0 Define the undescended testes.

0 Differentiate between the undescended testes ,

retractile testes .
0 Etiology and complication of the undescended
testes.
0 Work up and management plan for the
undescended testes .
 Introduction
0 Cryptorchidism is the most common congenital
abnormality of the genitourinary tract . Most
cryptorchid testes are undescended, but some are
absent .
0 Cryptorchidism by definition suggests a hidden
testis: a testis that is not within the scrotum and
does not descend spontaneously into the scrotum
by four months of age .
Bilateral undescended
testicles
 Cont…
0 Undescended testes – True undescended testes
have stopped short along their normal path of
descent into the scrotum .They may remain in the
abdominal cavity (or they may be palpable in the
inguinal canal (intracanalicular) or just outside the
external ring (suprascrotal) .
Laparoscopic view of
intraabdominal testis
Bilateral suprascrotal
undescended testes
 Cont..
0 Retractile testes : Retractile testes are normal
testes that have been pulled into a suprascrotal
position by the cremasteric reflex.
0 These testes can be brought into a dependent
scrotal position and will remain there if the
cremasteric reflex is overcome (eg , holding the
testis in the scrotum for at least one minute ).
 Cont..
0 Ascending testes : Ascending testes are noted to
be in a scrotal position in early childhood and
then to "ascend" and become undescended (ie,
acquired undescended testes) .
0 Ectopic testes : Ectopic testes descend normally
through the external ring but then are diverted to
an aberrant position. They may be palpable in the
superficial inguinal pouch (most common),
suprapubic region, femoral canal, perineum , or
contralateral scrotal compartment (least common).
 Ectopic testis : Right ectopic
testis palpable in the perineum.
 Embryology

(A) The testes appear on the urogenital ridge (second month).

(B) The coelomic cavity evaginates into the scrotal swelling where it forms
the processus vaginalis (middle of the third month).
(C) Testes begin descent into the scrotum guided by the gubernaculum
(seventh month).
(D) The processus vaginalis obliterates spontaneously (shortly after birth).
 Cont..
0 The mechanisms responsible for normal testicular
descent are not well understood.
0 The intraabdominal phase of descent is thought
to be androgen-independent and mediated by
descendin .
0 Passage through the inguinal canal, which begins
in the 28th week of gestation, is believed to result
from interaction between mechanical, hormonal,
and neurotransmitter effects.
 Cont..
0 Changes in abdominal pressure, patency of the
processus vaginalis, gubernacular regression,
androgens, gonadotropins, müllerian inhibiting
substance (MIS), and calcitonin gene-related
peptide are all thought to play a role.
 PATHOGENESIS
0 The pathogenesis of undescended testes is less
well understood than that of normal testicular
descent .
0 Alterations in any of the factors that contribute
to normal testicular descent may theoretically
result in undescended testes.
0 Gonadotropin deficiency in utero, decreased MIS,
and increased expression of estradiol in the
placenta have been proposed as contributing
factors
 EPIDEMIOLOGY
0 Between 2 and 5 percent of full-term and
approximately 30 percent of premature male
infants are born with an undescended testis.
0 Most (approximately 70 percent) congenitally
undescended testes descend spontaneously.
 RISK FACTORS
0 Risk factors for undescended testes include
prematurity, and birth weight <2.5 kg .
0 Prenatal exposure to endocrine disruptors (eg,
diethylstilbestrol, pesticides) also has been
associated with cryptorchidism in some studies .
 COMPLICATIONS
0 complications and sequelae of undescended
testes include inguinal hernia, testicular torsion,
testicular trauma, subfertility, and testicular cancer.
0 Surgical repositioning of the testis (orchiopexy)
before puberty appears to decrease the risk of
testicular cancer, but does not completely
eliminate it.
0 Important aspects of the history in a patient with
cryptorchidism include :
 Whether or not the testes were in a scrotal location in
the neonatal period .
 Previous inguinal surgery (may be associated with
iatrogenic cryptorchidism related to mechanical
tethering of the testis or cord in scar tissue).
 Evidence of endocrine abnormalities during pregnancy
(eg, maternal androgen exposure, which may result in
significant virilization of a female fetus).
 Family history of unexplained neonatal deaths or
genital anomalies, abnormal pubertal development, or
infertility.
0 The testicular examination in the infant and young
child requires two hands. The hands may be lubricated
with surgical lubricant or warm, soapy water if
necessary. One hand is placed near the anterior
superior iliac spine and the other on the scrotum.
0 The first hand is swept from the anterior iliac spine
along the inguinal canal to gently express any retained
testicular tissue into the scrotum. A true undescended
or ectopic inguinal testis may slide or "pop" under the
examiner's fingers during this maneuver.
0 A low ectopic or retractile testis may be felt by the
second hand as the testis is milked into the scrotum
by the first hand.
 Cont…
0 The ectopic testicle will immediately spring out of
the scrotum when it is released. The retractile
testicle will remain momentarily in the scrotum
until further stimulation causes a cremasteric
reflex.
 Cont..
0 Differentiation of a retractile testis from a true
undescended testis is sometimes difficult;
consultation with a urologist may be valuable.
Position, consistency and size of the undescended
testicle in relation to the opposite testis are noted.
0 If a testis cannot be palpated in the inguinal canal
or the scrotum, or in ectopic sites such as the
femoral region or perineum, evaluation for a
nonpalpable testis must be initiated.
 Cont..
0 Sometimes tissue in the scrotum may feel like an
atrophic testicle. Occasionally this tissue
represents gubernaculum or dissociated
epididymis and vas deferens, and may coexist
with an intra-abdominal testis. Unless the
presence of a testicle is clear, examination by a
urologist is indicated.
 Cont..
0 In addition to examination of the testes,
examination of the genitalia should include
assessment of the phallus, position of the urethral
meatus, scrotum, and inguinal canal.
 Phallus – A small phallus may be a clue to a
disorder of sexual development or
hypopituitarism.
 Urethral meatus – Hypospadias, particularly if the
meatus is scrotal or perineal, is associated with
disorders of sexual development.
 Cont..
0 Scrotum – A hypoplastic or poorly rugated scrotum
may indicate decreased likelihood of spontaneous
descent , a bifid scrotum may be a clue to a disorder
of sexual development.
0 Inguinal canal – The inguinal area should be examined
for fullness. Inguinal fullness may be associated with
an intracanalicular testis, inguinal hernia, or inguinal
lymphadenopathy.
0 Almost 90 percent of undescended testes have an
associated patent processus vaginalis .Occult inguinal
hernia in boys with untreated undescended testis can
present at any time with the typical symptoms or
complications, including incarceration.
 Imaging
0 Imaging is not routinely warranted to locate
nonpalpable testes. Imaging studies lack the
sensitivity and the specificity to alter the need for
exploratory surgery .
0 Ultrasound examination may be advisable in the
infant with bilateral nonpalpable testes to look for
gonads and to exclude the presence of a uterus,
which would suggest a state of intersexuality.
0 Ultrasound examination may also be helpful in the
overweight child to detect inguinal testicles that
are difficult to palpate.
(eg, mixed gonadal
dysgenesis)
Mixed gonadal dysgenesis
Mixed gonadal dysgenesis
 Hormonal therapy
0 Treatment for cryptorchidism can be hormonal,
surgical or a combination of the two. Because the
process of testicular descent is hormonally
mediated, it can sometimes be induced with
hormone administration.
0 In the United States, the only hormone labeled for
the treatment of cryptorchidism is hCG, which is
administered intramuscularly.
0 A high undescended testis is unlikely to descend
completely; if it does, it will probably ascend after
the hormone stimulation is withdrawn.
 Cont..
0 Some side effects of hCG administration can be
disturbing for parents. These include enlargement
of the penis, pubic hair growth, increased
testicular size and aggressive behavior during
administration.
0 GnRH is not currently labeled for use in the
treatment of cryptorchidism in the United States.
0 Testosterone minimally effective . (why )
 SURGERY FOR THE
UNDESCENDED TESTIS
o Palpable testes :

