Cryptorchidism, or Undescended Testicle, is a condition in boys. Learn about its causes, complications, and treatment options at Meri Sehat.

Undescended Testicle (Cryptorchidism)

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Syed Intisar Hussain

Overview

Cryptorchidism or undescended testicle is a testicle that hasn&#39;t descended into the correct place in the pouch of skin hanging below the penis (scrotum) before birth.

Often, it&rsquo;s just one testicle that is afflicted; however, in approximately 10% of the cases, both testicles can remain undescended<a href="#accordion">[1]</a>. An undescended testicle is the most common birth defect of the male genitalia. 
&nbsp;

The male sex glands known as testicles (testes), which are oval-shaped organs forming part of the male reproductive system, are responsible for the production of sperm and testosterone (male sex hormone).

These testicles develop inside the abdomen of a male baby when he is just a fetus in the uterus. Following birth, the testicles drop into the scrotum from inside the abdomen. The scrotum is a pouch of skin that hangs behind the penis and houses the testicles. 
&nbsp;

Undescended testicles (UDT) or cryptorchidism occurs when one or both of these testicles do not descend into the scrotum and are instead located in the groin&nbsp;or lower belly. Nearly 3% of male children born at full-term and 30% born prematurely present with undescended testicles.

While it can happen to any baby boy, it is frequently seen in baby boys born prematurely, and even though it can affect both testicles, it mostly affects the right testicle<a href="#accordion">[2]</a>. 
&nbsp;

However, 80% of UDT descend by the third month post-delivery<a href="#accordion">[2]</a>. Surgery to relocate the testicle to the scrotum is recommended if the testicles remain undescended after 6 months of age.

The testicle that has failed to descend can be present at any point along its path of descent, such as high in the retroperitoneal abdomen to the inguinal ring or in the inguinal canal; it can also be ectopic from the path of descent, hypoplastic, dysgenetic, missing or absent, or unilateral. 
&nbsp;

It is usually palpable in the inguinal canal. However, in around 20-30% of cases, the testes are not palpable; 20-40% of nonpalpable testes are found absent when explored surgically<a href="#accordion">[5]</a>.

10-30% of men with unilateral UDT are infertile. When the illness is bilateral, the infertility rate rises to 35-65% or higher. The rate of infertility increases to over 90% if bilateral undescended testes are left untreated<a href="#accordion">[2]</a>. 
&nbsp;

The main factor in the majority of cases of UDT is insufficient pituitary or placental stimulation, which results in insufficient production of insulin-like hormone 3 (INSL3) and androgens in the developing testis. Fetal testicular hormones are essential for testicular descent<a href="#accordion">[4]</a>.

A baby with UDT by the age of six months should be seen by a pediatric urologist or another certified specialist so that they can help with diagnosis and treatment. 
&nbsp;

Several different forms of undescended testicles are: 
&nbsp;

<ol>
	<li>Congenital: This implies that a testicle fails to descend into the scrotum. It can be diagnosed at birth.</li>
	<li>Acquired: Sometimes a child&#39;s testicles are in the scrotum when they are born, but they develop undescended testes later. The spermatic cord stops expanding at the same rate that the kid does. It becomes too short in the end and forces the testis back into the groin. This can happen between the ages of 1 and 106.</li>
	<li>Vanishing Testicle: This means a testicle is absent.</li>
	<li>Retractile Testicle: The testicle is present in the scrotum but it slips up into the groin and disappears temporarily due to a muscle reflex typically caused by cold temperatures. It doesn&rsquo;t require surgery for correction<a href="#accordion">[3]</a>. 
	&nbsp;</li>
</ol>

Signs and Symptoms

Most infants and kids with this illness don&#39;t exhibit any symptoms. The only indication is that the scrotum is empty due to the absence of the testicle or testicles, making it look small or underdeveloped.

If only one testicle is missing, the scrotum will appear asymmetrical. Nevertheless, the condition will not cause any pain or problem with urination.

If the doctor can feel the UDT during a physical exam, it means that the testicle is palpable. The location is often the inguinal canal, which is the channel carrying the spermatic cord to the penis and the scrotum.

If the doctor cannot feel the testicle during the examination, it means the testicle is impalpable and it may be<a href="#accordion">[7]</a>: 
&nbsp;

<ul>
	<li>Abdominal: It is the least common location.</li>
	<li>Inguinal: It is present in the inguinal canal, but has not descended enough to be detected through touch.</li>
	<li>Atrophic Or Absent: Either the size of the testicle is too small or it is nonexistent. 
	&nbsp;</li>
</ul>

Causes

The precise cause of cryptorchidism is yet unknown. However, some experts claim the following factors can cause undescended testicles:

