THE MEDICAL JOURNAL OF AUSTRALIA March 31, 1984
Discussion
In our series of patients, the results are similar to those of
Kirkwood et al:" Gallium-67 scintigraphy is a reliable
procedure in the assessment of lymph-node status; because
of its high degree of accuracy, it indicates to the clinician
when a lymph-node dissection is required. The improved
early detection of metastatic disease allows for the better
selection of treatment options.
One explanation for the poor results of earlier studies':' is
that they were performed with rectilinear scanners, which
are now obsolete. Modern gamma cameras have better
resolution and sensitivity. Our study was carried out by
means of gamma cameras with triple-pulse heightanalysis to
obtain maximum information for the examination. Another
explanation for the disparity in results is that the dose of
gallium-67 administered in these earlier studies was
significantly lower than that administered by Kirkwood et al.
and our group. The higher dose results in better counting
statistics, making the detection of abnormal foci more likely.'
Gallium-67 studies are useful: (i) to determine whether
regional lymph nodes have been invaded by metastatic
melanoma and thus necessitate surgical resection; (ii) to
monitor the response of distant metastases to systemic
therapy - because lesions may not change in size and yet be
fibrosed and inactive the assessment of response by serial CT
scans may be unsatisfactory, whereas gallium studies can
indicate whether the disease is metabolically active or not;
and (iii) as part of routinesurveillance for the early detection
of metastatic disease.
Short Papers
The retractile testis
ABSTRACT: One hundred boys who had a retractile testis
on one side were followed up for five years. The position
of the retractile testis became higher (in some, it left the
scrotum) in 42 boys and the development of this testis
MOST AUTHORS of textbooks on paediatric surgery state
that the retractile testis can be regarded as normal, and that
the lower limit of the rangeof movement of a testis will be its
final position."! These descriptions do not indicate the level
in the scrotum which the testis reaches, nor do they
distinguish between similar findings in young children and in
those who are older.
There are some general observations about testes, which
question the assertion that retractile testes should be
regarded as normal. 4
The Adelaide Children's Hospital, North Adelaide, SA 5006.
Geoffrey G. Wyllie, FRCS, FRACS. Surgeon.
Reprints: Mr G.G. Wyllie.
403
The onlydiscordance between the findings of Kirkwood et
al" and our group is in the detection of cerebral metastases.
Kirkwood et al. foundfour patients with cerebral metastases,
which were not demonstrable on the gallium-67 study. We
had two patients with cerebral metastases; in both cases,
these were clearly visible on the gallium-67 study (Figure 2).
The reason for this difference is unknown. However, our
results at other sites were similar to those of Kirkwood et al.
It is concluded that gallium-67 studies playa useful rolein
the staging and management of patients with malignant
melanoma. The combination of lymphoscintigraphy and
subsequent gallium-67 study may prove a useful diagnostic
tool, and further assessment of these combined
investigations is in progress.
Acknowledgement
Wewishto thank the NuclearMedicine Departmentof the Westmead Centre,Sydney.
for supplying the 99mTc antimonysulphide colloid usedin our study.
References
I. HofferPB, Bekerman C, Henkin RE. Gallium·67 imaging. New York: Wiley, 1978:
154-156.
2. Halpern S, Hagan P. Gallium-67 citrate imaging in neoplastic and inflammatory
disease. In: Nuclearmedicine annual. New York: Raven Press, 1980: 219-265.
3. Milder MS, Frankel RS, Bulkley GB, et 01. Gallium-67 scintigraphy in malignant
melanoma. Cancer 1973; 32: 1350-1356.
4. Jackson FI, McPherson TA, Lentle Be. Gallium-67 scintigraphy in multisystem
malignant melanoma. Radiology 1977; 122: 163-167.
5. Romolo JL, FischerSG. Gallium-e? scanning compared with physical examination
in the preoperative stagingof malignant melanoma. Cancer 1979; 44: 468-472.
6. Kirkwoood JM, MyersJE, Vlock DR, et 01. Tomographic gallium-67 citrate sean-
ning: useful new surveillance for metastatic melanoma. Ann Intern Med 1982;
97:694-699
7. Hoffer P. Gallium and infection. J Nucl Med 1980; 21: 484-488.
8. Bennett LR, Lago G. Cutaneous Iymphoscintigraphy in malignant melanoma.
Semin Nucl Med 1983; 13: 61-69.
Geoffrey G. Wyllie
was adversely affected in 49. Because of this, regular
review of boys with retractile testes should be continued
as long as retraction persists.