0 Orchiopexy is a well-established surgical

procedure for repositioning undescended testes
that are palpable . The testis is manipulated into
the scrotum and sutured in place.
0
Orchiopexy
 Cont..
o Nonpalpable testes :
0 Exploratory surgery for the nonpalpable testis is
diagnostic and potentially therapeutic. The first
surgical objective is to determine whether or not
the testis is present; viable testes are positioned
and fixed within the scrotum.
0 nonviable testicular remnants are removed. At
the time of surgery, approximately 10 percent of
boys with nonpalpable testes are found to have
blind-ending testicular vessels, indicating an
absent testicle .
 (A) Left internal ring laparoscopy view with blind ending
vessels (arrows) and vas deferens (arrowheads) confirming
an absent testis.
(B) Right internal ring laparoscopy view with
normal testicular vessels and vas deferens exiting the
internal ring
 Two surgical approaches are used in the
management of boys with nonpalpable testes: the
open inguinal approach and the laparoscopic
approach.
 In the open inguinal approach, the groin is
explored. If cord structures or testicular remnants
are found, they are removed, and the procedure is
terminated. If the groin exploration is negative,
the incision is extended, and the peritoneum is
entered in a search for an intra-abdominal testis.
 Cont..
 The diagnostic laparoscopy is a safe procedure in
experienced hands . The laparoscope, placed via
the umbilicus, is used to examine the inguinal
rings, determine the patency of the processus
vaginalis, and examine testicular vessels.
 Cont..
0 The finding of blind-ending spermatic, confirming
the absent testis, permits termination of the
procedure without a groin incision. Groin
exploration is carried out if testicular vessels and
vas deferens are visualized exiting the internal
ring.
0 The laparoscopic identification of an
intraabdominal testis permits planning for the
definitive procedure (eg, open versus
laparoscopic).
 Summary
0 Most testes that are undescended at birth complete their
descent within the first three to four months of life.
0 omplications and sequelae of undescended testes include
inguinal hernia, testicular torsion, testicular trauma,
subfertility, and testicular cancer.
0 the goal of management is to place and fix viable
undescended testes in a normal scrotal position or to
remove nonviable testicular remnants.
0 Surgical treatment of congenitally undescended testes is
recommended as soon as possible after six months of age
and definitely should be completed before the child is two
years old. In children with testicular ascent later in
childhood, surgery generally should be performed within six
months of identification.
Reference