A new family for the first time came in with their 4-day-old son.

 

The mother had delivered at a hospital where her obstetrician was in another city. It was an uncomplicated vaginal delivery with mom and baby doing just fine. She was breast feeding successfully and the baby had started gaining weight with no significant jaundice. They were a lovely couple, beaming with pride of their new son Tyler.
 

We talked and I got a detailed history. Then I wanted to now examine Tyler. Both parents became very serious and their demeanor changed abruptly.

 

Dad spoke up and said, “The doctor in the nursery said that one of Tyler’s testicles had not come down .It was not a big deal but just have the pediatrician discuss this with you. He might need surgery later on.” Needless to say Tyler’s parents were very concerned and quite worried.

 

After my exam I found that his left testicle was NOT in the scrotum

The scrotum on the left side looked like it “hadn’t been lived in”. That is to say, it looked like a testicle had not been there to fill it in. Finishing my exam I commented on what a beautiful baby he was. Then I said, “Let’s talk about undescended testicles in newborn males”.
 

When a male fetus is developing in the mother’s womb, both testicles are actually in the scrotum.

By 34 to 36 weeks of gestation, the testes usually descend down into the scrotum through the inguinal canal They are present in the scrotum at the time of birth. In about 3% of all term male babies the testicle has not descended. In about 10% of these, both testes have not descended. For obvious reasons, the incidence of undescended testicles is much higher in premature babies, as high as 20%. A testicle that has not descended by birth is called cryptochordism.
 

Of the males born with cryptochordism, the testicle will spontaneously move down into the scrotum by 3-4 months of age in 50% of the cases. By 6 months of age, only around 1% will remain undescended.

 

I explained to Tyler’s parents that this was nothing to worry about. We will keep a close eye on this at his well checks and the odds are that it will spontaneously come down on its own. If the testicle has not come down by 1 year of age, then we would refer him to a specialist (Pediatric Urologist) about intervening at that time.

They appropriately asked what would happen if nothing was ever done. I explained to them that the testicle needs to be 2-3 degrees cooler than body temperature for the formation of sperm. There is a natural reflex called the cremasteric reflex whereby the testicle can be drawn up near the body to maintain a constant temperature if it is cold. Conversely, if it is hot, the testicles will hang low in the scrotum. This is to insure a safe and constant temperature for sperm development. If an undescended testicle is not resolved until later in life, there may be problems with fertility.
 

Another problem that may arise if the testicle is not brought down until later in life is testicular cancer because of the exposure to constantly high temperatures from the body’s core. These cancers may not show up until a male is in his 30’s or 40’s.

 

Another problem that can arise if not treated early, is the testicle may twist on itself (torsion of the testicle) which is a surgical emergency. When the testicle torses it can cut off the blood supply to the testicle and the testicle can actually die. This usually occurs suddenly, is very painful and a surgeon has a matter of a few hours to get the patient to the OR to hopefully save the testicle.
 

A final concern regarding an undescended testicle is a cosmetic one. Because of the obvious visual differences, a boy may become very self-conscious about his appearance if he is “missing” a testicle on one side.

 

In the 1990’s, it was generally accepted that an undescended testicle should be repaired before the age of 5 years. Now, the standard of care is to bring the testicle down by one to two years of age. Most pediatricians will refer a male to a specialist by one year of age. Some will do this as early as 6 months of age but this is not the norm. There are two ways that the testicle can be brought down. One is hormonal therapy, and the other option is surgery. Around 10 years ago, the hormonal option was gaining popularity but its’ success rate was less than optimal.. If it didn’t work, they needed to have surgery anyway. The hormone that is given is Human Chorionic Gonadatropin, or HCG, which was supposed to stimulate the testicle to drop into the scrotum.

 

The surgery to bring the testicle down into the scrotum is called an orchiopexy. This can be done with a laparoscope or can be done with an open procedure.

 

Both are considered minor and safe procedures and have nearly a 100% success rate. Most pediatricians would advise the surgical approach. After we talked, Tyler’s parents were again proud and beaming and were relieved to hear the actual facts.