal scrotal location, several possibilities exist:

Testis may be absent by birth (congenital absence).
The testicle may have withered away (atrophied) before birth due to torsion (twist) or blockage of the testicular blood vessels.
The testicle may have descended but incompletely and may lie within the inguinal canal (just above the scrotum).
The testicle may have not descended properly and thus remains high up within the abdominal cavity.
It is important to distinguish undescended testis from retractile testis. In children with retractile testis, the testis can be brought down into the scrotum during examination. These ‘retractile’ testicles will be seen to descend when the child is in the bathtub or in squatting position. Retractile testicles are due to hyperactive cremaster muscles that temporarily pull the testicle into the groin. However, retractile testicles generally do not harm the testis and require no treatment. Rarely, the testis may become ascending testis and require a late orchiopexy and as such a yearly follow-up is recommended.

Rationale for treatment of undescended testis

In humans, the scrotal location of the testicles keeps them cooler than the average core body temperature. This lower temperature is important for the proper functioning of the testicle as well as for production of normal sperm. Studies have shown that there is an increased risk of infertility in men with a history of undescended testicles. Relocating the testicle into the scrotum may decrease the risk of infertility problems, particularly if done at an early age.

There are other benefits of a scrotal testis. There is a cosmetic advantage. The scrotal testicle may be less exposed to injury than a testicle outside the scrotum. Finally, and perhaps as important as any other reason, a testicle that is higher up is not accessible for a regular physical examination. Undescended testicles are at an increased risk for testicular cancer. Testicular cancer may not occur later than the third decade. Testicular carcinoma is fully curable if detected in early stages and the best way to do this is monthly self-examination, which can be comfortably done if the testicles are within the scrotum.

Treatment of undescended testis

We recommend surgery for undescended testicle before one year of age, preferably by 6-9 months of age. There is evidence that early damage to the germ cells (sperm producing cells) begins at this age. Earlier options like multiple injections of a hormone, HCG, several times per week over several weeks can produce descent in some children. However, the success rates are quite low (10%) and unpredictable.

The most effective treatment is surgery, which can be performed as a day care procedure. When a testis can be felt by the surgeon, the so called palpable undescended testis, the surgery is done via a small incision in the groin area. Most Undescended testes have an associated hernia that is also concurrently repaired. After hernia is closed, the testis is brought down to the scrotum and fixed in a space created in the scrotum (orchiopexy).

When a testis cannot be felt (non-palpable) on physical examination, its location must be determined. Ultrasound, CT scan or MRI scans are not 100% reliable in this regard. The gold standard is to do a Diagnostic Laparoscopy for these children. In laparoscopy, a telescope is placed through a small incision in the ‘belly button’ to look in the abdomen and find the testis. Then the further course is decided upon the findings on Laparoscopy

1. Testis may be absent by birth – This is confirmed by seeing blind ending testicular blood vessels – This mostly happens as the testis may have twisted on itself before birth and lost its blood supply (antenatal torsion). Nothing further is done and parents are explained.

2. Testis may be small and abnormal – In such cases, the testis are removed laparoscopically (orchiectomy). This mostly results from torsion or twisting of the testis on its blood supply prior to birth that leads to the small testis.

3. Testis is present within the belly – In such cases, we assess if it is possible to bring the testis down in one stage or two stages. In those patients found to have testes very high in the abdomen, testis is brought down in two stages to preserve the blood supply.