Undescended Testis (Cryptorchidism)

1. Clinical Overview

Summary

Undescended Testis (UDT), or Cryptorchidism, is the failure of one or both testes to descend from the retroperitoneum into the scrotum by term gestation. It represents the most common genital anomaly in male neonates, affecting approximately 3% of term and up to 30% of preterm infants at birth. [1,2]

The incidence decreases to approximately 1% by 3-6 months of age as many testes descend spontaneously during the first postnatal months. However, spontaneous descent beyond 6 months is rare, and surgical intervention becomes necessary. [3]

Untreated cryptorchidism carries significant long-term sequelae:

• Impaired Fertility: Elevated testicular temperature impairs spermatogenesis, with bilateral UDT conferring worse prognosis than unilateral disease [4]
• Testicular Malignancy: 3-8 fold increased risk of germ cell tumours (primarily seminoma), highest in intra-abdominal testes [5]
• Testicular Torsion: Abnormal testicular fixation increases torsion risk [6]
• Psychological Impact: Body image concerns and awareness of cancer risk

Orchidopexy (surgical fixation of the testis in the scrotum) is recommended between 6-18 months of age, ideally by 12 months, to optimize fertility potential and facilitate long-term surveillance. [7,8] Earlier intervention preserves germ cell populations and reduces but does not eliminate malignancy risk.

Clinical Pearls

Retractile Testis is NOT Undescended: A retractile testis resides normally in the scrotum but is pulled into the inguinal canal by an overactive cremasteric reflex. It can be manually manipulated to the bottom of the scrotum where it remains momentarily without tension. This is a normal variant requiring annual surveillance (5-30% may develop ascending testis) but does NOT require immediate surgery. [9]

Ascending (Acquired) Testis: A testis that was previously documented in the scrotum but later "ascends" into the inguinal canal due to failure of spermatic cord elongation during growth. This requires orchidopexy despite prior normal position. [10]

Bilateral Impalpable Testes = Red Flag: Raises suspicion for Disorder of Sex Development (DSD), particularly Congenital Adrenal Hyperplasia (CAH) in a virilized 46,XX individual, or bilateral anorchia. Urgent karyotype and endocrine evaluation are mandatory. [11]

Laparoscopy is Gold Standard for Impalpable Testis: Diagnostic laparoscopy provides definitive localization and allows for therapeutic intervention (orchidopexy or orchiectomy) in the same procedure. [12]

Cancer Risk Persists After Surgery: Orchidopexy facilitates surveillance and may reduce cancer risk, but does NOT eliminate it. Lifelong testicular self-examination and awareness are essential. [5]

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2. Epidemiology

Demographics

Risk Factors

Prematurity and Low Birth Weight

• Most significant risk factor
• Directly proportional to degree of prematurity
• Reflects incomplete gesticular descent during third trimester [1]

Maternal Factors

• Maternal diabetes (gestational and pre-existing) [13]
• Maternal smoking during pregnancy
• Alcohol consumption
• Exposure to endocrine-disrupting chemicals (phthalates, pesticides) [14]

Fetal/Neonatal Factors

• Small for gestational age (SGA)
• Low birth weight independent of gestational age
• Family history of cryptorchidism (3-4 fold increased risk) [2]
• Congenital syndromes (Prader-Willi, Down syndrome, abdominal wall defects)

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3. Aetiology and Pathophysiology

Normal Testicular Descent (Two-Phase Process)

Testicular descent is a complex, hormonally-regulated process occurring in two distinct phases during fetal development. [15]

Phase 1: Transabdominal Phase (Weeks 8-15 of Gestation)

• Testis migrates from its origin near the kidney to the internal inguinal ring
• Mediated by Insulin-Like Factor 3 (INSL3) secreted by fetal Leydig cells
• INSL3 binds to RXFP2 receptor causing gubernaculum swelling
• Independent of androgen signaling [15]
• Rarely disrupted in humans (most UDT are inguinal, not abdominal)

Phase 2: Inguinoscrotal Phase (Weeks 25-35 of Gestation)

• Testis descends through inguinal canal into scrotum guided by the gubernaculum
• Mediated by androgens (testosterone and dihydrotestosterone)
• Requires intact hypothalamic-pituitary-gonadal (HPG) axis
• Genitofemoral nerve plays a role via calcitonin gene-related peptide (CGRP) release [16]
• Processus vaginalis normally obliterates; if patent, predisposes to inguinal hernia/hydrocele [6]

