Undescended testis (chriptorchidism) is one of the congenital anomalies (developmental disorder) of the urogenital system that is common in boys. Early diagnosis and treatment is very important as it may cause serious complications in the future. In this article, I will give general and up-to-date information about the undescended testis in the light of my own experiences and literature.

What is/means an undescended testis?

Normally, the testicles develop at the level of the kidneys in the retroperitoneal region in the posterior part of the abdomen during the development period and descend to their normal place (scrotum) close to birth. Undescended testis (chriptochidism) is the absence of the testicle in the scrotum in boys where it should normally be. It is mostly seen unilaterally and on the right. 10% of both testicles may not be in their normal place. In 3% of term children and 30% of premature children, one or both testicles may not descend normally into the scrotum.

What are the causes of an undescended testis?

The causes of undescended testis are not known exactly. Some of the factors put forward as causes are:

• Genetic causes
• Maternal health problems: Causes hormonal disorders
• Environmental factors: Hormonal factors and ultimately can cause undescended testicles
• Physical causes and problems with nerve function

What are the risk factors for an undescended testis?

There are some risk factors that can cause an undescended testis. It is very important for mothers to pay attention to these risk factors during pregnancy. Risk factors for an undescended testis are:

• The child is born with a low birth weight
• Premature (premature birth)
• Undescended testis in close relatives
• Conditions that adversely affect the development of the baby 8Down syndrome, incomplete development of the abdominal wall muscles)
• The mother’s use of alcohol during pregnancy
• Maternal smoking during pregnancy
• Exposure to various chemicals

What can happen in the future if the undescended testis is not treated?

Undescended testis is an important disease. Families should be very careful in this regard. If timely measures are not taken, the undescended testis will have serious complications in the future. These complications are:

• Development of testicular cancer: Testicular cancer is common in men with undescended testicles at advanced ages. The development of cancer in a displaced testis is related to the location of the testis. The higher the testicle, the higher the rate of cancer development. In other words, the rate of cancer development is less in the testicles in a region close to the scrotum (the bag in which the testicles are normally contained). On the other hand, in the case of an undescended testis remaining in the abdomen, cancer development is more likely.
• Infertility: The testicles have two most important tasks: producing testosterone (male hormone) and making sperm. In undescended testicles, sperm production cannot fully develop and infertility is seen in these people in the future. In this respect, early diagnosis and treatment are very important to prevent infertility in the future.
• Testicular torsion: Testicular torsion is the rotation of the structure called the spermatic cord, which contains the vessels and nerves of the testicle, around itself. As a result of this, the blood supply of the testis is disturbed and the testis loses its functions. Testicular torsion is common in cases of undescended testicles.
• Trauma: Trauma can occur in testicles that are not in their normal place. This is more common in testicles located in the groin.
• Development of inguinal hernia: Inguinal hernia can be seen in children with undescended testicles. In such cases, the hernia is corrected by surgery.
• Psychological problems: Psychological problems may occur in older ages in people whose testicles are not in place.
• Sexual problems: If there is a problem in testosterone production in advanced ages, erection problems and sexual reluctance (decreased libido) can be seen.

When to go to the doctor if there is an undescended testicle?

Families should have their children examined regularly. Normally, the testicles should be in the scrotum, if not, a physician should be consulted. Especially in young children, since the scrotum will loosen during a hot bath, it is better understood whether the testicles are in place or not. Normally, both scrotums are symmetrical. The scrotum on the side of the undescended testis is underdeveloped and small compared to the opposite side. If scrotum development is not good, then undescended testis should be suspected.

Will there be a child after undescended testicle surgery?

With a timely and appropriate surgery, the rate of having a child in the future is high. In patients with unilateral testis, this rate is close to normal people. If timely surgery is performed in patients with undescended testicles on both sides, the rate of having a child is approximately 65%. In cases with delayed descent, the testicles are adversely affected by the high temperature in the abdomen and sperm production is impaired. Normally, the temperature in the scrotum is 3-5 degrees lower than in the abdomen.

Does undescended testicle surgery completely remove the risk of cancer?

Orchiopexy surgery reduces the risk of testicular cancer, but does not completely eliminate it. Therefore, these patients should be checked at regular intervals. Lowering a testis in the abdomen into the scrotum provides convenience in examination for control.

Is there any problem in the transition to puberty in children with undescended testicles?

Testosterone production in the testicles of children with undescended testicles is not affected. Since the male hormone (testosterone) is normal in these, there is no problem in the transition to puberty. Penis development, hair beard and muscle development are normal. He has a normal male appearance.

How many types of undescended testis are there?

Undescended testis is of two types according to the examination finding.

• Palpable examination: The testicles are palpable in the groin in the hand-made muscle. About 70% of cases are of this type.
• Unpalpable on examination: The testicles are not palpable in the examination. They are located in the abdomen, above the groin. However, it can be demonstrated with USG and MRI.

What are the symptoms of an undescended testis?

In babies, if the testicle is not in its normal place, the scrotum cannot develop much, so it remains small. If bilateral testicles are not descended, both scrotums are not developed. The most important symptom of an undescended testis is the absence of one or both testicles on palpation.

How is an undescended testis diagnosed?