(Med J Aust 1984; 140: 403-405)
These are that (i) in mostboys, the testes are always at the
bottom of the scrotum, unless the scrotum has contracted
because of cold; (ii) in these boys, the cremasteric reflex
produces a small upward movement, but the testes do not
leave the scrotum; and (iii) there are some boys in whom one
testis is stable in the scrotum, while the other retracts.
This paperalsoquestions the view that a retractile testis is
normal, and suggests that, for too long, the complexity of the
retractile testis has been overlooked.
Patients and methods
One hundred boys, aged from 1.5 to 9 years (mean, 5.5 years),
who were referred consecutively because of a retractile testis and
404
who had a stable testis on the other side, were reviewed. The
retractile testes could be brought to a low scrotal position at least 70
min from the pubic tubercle - a position defined by Scorer and
Farrington as normal. 5 The retractile testes were low in the
scrotum when the boys squatted, were stable in the scrotum when
not being handled, and not only were they normal in size when
measured and matched against a chart of normal values but they
were the same size as the contralateral stable testis.
When boys with retractile testes were examined, the testicular
volume was assessed with an orchidometer, and the results were
compared with a chart of normal values of mean testicular
volumes. The distance between the pubic tubercle and the centre of
the testis was measured with a ruler.
An assessment of the size and position of the testes was made
regularly, at least once a year. All measurements were carefully
recorded. The survey was continued for five years. Often changes
were noted sooner, at times after two or three years of observation,
particularly in the older boys.
Results
Changes in the position and size of the retractile testis in 100
boys, which were found five years after the first assessment
was made, are as follows: unchanged, 36; testis smaller and
higher, 27; testis smaller, 22; testis higher, 15.
This shows that, five years later, the retractile testis was
smaller in 49 boys, while its position had become higher in 42
boys, compared with its normal partner. In 36 boys, the
position and size of the testis was maintained. Generally, if
the testis moved higher, its development was affected; the
size of the rectractile testis remained normal only in five of
the 42 boys in whom its position had become higher.
Of the 100 boys surveyed, 45 subsequently underwent
orchidopexy, because either the position or the size (or both)
of the retractile testis was unsatisfactory.
Discussion
Some authors have, at times, experienced difficulty in dis-
tinguishing between retractile and incompletely descended
testes." Three signs may be useful in this assessment:
1. Testicular size. - If the doubtful testis is smaller than
the contralateral normal testis, retarded development as a
result of incomplete descent is probable.
2. Speed of retraction. - A retractile testis which will
remain in the scrotum after puberty is usually stable for a
time after being manipulated into the lower part of the
scrotum. Immediate retraction suggests a tight cord.
3. Traction on the cord. - Gentle traction exerted on the
cord, while the testis is held with fingers, causes no pain
when the testis is normal. When the cord is abnormally tight,
this manoeuvre causes pain over the lateral half of the
inguinal canal.
When two or more of these signs are present, an
incompletely descended, rather than a retractile, testis is the
likely diagnosis.
I define a retractile testis as one which can be brought to a
low scrotal position, at least 7 em from the pubic tubercle,
when the testis is held down gently. It should be stable before
it retracts from the scrotum to the superficial inguinal pouch,
and it should be low in the scrotum when the boy is
squatting.
The commonly made statement "the testis was brought to
the scrotum" is not helpful. The assessment of retractile
testes is made easier if three levels in the scrotum are
considered. The normal position is low in the scrotum,
March 31, 1984 THE MEDICAL JOURNAL OF AUStRALIA
HIGH.....u~~
MID
FIGURE: Scrotal
positions, showing the
distance from the pubic
tubercle.
70 mm to 75 mm from the pubic tubercle; the midpoint is
60 mm; and the high scrotal level is only 50 mm from the
tubercle (Figure). There is a great deal of difference between
a retractile testis which reaches the bottom of the scrotum
and one which only reaches the top.
Scorer and Farrington have shown that spontaneous
descent of the testis stops during the first few months of life.5
However, changes in position are known to occur. These
authors have also drawn attention to the testis which
descends late, lies in the upper part of the scrotum, and is
always smaller than normal. The testes described in my
paper were different, because they reached the bottom of the
scrotum earlier in life and were normal in size, which
indicates that these testes were not dysmorphic.
Many surgeons who have seen a baby for other reasons
and have noted that the testes were at the bottom of the
scrotum, may have the same boy referred back at nine or 10
years of age (or even earlier) with one or both testes in the
superficial inguinal pouch. This has happened because the
testes became retractile and continued to retract. Two
common observations support this view. Many parents of
older boys with undescended testes insist that the testes were
in the scrotum in infancy. At operation a much better-
developed scrotum than in, say, the boy with an emergent
type of undescended testis is found in such boys.