Pathophysiology of Cryptorchidism

Hormonal Deficiency

• Hypogonadotropic hypogonadism (central deficiency of GnRH, LH, FSH)
• Leydig cell dysfunction (reduced testosterone synthesis)
• Androgen insensitivity (receptor defects)
• INSL3/RXFP2 pathway defects (rare) [15]

Gubernacular Abnormalities

• Defective gubernaculum development prevents normal guidance
• Abnormal insertion sites may cause ectopic locations [16]
• Matrix metalloproteinase deficiency impairs gubernacular migration [17]

Anatomical Obstruction

• Patent processus vaginalis creating mechanical barrier
• Narrow inguinal canal
• Cremasteric muscle hypertrophy

Prematurity

• Testicular descent primarily occurs during third trimester
• Preterm infants born before completion of inguinoscrotal phase [1]

Consequences of Undescent on Testicular Histology

Temperature-Dependent Damage

• Scrotum maintains temperature 2-4°C below body core, essential for spermatogenesis
• Cryptorchid testis exposed to core body temperature [4]
• Germ cell loss begins at 6-12 months of age - hence importance of early surgery
• Progressive depletion of Ad spermatogonia (germ cell stem cells)
• Peritubular fibrosis and Leydig cell hyperplasia in long-standing cases [4]

Bilateral vs. Unilateral

• Bilateral UDT: Both testes affected, fertility severely compromised even with surgery
• Unilateral UDT: Contralateral descended testis often shows impaired spermatogenesis (suggests systemic etiology, not just local temperature effect) [4]

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4. Clinical Presentation and Examination

History

Antenatal

• Undescended testis rarely detected on antenatal ultrasound
• May be identified in context of disorders of sex development or syndromes

Postnatal

• Routine newborn examination (Newborn and Infant Physical Examination - NIPE) at birth and 6-8 weeks [18]
• Parental concern regarding empty hemiscrotum
• Incidental finding during examination for other conditions

Developmental History

• Gestational age at birth (prematurity)
• Birth weight
• Family history of cryptorchidism or infertility

Physical Examination Technique

Preparation

• Warm environment (cold activates cremasteric reflex)
• Warm hands
• Calm, relaxed child
• Frog-leg position (hips flexed and abducted) relaxes cremasteric muscle [18]

Systematic Palpation

• Examine contralateral descended testis first (establish normal testicular size/consistency)
• Palpate along line of descent from internal ring to scrotum
• Use "milking" technique from internal ring downward
• Assess whether testis can be manipulated to bottom of scrotum
• Note whether testis remains in scrotum without tension or retracts immediately

Classification by Palpability and Position

Assessment of Scrotum

• Hemiscrotum on affected side often hypoplastic (underdeveloped)
• Contralateral hemiscrotum may show compensatory hypertrophy in unilateral cases

Associated Findings

• Inguinal hernia (common, due to patent processus vaginalis) [6]
• Hypospadias (raises suspicion for DSD)
• Micropenis (consider hormonal deficiency)
• Ambiguous genitalia (urgent DSD workup)

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5. Differential Diagnosis

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6. Investigations

Clinical Diagnosis is Primary

Cryptorchidism is primarily a clinical diagnosis based on physical examination. Imaging has limited utility for palpable testes and should NOT delay referral. [7,8]

When to Investigate

Bilateral Impalpable Testes → High DSD suspicion → Urgent workup:

Hormonal Assessment

• hCG Stimulation Test: [11]
  • Administer hCG 1500-2000 IU IM on days 0, 3, 7
  • Measure serum testosterone before and 24-48 hours after final dose
  • "Positive response (testosterone > 2.9 nmol/L or > 84 ng/dL): Suggests functional testicular tissue present (intra-abdominal testes or DSD)"
  • "Negative response: Anorchia likely"
• Anti-Müllerian Hormone (AMH): Produced by Sertoli cells; detectable if testicular tissue present
• Baseline LH, FSH: Elevated in anorchia (lack of negative feedback)
• 17-Hydroxyprogesterone (17-OHP): Elevated in CAH

Genetic/Chromosomal Studies

• Karyotype: Essential in bilateral impalpable testes to exclude DSD (46,XX CAH, ovotesticular DSD) [11]
• Consider SRY gene analysis if karyotype abnormal