Early diagnosis of undescended testis and timely treatment planning are very important to prevent future complications. The steps to be followed for diagnosis are as follows;

• Medical history (anamnesis): The first step to make a diagnosis is to get detailed information from the family. Reasons such as drugs used by the mother during pregnancy, smoking habit, environmental factors, premature birth, low birth weight should be investigated.
• Examination: It should be checked whether the testicles are in place in male babies. This is easily understood on examination. If the testis has not descended into the scrotum, the development of the scrotum is weak on that side, and it remains small compared to the other side.
• Ultrasonography (USG): If the testis is not in place during the examination, USG examination should be performed. With USG, the testicle can be seen in the groin or in the abdomen.
• MR: If testicle is not found on examination and USG, MR is requested. With MRI, if there are testicles, it is possible to show them in the abdomen.
• Laparoscopy: In children where the testis is not in place, the testis is investigated by entering the abdomen with laparoscopy (light, camera system). If the testis is too small and in a position that cannot be lowered, it is removed to prevent future complications. If it needs to be preserved, it is lowered into the scrotum.
• Open surgery: Another method for diagnosis in children with undescended testicles is open surgery. In open surgery, the testis is lowered into the scrotum from where it is.

What is the most common genetic cause of undescended testis?

There is no clear information about the genetics of the undescended testis. The incidence is higher in first-degree relatives with the disease. The most common genetic disorder is a mutation in the androgen receptor gene (AR gene).

What type of testicular cancer will most often develop in the future in children with undescended testicles?

Testicular cancer is most common between the ages of 35 and 45, and is extremely rare under the age of 18. Patients with cryptorchidism have a high risk of developing testicular cancer in the future. The most common testicular cancer in these patients is seminoma.

What other congenital disorders are often associated with cryptorchidism?

Some congenital anomalies can also be seen, albeit rarely, with cryptorchidism. We can list them as follows;

• Down syndrome
• Prader-Willi syndrome
• Noonan syndrome

Can undescended patients be intersex?

If the patient has hypospadias together with undescended testis, they are likely to be intersex (bisexual, gender uncertainty). The more serious these two conditions are, the higher the probability of intersex.

Until what age should undescended testis surgery be performed?

In children with undescended testicles, the time to lower the testicles, that is, the time of surgery, is very important. The ideal age for surgery in these children is between 6-12 months. If the operation period is delayed, testicular development cannot be complete and serious problems will arise in the future. The most important of these is the development of testicular cancer and the problem of infertility.

Undescended testis is confused with which diseases?

Absence of testicles in the scrotum does not always mean undescended testicles or cryptorchidism. There are two diseases that are often confused with undescended testis. These diseases are:

• Ectopic testis: It is the situation where the testicles are in a place other than the normal descent path. In cryptorchidism, the testicles can be anywhere along the normal descent path between the kidneys and the scrotum.
• Retractile testis: In these patients, the testicles normally descended into the scrotum. However, from time to time it runs towards the groin. Especially in cold weather. When viewed in a tub in a hot tub, the testicles are seen descending into the scrotum. In the palpable examination, the testicles may be in the groin, they descend into the scrotum by hand and escape again. Retractile testis is caused by a reflex of the scrotum muscle, it is not an abnormal condition. As the age progresses, the testicles stay in their normal place and do not go up to the groin.

Does the undescended testis descend spontaneously?

Not all undescended testicles require surgery in the first months. In these children, about 80% of the testicles descend in the first three months after birth. If it does not descend, surgery (orchiopexy) should be performed without further waiting.

How many hours does the surgery take, what kind of anesthesia is applied?

The surgery is performed under general anesthesia. The duration of the operation depends on the type of the operation and the placement of the testis, whether it is unilateral or bilateral. It takes about 1 hour on average.

Treatment/surgery of undescended testis?

The most effective treatment in children with undescended testicles is surgery. The operation performed to lower the testis to its normal place is called “orchiopexy surgery” (pexy if it is orchioyor). With the operation, the testicle is lowered to the place where it should be normal, namely the scrotum. The testicle may not always be lowered to its normal place with surgery. This is because the testis is either too high in the abdomen or the spermatic cord is short. Sometimes surgery can be performed in two sessions. If there is a hernia together, hernia surgery is also performed in the same session.

Orchiopexy surgery is performed in two ways;

• Laparoscopic orchiopexy surgery
• Orchiopexy with open surgery

Undescended testis and hormone therapy

Some children may be treated with hormone therapy for treatment. For this purpose, human chorionic gonadotropin (HCG) hormone is given. Thanks to this hormone, in some cases, the testicles descend to their normal place. But in general, hormone therapy is not preferred much. Because the success rate is low. We do not recommend hormone therapy to our patients in order not to waste time and because the success rate is low. Our first option for our patients with undescended testicles is surgery. In this way, our success rates are quite high.

Follow-up after orchiopexy surgery

Orchiopexy is a surgery with a high success rate. After the surgery, children are called for regular check-ups. In the controls, the patients are evaluated as follows;

• Examination of the testicles
• Checking the testicles with USG
• Controlling hormone levels

What is the success rate of orchiopexy surgery?

The success rate in orchiopexy surgery is high. It is successful around 95%, complications are extremely low, around 1%.

In summary; Undescended testis is a common congenital developmental defect of the urogenital system. The most effective treatment is surgery. The success of the surgery is quite high. The surgery should be done within 6-12 months. If left untreated, it causes serious problems such as testicular cancer and infertility in the future.

Prof. Dr. Emin ÖZBEK

Urology Specialist

Istanbul/ TURKEY