<ul>
	<li>The majority of cases of undescended testicles happen when a mix of genetics, maternal health, and a few environmental variables mess with hormones, physically alter the testicles, and interfere with nerve activity involved in the development of the testicles. 
	&nbsp;</li>
	<li>According to medical professionals, early birth is a significant risk factor for an undescended testicle. According to the Lucile Packard Children&#39;s Hospital, the illness affects over one-third of premature baby males. 
	&nbsp;</li>
	<li>An undescended testicle can be caused by extra fibrous tissue or muscles that won&#39;t stretch in the child&#39;s groin<a href="#accordion">[7][8]</a>. 
	&nbsp;</li>
</ul>

Diagnosis

The doctor will take the history, perform a physical exam, and use an x-ray, ultrasound, or MRI. 
&nbsp;

<ul>
	<li>Physical Exam: The infant is placed in a warm environment and the skin around the scrotum is expanded to make it easier to perform an examination. 
	&nbsp;</li>
	<li>Ultrasound Scan: The test helps show the location of the testicle if it is impalpable. 
	&nbsp;</li>
	<li>MRI Scan: It can be done after a contrasting agent is injected into the bloodstream to get a clear picture of whether the testicle is in the groin or abdomen. 
	&nbsp;</li>
	<li>Laparoscopy: A tiny tube with a camera attached to it is inserted through an incision in the abdomen. If required, the doctor can also perform corrective surgery using the same tools. 
	&nbsp;</li>
	<li>Open Surgery: It is rarely used unless it&rsquo;s a complicated case wherein the doctor has to perform it to directly explore the abdomen. 
	&nbsp;</li>
	<li>Genetic Test: If both testicles are undescended, a genetic test is recommended to determine the sex chromosomes of the baby. 
	 
	Some babies, who are genetically female, may have male genitalia or ambiguous genitalia. In this case, the doctor will use an ultrasound to look for any undescended testicles or ovaries. They&rsquo;ll also order further tests, such as blood or urine tests to determine hormone levels. 
	&nbsp;</li>
</ul>

Treatment

In about half of the patients with cryptorchidism, the testicle will descend on its own within 3 months; however, in 1-2 instances out of every 100 infants with the condition, the testicle will not descend by the time the baby is 6 months old. In such a case, early surgical intervention will reduce the likelihood of complications in the future.

In other situations, the testicle can be underdeveloped, abnormal, or dead tissue. In this case, the testicular tissue will be removed by the surgeon. If the undescended testicle is accompanied by an inguinal hernia, the hernia will also be repaired during surgery<a href="#accordion">[7]</a>. 
&nbsp;

<h5>Orchidopexy Or Orchiopexy</h5>

It is a surgical procedure that is usually recommended for infants aged 6 months to 1 year. It is the most common and successful in the treatment of UDT. This procedure is performed under general anesthesia, so the child will not be awake to feel any pain.

A small incision is created in the groin&nbsp;during surgery, and the chord is gently stretched to release the testis. The testis is fixed inside the scrotum after a second cut is performed there. The surgeon would typically close the inguinal canal to prevent the testicle from rising again.

After that, the cuts are stitched with absorbable sutures, which do not require removal and will dissolve after some time. The child is discharged the following day, though painkillers are to be administered for approximately 48 hours.

The procedure is effective 98% of the time, leading testicles to develop normally and produce healthy sperm in the future. 
&nbsp;

Note: Contact your child&rsquo;s surgeon if your child develops a fever, or if the wound has become infected, i.e., it becomes swollen, red, or leaks fluid. 
&nbsp;

<h5>Hormone Therapy</h5>

The doctor may advise hormonal therapy in rare circumstances, particularly when the testicles are close to the scrotum. The youngster receives several human chorionic gonadotropins (HCG) shots from the healthcare professional.

Hormone therapy isn&#39;t usually the preferred course of action. There may be side effects, and it typically doesn&#39;t function as well as surgery. 
&nbsp;

<h5>Other Treatments</h5>

Saline testicular prosthesis for the scrotum can be implanted during late childhood or adolescence, if the child is born without one or both testicles, or if one or both are missing or didn&#39;t survive following surgery. The prosthetics make the scrotum appear natural.

Additionally, the doctor will refer the child to an endocrinologist, or a hormone expert, to talk about potential hormone treatments that might be required to induce puberty and physical maturity if the individual doesn&#39;t have at least one healthy testicle. 
&nbsp;

Follow-Up: After the procedure, routine inspections are scheduled to ensure the testicle stays in the scrotum. It&#39;s crucial to monitor the testicles&#39; health even after corrective surgery to make sure they develop normally. 
&nbsp;

NOTE: Being aware of your son&#39;s physical growth will enable you to assist him. Frequently check the location of his testicles while bathing or changing his diaper. When you discuss the physical changes he can anticipate during puberty, make sure to include instructions on how he may examine his testicles on his own. Testicular self-examination will be a crucial ability for the early identification of any potential tumors. 
&nbsp;