Imaging (Limited Role)

Ultrasound

• NOT routinely recommended for palpable testes (low sensitivity for intra-abdominal testes ~50%) [18]
• May identify inguinal testis to confirm clinical examination
• High false-positive rate (identifies structures mistaken for testis)
• Should NOT delay referral or substitute for surgical exploration

MRI

• Higher sensitivity than ultrasound for intra-abdominal testes (~85%)
• Rarely used due to cost, need for sedation in children, and fact that laparoscopy provides definitive diagnosis and treatment simultaneously [12]
• May be considered in select cases (obese patients, discrepant findings)

Laparoscopy

• Gold standard for impalpable testis [12]
• Sensitivity and specificity approaching 100%
• Allows definitive localization:
  • "Intra-abdominal testis (viable): Proceed to orchidopexy"
  • "Atrophic nubbin: Orchiectomy"
  • "Blind-ending vessels: Vanishing testis (no further surgery)"
  • "Inguinal testis: Convert to open orchidopexy"
• Therapeutic as well as diagnostic

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7. Management

Management Algorithm

UNDESCENDED TESTIS SUSPECTED
(Empty Hemiscrotum on Examination)
         ↓
EXAMINATION IN WARM ENVIRONMENT
(Warm hands, frog-leg position)
         ↓
   TESTIS PALPABLE?
    ┌────┴────┐
   YES        NO (Impalpable)
    ↓          ↓
REACHES BOTTOM   UNILATERAL?    BILATERAL?
OF SCROTUM?          ↓              ↓
  ┌───┴───┐     IMAGING?       DSD WORKUP
 YES     NO     (optional)     (Karyotype,
  ↓       ↓         ↓           hCG, 17-OHP,
RETRACTILE TRUE UDT  LAPAROSCOPY   AMH, Genetics)
TESTIS    ↓        (Gold Standard)    ↓
  ↓      ↓              ↓         Determine Sex
ANNUAL  ORCHIDOPEXY   Intra-abdominal?  of Rearing
REVIEW  (6-18 months)  Inguinal?         ↓
(5-30%  IDEAL: 6-12mo  Absent/Atrophic?  Appropriate
become      ↓              ↓           Management
ascending) ↓          One or Two-Stage  (May include
        COMPLETED     Fowler-Stephens   Orchidopexy,
        BY 18 MONTHS  Orchidopexy       Gonadectomy,
                                        or Hormone Rx)

Conservative Management (Observation)

Indications

• Neonates and infants less than 6 months of age
• Spontaneous descent occurs in 70-80% of term UDT by 3-6 months [3]
• Preterm infants: Higher rate of spontaneous descent during first year

Monitoring

• Clinical examination at 6 weeks, 3 months, and 6 months
• Document testicular position at each visit
• If not descended by 6 months, spontaneous descent highly unlikely → refer for surgery

Hormonal Therapy

hCG or GnRH Analogue Therapy

• Historically used to stimulate testicular descent
• Success rate 10-20% with high relapse rate (up to 25%) [7]
• NOT recommended by AUA, EAU, or Nordic guidelines [7,8]
• May have role in:
  • Differentiating retractile from true cryptorchidism (no longer standard)
  • Improving testicular size prior to orchidopexy (controversial)
  • Countries where surgical resources limited

Why Not Recommended?

• Low efficacy
• High relapse rate
• Does not address anatomical causes (gubernacular abnormalities)
• Delays definitive surgical treatment
• Possible adverse effects on germ cells

Surgical Management: Orchidopexy

Timing [7,8]

• Recommended age: 6-18 months, ideally completed by 12 months
• Rationale for early surgery:
  • Germ cell loss accelerates after 6-12 months at elevated temperature [4]
  • Optimizes fertility potential (especially bilateral UDT)
  • Reduces (but does not eliminate) cancer risk [5]
  • Brings testis to palpable location for surveillance
  • Earlier surgery associated with better testicular growth

Palpable Testis: Standard Inguinal Orchidopexy

Procedure:

1. Inguinal incision
2. Identify and mobilize spermatic cord structures
3. High ligation of patent processus vaginalis (if present)
4. Division of gubernaculum
5. Mobilization of testis with preservation of vascular supply
6. Creation of subdartos pouch in scrotum
7. Fixation of testis in scrotum (various techniques: suture fixation vs. subdartos pouch alone)

