Undescended Testes

Cryptorchidism
(undescended testis)
TESTICULAR DESCENT
Testicular descent is necessary for normal spermatogenesis, which
requires the 2° C to 3° C cooler scrotal environment.
Guided by the gubernaculum, the testicle descends
into the scrotum, the left before the right.
Most testicles have reached the scrotum by the time of birth
Factors for descent
Endocrine factors: A normal hypothalamic-pituitary-gonadal axis is
essential for testicular descent to occur. (testosterone)
Pull of gubernaculum.
Increased intra-abdominal pressure increases the descent of testis.
Each testis begins to descend
during the 2nd month of the
intrauterine life (IUL).
It reaches the iliac fossa by the
3rd month of IUL.
It rests at the deep inguinal ring
from 4th to 6th month of IUL.
It traverses the inguinal canal
during the 7th month and
reaches the superficial inguinal
ring by the 8th month of IUL.
It enters the scrotum at the 9th
month of IUL.
It reaches the base of the
scrotum at or just after birth.
Undescended testis (UDT)
Undescended testis or cryptorchidism is the absence of
one or both testes in normal scrotal position .
Absence of both testes from the scrotum caused by a failure of
descent is known as cryptorchism .
Definition of UDT
“A testis which is in its correct anatomical path but has
failed to reach the scrotum is called undescended
testis “
(80%)
Aetiology
Abnormal testis or gubernaculum (tissue that guides the
testis into the scrotum during development).
Endocrine abnormalities: low level of androgens, HCG, LH
or MIS.
Decreased intra-abdominal pressure (prune belly
syndrome, gastroschisis)
Risk factors
Preterm infants (incidence at <30 weeks’ gestation is 40%).
Low birth weight or small for gestational age.
Twins.
Family history of UDT.
Long-term complications of UDT
Testicular Tumor/Cancer
Relative risk of cancer is 5-10 fold higher in UDT.
Majority are seminomas.
Infertility
Paternity rate in unilateral UDT is 80–90% and in bilateral UDT is
45–65% .
Beyond 18 months of age, deterioration of the germ cell
population of the testis occurs.
Paternity rates improve if orchidopexy is performed before 2y of
age.
Increased risk of Trauma
Increased risk of Torsion of testis.
Increased risk of indirect inguinal hernias (due to a patent
processus vaginalis)
Endocrine functions are retained as the Leydig cells are less sensitive to temperature
Diagnosis
Clinical features
Symptoms :
An absence of one or both
testes from
the scrotum is the
presenting symptom.
The parents may first notice
that the scrotum has not
developed – unaware of the
absence of the testes.
Groin swelling (due to
associated hernia)
Clinical features
Signs
1. Scrotum
Scrotum is small and hypoplastic.
Scrotum is markedly asymmetrical
if unilateral UDT.
2. Site
Palpate along the normal line of descent .
It may or may not be palpable
3. If not palpable
Check in sitting or squatting position (peeping testis can be palpated).
 Examine for ectopic sites.
4. Examine for complications

Inguinal hernia (reducible groin lump)
Tumor (Palpable mass at inguinal area with empty scrotum
Diagnostic Investigations
Imaging (Limited
value)
USG of scrotum and
abdomen
MRI
Diagnostic
laparoscopy to locate
intra-abdominal testis
Management
• Treatment should be started at the age of 6 months. After
that age, undescended testes rarely descend.
Treatment/Management
Medical treatment
The overall efficacy of medical treatment in cryptorchid
boys is less than 20%
 Human Chorionic Gonadotropin (HCG)
 Luteinizing Hormone–Releasing Hormone
Surgery (Orchidopexy)
Gold standard treatment for UDT.
Time; 6-12 months ; upto 18 months
 The early timing of treatment helps to improve spermatogenesis and
hormone production, as well as decrease the risk of tumour development .
Intra-abdominal testes: require a laparoscopic approach to
mobilize the testis for orchidopexy as a single or 2-stage (Fowler–
Stephens) procedure.
Surgery (Orchidopexy)
Best time for surgery of undescended testis
is:
a. Just after birth
b. 6 months of age
c. 12 months of age
d. 24 months of age
6 months of age
Most common tumors in undescended
testis:
a. Seminoma
b. Teratoma
c. Embryonal carcinoma
d. None
Seminoma
Stephen Fowler surgery is done for:
a. Ectopic testis
b. Undescended testis
c. Hypospadias
d. Epispadias
Undescended testis
Best investigation for undescended testis in
1-year-old child is:
a. USG abdomen
b. CT
c. MRI
d. Laparoscopy
d. Laparoscopy
A 5-year-old male child has been brought with a
complaint that there is only one testis in the scrotum.
On examination, it is found that the testis on the
opposite side is felt in the inguinal canal. The patients
should be advised:
a. Orchiopexy
b. To wait till puberty
c. Orchidectomy
d. Administration of androgens
a. Orchiopexy
True about incompletely descended testis are all of
the following except:
a. Early repositioning can preserve function
b. It may lead to sterility, if bilateral
c. Poorly developed secondary sexual characters
d. May be associated with indirect inguinal
hernia
c. Poorly developed secondary sexual characters

Testis does not descend beyond:
a. 2 months
b. 4 months
c. 6 months
d. 8 months
6 months
Ectopic testis
A testis which has
descended to an
abnormal site is an
ectopic testis.
The mechanism causing
descent is normal but
the guidance system
(gubernaculum) has
gone wrong.
The testicle itself is
normal.
Most common location for an ectopic UDT is within the superficial pouch
Clinical features
Symptoms
Absence of a testis is the common presenting symptom.
Pain or discomfort if the testis is in a site,
such as the superficial inguinal pouch, likely to be
rubbed or compressed during normal physical
activity.
Signs/ Examination
Scrotum: The side of the scrotum without the testis may be poorly
developed.
An ectopic testis is nearly always palpable (absent at scrotum but
found at ectopic sites)
Testis is felt as;
 Ovoid, smooth, slightly tender and soft-solid in consistence.
 It should be mobile within the subcutaneous tissues, and gentle pressure
should
cause the mild sickening sensation recognized by most males as testicular
sensation .
Most common site of ectopic testis:
a. Superficial inguinal pouch
b. Root of penis
c. Femoral triangle
d. Perineum
Superficial inguinal pouch

Retractile testis
Retractile testes move freely up and down between the scrotum
and the inguinal canal or the superficial inguinal pouch.
Testis can be manually replaced in a stable scrotal position and
remain there at least temporarily until there is recurrent
stimulation.
Scrotum is well developed.
A cold examining hand may be sufficient stimulus to cause
retraction.
Cause
Hyperactive Cremasteric reflex
Retractile testes ultimately descend properly, before or at

puberty
Causes/ Differential diagnosis of
Empty scortum
EMPTY SCROTUM
PALPABLE TESTIS NON PALPABLE TESTIS
Undescended testis Undescended testis

(Inguinal) (Intra abdominal)
Absent testis
Ectopic testis 1. Agenesis testis
2. Vanishing testis
Retractile testis
THANK YOU
Reference
Cambell and walsh Urology
Bailey & Love's Short Practice of
Surgery
Smith & Tanagho's General Urology
Browse's Introduction to the
Symptoms & Signs of Surgical
Disease

Undescended Testes

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Undescended Testes

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Cryptorchidism

4. Examine for complications

c. Poorly developed secondary sexual characters

Superficial inguinal pouch

Retractile testes ultimately descend properly, before or at

PALPABLE TESTIS NON PALPABLE TESTIS

Undescended testis Undescended testis

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