After leaving the neonatal ICU Max was brought in for his first visit. He was ten days old and had spent a week in the NICU. He had been a 36-week premie baby with some breathing issues which subsequently resolved along with some jaundice. He was discharged home with no medications other than vitamins. Mom was successfully breast-feeding as evidenced by his good weight gain.
Max’s parents brought in the discharge papers which corroborated that he had an uneventful stay in the NICU. He had passed the hearing test and received the Hepatitis B vaccine. The exam was showing him to be an alert and healthy baby boy until I got to his genital region. His circumcision had healed nicely, but it was noticed that the left testicle was not palpable. His dad said, “Oh yeah, the neonatal doctor said that his testicle had not come down, and that you would need to follow this. He told us this was not uncommon and not a problem. What do you think?”
After finishing my exam I had them dress Max and said, “Let’s talk about undescended testicles”. When the male fetus is developing in-utero, the testes (testicles) are located within the abdomen. By around 6-7 months of gestation the testes usually “migrate” down into the scrotum passing through the inguinal canal. In about 3-4% of term males, the testicle has not descended into the scrotum at birth and this is known as cryptorchidism. This number is much higher in premature males, as high as 30%. This is not a problem but must be followed closely. In the vast majority of cases the testes will eventually come down by nine months of age. If the testes have not come down into the scrotum by one year of age, this then needs to be evaluated and treated to avoid more serious complications. These can include an increased risk for infertility and cancer, hernia, compromise of the blood supply to the testicle and a twisting (torsion) of the blood vessels to the testicle.
The testes are where the sperm form and are stored for life. The body has a number of built-in mechanisms to protect them. It is vital that the temperature of the testes remain fairly constant, just a little below the core temperature of the body. This is insured by a muscle, the cremasteric muscle, which regulated the position of the testes relative to the body, which is driven by temperature. When it is cold, the muscle contracts and pulls the testes high up in the scrotum. When it is hot, the muscle relaxes and the testes drop low and sag in the scrotum. Some boys have a very sensitive and active cremasteric reflex as the testes retract into the inguinal canal appearing as though the testicle is undescended.
Once a doctor has established that both testes are down into the scrotum, no further work-up or intervention is necessary. This means that, if in the delivery room shortly after birth, the doctor establishes that both testes are descended, then one NEVER has to worry about undescended testes at all. Retractile testes can cause undue concern to emergency room or urgent care doctors, who are seeing a patient for the first time. Often the examining room is cold and the patient might be anxious or afraid.
The risk of testicular malignancy is much higher in males with undescended testicles. The most common cancer is a seminoma and the incidence is 4-40 times higher than the general population. When this cancer does occur, it usually presents in the 3rd and 4th decades of life. In the case of one undescended testicle, the rate of cancer is 1 in 80. If it is bilateral, the rate increases to 1 in 40.
As for infertility, the incidence in unilateral cryptorchidism is around 10% compared to 6% in the general male population. If it is bilateral, the incidence jumps up to 38%.
Another possible complication may be an inguinal hernia. This is because normally after the testicle migrates from the abdomen into the scrotum, the tube in which it passes (the inguinal canal) closes. If it fails to close, then there is a connection between the abdomen and the scrotum in which the intestines can bulge into…hence a hernia by definition.
When the testicle is not down in the scrotum, it is more vulnerable to torsion of the testicle. This is a condition whereby the spermatic cord, which houses the blood supply and other vital structures for the testicle, twists upon itself thereby compromising the blood supple to the testicle. This causes acute pain and may result in the testicle dying.
Once it has been determined that the testicle(s) have not descended into the scrotum by one year of age, intervention is than required to prevent the complication listed above. To determine that the testicle is not merely retractile but truly undescended the physician may order an ultrasound or an MRI to confirm their clinical findings. The standard of care is to bring the testicle down into the scrotum with a surgical procedure known as an orchiopexy. This is usually performed by a pediatric urologist. This is a relatively minor procedure and is typically done as an outpatient. Another option might be a series of hormonal injections using human choriono-gonadotropic hormone (HCG). This requires ten weekly injections over a five week period. However, the success rate is reported to be between 5 and 50%. Most physicians opt for surgery.
Having gone through all of the facts Max’s parents were comfortable in watchful waiting. At Max’s six-month well check I am pleased to report that both testes were felt securely in the scrotum.