Success rate: 92-98% [20]

Impalpable Testis: Laparoscopic Approach [12]

Diagnostic Laparoscopy Findings and Management:

Intra-Abdominal Testis Management:

• Single-Stage Laparoscopic Orchidopexy: If vessels reach scrotum without tension (less than 2 cm from internal ring)

  • Mobilize testis laparoscopically
  • Preserve testicular vessels
  • Bring testis down to scrotum through new inguinal canal or transperitoneal route

• Two-Stage Fowler-Stephens Orchidopexy: If testicular vessels too short [20]

  • "Stage 1 (First operation): Clip/ligate testicular vessels laparoscopically, preserve vas deferens and its collateral blood supply (vasal and cremasteric vessels)"
  • Wait 6 months for collateral circulation to develop
  • "Stage 2 (Second operation): Mobilize testis on vasal pedicle and bring to scrotum"
  • "Success rate: 60-85% (higher than one-stage Fowler-Stephens)"

Bilateral Impalpable Testes

• Stage procedures (not both sides simultaneously if two-stage Fowler-Stephens required)
• Consider hormonal evaluation and DSD workup first [11]

Management of Specific Scenarios

Retractile Testis [9]

• No immediate surgery indicated
• Annual clinical surveillance mandatory
• Educate parents about risk of becoming ascending testis (5-30%)
• If testis no longer reaches bottom of scrotum → ascending testis → orchidopexy required

Ascending Testis [10]

• Orchidopexy indicated regardless of age at diagnosis
• May require more extensive mobilization due to acquired fibrosis

Anorchia / Vanishing Testis

• Unilateral: Observation vs. testicular prosthesis for cosmesis (typically deferred until puberty)
• Bilateral: Testosterone replacement therapy at puberty; bilateral testicular prostheses

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8. Complications and Outcomes

Complications of Untreated Cryptorchidism

Infertility [4]

• Bilateral UDT:
  • Fertility rates 30-65% even with early orchidopexy
  • Paternity rates lower than general population
  • Abnormal semen parameters in 50-70%
• Unilateral UDT:
  • Paternity rates approach normal if orchidopexy performed less than 2 years of age
  • Contralateral descended testis often shows abnormal histology (suggests systemic factor)

Testicular Malignancy [5]

• 3-8 fold increased risk of germ cell tumors (seminoma most common)
• Risk highest in intra-abdominal testes (abdominal UDT: 4x risk vs. inguinal UDT)
• Bilateral UDT carries higher risk than unilateral
• Orchidopexy reduces but does NOT eliminate risk
  • Early surgery (less than 2 years) may reduce risk more than delayed surgery
  • Primary benefit of orchidopexy is bringing testis to palpable location for self-examination and surveillance
• Contralateral descended testis also at increased risk (2-3x)
• Peak age for testicular cancer: 20-40 years
• Lifelong testicular self-examination and awareness essential

Testicular Torsion [6]

• Abnormal testicular fixation predisposes to torsion
• Risk persists even after orchidopexy (albeit reduced)
• Torsion of undescended testis may present as acute inguinal/abdominal pain rather than scrotal pain

Inguinal Hernia

• Associated with patent processus vaginalis in 80-90% of cases [6]
• Herniation may occur before or after orchidopexy

Psychological and Psychosocial

• Body image concerns (especially if unilateral with scrotal asymmetry)
• Anxiety regarding fertility potential and cancer risk
• Impact on sexual health and confidence

Surgical Complications

Intraoperative

• Vascular injury to testicular vessels (rare less than 1%)
• Vas deferens injury (less than 1%)
• Bleeding

Early Postoperative

• Wound infection (1-2%)
• Scrotal hematoma
• Testicular swelling

Late Complications

• Testicular atrophy (1-5%): [20]
  • Higher risk with Fowler-Stephens procedures (10-20%)
  • Vascular compromise most common cause
  • Progressive over months to years
• Re-ascent of testis (1-3%): Testis returns to inguinal position
  • More common if inadequate mobilization or fixation
  • Requires repeat orchidopexy
• Testicular retraction (5-10%): Testis sits high in scrotum but palpable
  • May not require reoperation if palpable

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9. Prognosis and Long-Term Outcomes