<ul>
	<li>The postpartum human testis is evolved to function at a&nbsp;cooler temperature because the scrotal environment is 4&deg;C cooler than the core body temperature. Infants with UDT experience higher postnatal temperatures, which causes gradual abnormalities in the biochemistry and physiology of the testis as a result of heat stress.</li>
	<li>There could be damage to the testis from surgery.</li>
	<li>Infertility.</li>
	<li>Testicular cancer in either one or both of the testes.</li>
	<li>If left untreated, undescended testicles can lead to infertility<a href="#accordion">[6]</a>.</li>
	<li>A testicle that hasn&#39;t descended naturally has a high chance of developing a tumor<a href="#accordion">[10]</a>.</li>
	<li><a href="https://merisehat.pk/disease/anxiety">Anxiety </a>and embarrassment if the scrotum is empty or lopsided.</li>
	<li>Inguinal hernias can occur occasionally<a href="#accordion">[10]</a>.</li>
	<li>If the location of the testicle is in the groin, it can be damaged from pressure against the pubic bone.</li>
	<li>Twisting&nbsp;of the spermatic cord, which houses blood vessels, nerves, and the tube that transports semen from the testis to the penis, is known as testicular torsion. This disorder prevents blood flow to the testicles. Undescended testicles are 10 times as likely than normal testicles to experience testicular torsion<a href="#accordion">[1]</a>. 
	&nbsp;</li>
</ul>

Factors that increase the risk of undescended testicle or cryptorchidism are:

<ul>
	<li>Low birth weight</li>
	<li>Premature birth</li>
	<li>Any other condition of the fetus that restricts its growth, like Down syndrome or abdominal wall defect</li>
	<li>Family history of genital development problems or undescended testicles &ndash; 1.5-4% if the father has the same condition and 6% if the brother has it<a href="#accordion">[2]</a>; the risk increases to 25% if the brother is an identical twin<a href="#accordion">[3]</a>.</li>
	<li>Alcohol consumption by the mother during pregnancy</li>
	<li>Cigarette smoking or secondhand smoke exposure during pregnancy</li>
	<li>Pesticide exposure</li>
	<li>Maternal <a href="https://merisehat.pk/disease/obesity">obesity</a><a href="#accordion">[2]</a>.</li>
	<li>Maternal diabetes (type 1, type 2, or gestational)<a href="#accordion">[2][9]</a>.</li>
	<li><a href="https://merisehat.pk/disease/pre-eclampsia">Preeclampsia</a><a href="#accordion">[2]</a></li>
	<li>In vitro fertilization<a href="#accordion">[2]</a>. 
	&nbsp;</li>
</ul>

Unfortunately, there is no known way to prevent undescended testicles. 
&nbsp;

<ol>
	<li>In a study of 5,014 males born at a single hospital in Estonia, 2.1% had one or both testicles undescended at birth. The following variables affected the rates of the undescended testicle<a href="#accordion">[12]</a>:</li>
</ol>

<ul>
	<li>Preterm birth &ndash; 11.9%</li>
	<li>Low birth weight &ndash; 16.7%</li>
	<li>Small for gestational age &ndash; 14%</li>
	<li>Full-term birth &ndash; 1.1% 
	&nbsp;</li>
</ul>

<ol start="2">
	<li>According to a Japanese study, after the Fukushima nuclear accident, the rate of cryptorchidism increased nationwide by 14.3%. The prevalence of other cryptorchidism risk factors, such as low birth weight and preterm deliveries, remained essentially consistent during the study period<a href="#accordion">[5]</a>.</li>
	<li>In a study of 51 formerly cryptorchid individuals who underwent surgery in the first two years of birth, sperm count and motility were found to be normal in more than 95% of participants at ages 18 to 26. The fertility prognosis was even better if orchiopexy was performed in the first year of life &ndash; 96.3% for both normal sperm count and sperm motility<a href="#accordion">[5]</a>. 
	&nbsp;</li>
</ol>

Key Points

<ul>
	<li>Cryptorchidism or undescended testicle is a testicle that hasn&#39;t descended into the correct place in the pouch of skin hanging below the penis (scrotum) before birth. It&rsquo;s the most common birth defect of the male genitalia.</li>
	<li>While it can happen to any baby boy, it is frequently seen in baby boys born prematurely.</li>
	<li>10-30% of men with unilateral undescended testis are infertile. When the illness is bilateral, the infertility rate rises to 35-65% or higher. The rate of infertility is nearly 90% if bilateral undescended testes are left untreated.</li>
	<li>Most infants and kids with this illness don&#39;t exhibit any symptoms. The only indication is that the scrotum is empty due to absence of the testicle or testicles, making it look small or underdeveloped.</li>
	<li>Orchidopexy is the most common and most successful treatment option. 
	&nbsp;</li>
</ul>

[1] Undescended testicle. Mayo Clinic.

[2] Leslie SW, Sajjad H, Villanueva CA. Cryptorchidism. [Updated 2022 Nov 28]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls

[3] Undescended testicles: What parents need to know. HealthyChildren.org.

[4] panelJayaVikramanMBBS Alinks open overlay, JayaVikramanMBBS, a, et al. The undescended testis: Clinical management and scientific advances. Seminars in Pediatric Surgery