Fertility Outcomes

[4,20]

Cancer Surveillance Recommendations

• Testicular self-examination monthly from puberty onwards
• Education on signs of testicular mass (painless, firm swelling)
• Clinical examination annually by healthcare provider
• Low threshold for ultrasound if any palpable abnormality
• No role for routine screening ultrasound in asymptomatic individuals (not cost-effective)

Risk Stratification:

• Bilateral UDT: Higher risk
• Intra-abdominal testis: Highest risk
• Delayed orchidopexy: Higher risk
• Contralateral descended testis: Also at increased risk (2-3x)

Testicular Function

Endocrine Function (Testosterone Production)

• Usually preserved even in bilateral UDT
• Leydig cells more resistant to temperature damage than germ cells
• Most men with UDT have normal testosterone levels and masculinization at puberty

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10. Guidelines and Evidence Base

Key Guidelines

Landmark Evidence

Timing of Surgery and Fertility

• Kollin et al. (2006): [4] Early orchidopexy (9 months) associated with better germ cell preservation than late surgery (3 years)
• Hadziselimovic et al. (2007): Germ cell counts decrease progressively after 6 months in cryptorchid testes
• Nordic study (2013): Fertility rates 2-3x better with surgery less than 1 year vs. > 1 year

Cancer Risk

• Pettersson et al. (2007): [5] Large Swedish cohort study - 3-4x increased risk; early orchidopexy (less than 13 years) reduced risk compared to late or no surgery
• Wood & Elder (2009): Intra-abdominal testes 6x higher cancer risk than inguinal testes
• Meta-analysis (Akre et al. 2009): Contralateral descended testis also at 1.7-2.3x increased risk

Laparoscopy for Impalpable Testis

• Elder (1989): [12] Early description of diagnostic laparoscopy; established as gold standard
• Radmayr et al. (2022): [8] Laparoscopy sensitivity/specificity ~100% for localizing impalpable testis

Gubernacular Pathophysiology

• Hutson et al. (2015): [15,16] Detailed molecular mechanisms of testicular descent; role of INSL3, androgens, genitofemoral nerve
• Churchill et al. (2011): [17] Matrix metalloproteinase role in gubernacular migration

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11. Examination Focus

Common Viva Questions

Q1: What are the two phases of testicular descent and what controls each phase?

Model Answer:
"Testicular descent occurs in two distinct phases. The transabdominal phase (weeks 8-15) involves descent from the renal area to the internal inguinal ring, mediated by Insulin-Like Factor 3 (INSL3) from fetal Leydig cells acting on the gubernaculum. The inguinoscrotal phase (weeks 25-35) is descent through the inguinal canal into the scrotum, mediated by androgens (testosterone and dihydrotestosterone) and modulated by the genitofemoral nerve. Disruption of the second phase is far more common in human cryptorchidism." [15,16]

Q2: How do you distinguish a retractile testis from true cryptorchidism?

Model Answer:
"A retractile testis can be manually manipulated to the bottom of the scrotum and remains there momentarily without tension, whereas a cryptorchid testis cannot reach the scrotal base or immediately retracts upon release. The examination must be performed in a warm environment with warm hands and the child relaxed (frog-leg position) to minimize cremasteric reflex activation. Retractile testes require annual surveillance as 5-30% may become ascending testes over time, but do NOT require immediate surgery." [9,18]

Q3: What is the recommended timing for orchidopexy and why?

Model Answer:
"Current guidelines recommend orchidopexy between 6-18 months of age, ideally by 12 months. This timing is based on histological studies showing progressive germ cell loss beginning at 6-12 months due to elevated testicular temperature. Earlier surgery optimizes fertility potential, particularly in bilateral cases. Additionally, early orchidopexy may reduce testicular cancer risk and brings the testis to a palpable location for lifelong surveillance." [4,7,8]

Q4: Describe your approach to a child with bilateral impalpable testes.

Model Answer:
"Bilateral impalpable testes is a red flag for potential disorder of sex development (DSD) or anorchia. I would conduct urgent investigations including karyotype (to exclude 46,XX CAH or ovotesticular DSD), serum 17-hydroxyprogesterone (for CAH), hCG stimulation test (functional testicular tissue), AMH (Sertoli cell marker), and baseline LH/FSH. Imaging has limited value; diagnostic laparoscopy is the gold standard for localization. A multidisciplinary team including paediatric endocrinology, genetics, urology, and psychology should be involved early." [11]

Q5: What is the Fowler-Stephens procedure and when is it used?

Model Answer:
"The Fowler-Stephens procedure is used for intra-abdominal testes when the testicular vessels are too short to allow the testis to reach the scrotum. In the two-stage approach (higher success rate than one-stage), the testicular vessels are clipped/ligated laparoscopically at the first operation, preserving the vas deferens and its collateral blood supply from vasal and cremasteric vessels. After 6 months allowing collateral development, a second operation mobilizes the testis on the vasal pedicle and brings it to the scrotum. Success rate is 60-85% with lower testicular atrophy risk than one-stage approach." [12,20]

Q6: What is the long-term cancer risk after orchidopexy and how do you counsel patients?

Model Answer:
"Men with a history of cryptorchidism have a 3-8 fold increased risk of testicular cancer (primarily germ cell tumors, especially seminoma), with highest risk in those with intra-abdominal or bilateral UDT. Orchidopexy reduces but does NOT eliminate this risk. The contralateral descended testis also carries a 2-3x increased risk, suggesting a systemic etiology. I counsel patients and families that lifelong monthly testicular self-examination from puberty onwards is essential, with low threshold for ultrasound if any abnormality is palpated. Peak incidence is age 20-40 years. The main benefit of orchidopexy regarding cancer is bringing the testis to a palpable location for surveillance." [5]

Common Mistakes in Exams

• Failing to distinguish retractile from true cryptorchidism – always assess whether testis reaches and stays at bottom of scrotum
• Recommending hormonal therapy – NOT recommended by major guidelines (AUA, EAU) due to low efficacy [7,8]
• Delaying referral beyond 6 months – spontaneous descent rare after this age [3]
• Not recognizing bilateral impalpable testes as a DSD red flag [11]
• Stating orchidopexy eliminates cancer risk – risk reduced but persists [5]
• Ordering imaging (ultrasound/MRI) for palpable testis – unnecessary, delays treatment [7,8,18]

Key Facts for Exam Success

• Most common genital anomaly in males (3% of term, up to 30% of preterm) [1]
• Spontaneous descent up to 6 months; rare thereafter [3]
• Orchidopexy 6-18 months (ideally by 12 months) [7,8]
• Laparoscopy is gold standard for impalpable testis [12]
• Bilateral impalpable testes → urgent DSD workup [11]
• Retractile testis = NO immediate surgery, annual surveillance [9]
• Testicular cancer risk 3-8x increased; persists lifelong after orchidopexy [5]
• Fertility worse in bilateral vs. unilateral; worse with delayed surgery [4]
• Hormonal therapy NOT recommended (low efficacy, high relapse) [7,8]
• Two-stage Fowler-Stephens for high intra-abdominal testis [20]

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12. Patient and Layperson Explanation

What is an Undescended Testis?

Before a baby boy is born, his testicles (testes) develop inside his tummy (abdomen) and normally move down into the scrotum (the pouch of skin below the penis) during the last few months of pregnancy. Sometimes, one or both testicles don't complete this journey and remain inside the tummy or in the groin area. This is called an undescended testicle or cryptorchidism.

Is it Common?

Yes, it is the most common genital problem in baby boys. It affects about 3 out of every 100 full-term baby boys, and is even more common in premature babies (up to 1 in 3 very premature babies). Many testicles will come down on their own during the first few months of life, so by 6 months of age, only about 1 in 100 boys still have an undescended testicle.

Why Does it Matter?

Testicles need to be in the scrotum because it is cooler there than inside the body. This cooler temperature is important for the testicles to work properly later in life. If a testicle stays inside the warmer part of the body:

• It can affect the ability to have children (fertility) in adulthood. This is especially true if both testicles are undescended.
• There is a slightly higher chance of developing testicular cancer later in life (though testicular cancer is still rare overall).
• There is a higher risk of the testicle twisting (torsion), which is painful and needs emergency treatment.
• It can affect confidence and body image, particularly in teenage years and adulthood.

What is the Treatment?

If the testicle has not come down by 6 months of age, it is unlikely to come down on its own. A small operation called orchidopexy (say: or-kee-o-PEX-ee) is usually recommended. This is ideally done between 6 and 18 months of age, with most specialists recommending it by around 1 year of age.

What Happens During the Operation?

The surgeon makes a small cut in the groin area, gently brings the testicle down into the scrotum, and stitches it in place so it stays there. Most children go home the same day or the next day. The operation is very successful in more than 90% of cases.

What if the Testicle Cannot Be Felt?

Sometimes the testicle cannot be felt during examination (called "impalpable"). In this case, a small camera operation (laparoscopy) is done to look inside the tummy and find where the testicle is (or if it is absent). The surgeon can often complete the treatment during the same operation.

What About Long-Term Monitoring?

Even after successful surgery, it is important to know that there is still a slightly higher chance of testicular cancer in adulthood compared to men who never had an undescended testicle. The good news is that testicular cancer is very treatable, especially when caught early.

From teenage years onwards, regular monthly testicular self-examination is recommended. This means gently feeling each testicle to check for any lumps or changes. If anything unusual is noticed, it should be checked by a doctor promptly.

What if My Child Has a "Retractile" Testicle?

Some boys have a testicle that moves up and down between the scrotum and the groin because of a sensitive muscle reflex. This is called a "retractile" testicle and is normal in many boys. It does NOT need surgery, but your child should have regular check-ups to make sure the testicle is not getting "stuck" higher up as they grow.

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13. References

1. Sijstermans K, Hack WW, Meijer RW, van der Voort-Doedens LM. The frequency of undescended testis from birth to adulthood: a review. Int J Androl. 2008;31(1):1-11. doi:10.1111/j.1365-2605.2007.00770.x

2. Hutson JM, Balic A, Nation T, Southwell B. Cryptorchidism. Semin Pediatr Surg. 2010;19(3):215-224. doi:10.1053/j.sempedsurg.2010.04.001

3. Batra NV, DeMarco RT, Bayne CE. A narrative review of the history and evidence-base for the timing of orchidopexy for cryptorchidism. J Pediatr Urol. 2021;17(2):239-245. doi:10.1016/j.jpurol.2021.01.013

4. Kollin C, Karpe B, Hesser U, Granholm T, Ritzén EM. Surgical treatment of unilaterally undescended testes: testicular growth after randomization to orchiopexy at age 9 months or 3 years. J Urol. 2007;178(4 Pt 2):1589-1593. doi:10.1016/j.juro.2007.03.173

5. Pettersson A, Richiardi L, Nordenskjold A, Kaijser M, Akre O. Age at surgery for undescended testis and risk of testicular cancer. N Engl J Med. 2007;356(18):1835-1841. doi:10.1056/NEJMoa067588

6. Favorito LA, Costa SF, Julio-Junior HR, Sampaio FJ. The importance of the gubernaculum in testicular migration during the human fetal period. Int Braz J Urol. 2014;40(6):722-729. doi:10.1590/S1677-5538.IBJU.2014.06.02

7. Kolon TF, Herndon CDA, Baker LA, et al. Evaluation and treatment of cryptorchidism: AUA guideline. J Urol. 2014;192(2):337-345. doi:10.1016/j.juro.2014.05.005

8. Radmayr C, Bogaert G, Dogan HS, et al. EAU Guidelines on Paediatric Urology. European Association of Urology. 2023. https://uroweb.org/guidelines/paediatric-urology

9. Pakkasjärvi N, Taskinen S. Surgical treatment of cryptorchidism: current insights and future directions. Front Endocrinol (Lausanne). 2024;15:1327957. doi:10.3389/fendo.2024.1327957

10. Tang W, Wei Y. The timing of cryptorchidism surgery: analysis of the contradiction between guideline consensus and clinical practice implementation. Pediatr Surg Int. 2025;41(1):291. doi:10.1007/s00383-025-06187-4

11. Hutson JM, Thorup J. Evaluation and management of the infant with cryptorchidism. Curr Opin Pediatr. 2015;27(4):520-524. doi:10.1097/MOP.0000000000000237

12. Elder JS. Laparoscopy and Fowler-Stephens orchiopexy in the management of the impalpable testis. Urol Clin North Am. 1989;16(2):399-411.

13. Rodprasert W, Virtanen HE, Toppari J. Cryptorchidism and puberty. Front Endocrinol (Lausanne). 2024;15:1347435. doi:10.3389/fendo.2024.1347435

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