Some years ago, I became aware of two aspects of the
behaviour of retractile testes - first, that many retractile
testes gradually adopt a higher position as the boy grows;
and, second, that retraction which continues after about
eight years of age may have an adverse effect on the
development of the testis, similar to the delayed development
of incompletely descended testes.
Farrington found the peak period of retraction to be
between five and six years of age, after which cremasteric
activity steadily declined." During this survey, I found that,
in most of the affected boys, retraction continued
throughout childhood, and stopped only just before the
testes began to develop as the first major sign of puberty.
Examples of this were the cases of four extremely
handicapped boys who needed an orchidopexy at about four
years of age. In each boy, the opposite testis was larger, but
was retracting, though it could be brought into the lower
part of the scrotum, to at least 70 mm from the pubic
TH~ MEDICAL JOURNAL Of AUSTRALIA March 31, 1984
tubercle, and its size was normal. Retraction continued
throughout childhood, but the testis could be broughtdown
at least to the middle of the scrotum in each boy. Because of
the severe handicaps, the parents did not wish further
treatment, but these boys were reviewed during their
adolescence. In each boy, the untreated testis was stable in
the upper Part of the scrotum after puberty, but was about
half the size of the treated testis (8-10 mL in size, whereas
the treatedtestes were at least20 mL in size). These cases in-
dicate the effectof continued retraction on the development
of the testis, even after a final scrotal position is attained.
It was recognized during this survey that the testis which
descends late and remains high could be confused with a
retractile testis. Bylatechildhood, a testis may be high in the
scrotum and smaller than normal because of continued
retraction. It was to avoid this problem that a group of
young children was chosen, so that any changes in the
position or size of the testis could be recorded at regular
reviews during childhood.
The surgeon may face a difficult decision in the case of an
older boywhose retractile testis is not developing at the same
rate as its partner, but can be brought at least to the mid-
scrotum, and would remain there under general anaesthesia.
TQe development of this testis is likely to become further
retarded if retraction continues which is also likely, for, if a
boyhasa retractile testis at 10years of age, it is probable that
Changes in the caries experience of 12-year-old
Sydney schoolchildren between 1963 and 1982
V. Jean Burton, Marilyn I. Rob, Graham G. Craig and James S. Lawson
ABSTRACT: A study of the caries experience of 12-year-
old children attending public high schools in the northern
suburbs of Sydney was undertaken in 1982. The data
obtained were compared with those from a similar
study conducted in the same area in 1963. In the
period between the two examinations, Sydney's water
supply was fluoridated and fluoride toothpastes became
widely available. There was a major improvement in
dental health in the 19-year interval between the
TQ ENSURE the effective utilization of available dental
resources, it is important to monitor changes in the
Health Department of NSW, Northern Metropolitan Regional Office,
Cox's Road, North Ryde, NSW 2113.
V. [ean Burton, BDS, Dental Officer.
Marilyn I. Rob, BSc, MA, Research Officer.
Dep~rtment of Preventive Dentistry, The University of Sydney,
2 Chalmers Street, Sydney, NSW 2010.
Graham G. Craig, MDS, PhD, Associate Professor in Preventive Dentistry.
H~alth Department of NSW, Central Office, Mckell Building, Rawson Place,
Sydney, NSW 2000.
James S. Lawson, MD, MHA, Director, Health Service Policy and Development.
Reprints: Associate Professor G. G. Craig.
405
retraction will still be present at 12 or 13 years of age.
I propose that the retractile testis which has not developed
as expected after being normal in size at the firstassessment,
irrespective of the position in the scrotum to which the testis
can be brought, is a further indication for orchidopexy.
Though such a testis may attain a scrotal position after
puberty, its probable size of 8-10 mL would suggest that the
testis may not be fertile.
There has been a tendency in the past for surgeons to
advise the parentsof boys with retractile testes that the testes
will attain a normal position in the scrotum eventually, and
further surveillance has not been advised. Contrary to this
laissez-faire policy, boys with retractile testes should be
examined at regular intervals as long as retraction continues,
bearing in mind that adverse effects maynot beobvious until
the boy reaches eight or 10 years of age.
References
1. Woolley MM: Cryptorchidism. In: Ravitch MM, Welch KJ, Benson CD, et 01., eds.
Pediatricsurgery. 3rd ed. Chicago: Year Book, 1979: 1399·1410.
2. Nixon HH, O'DonnellP: The essentials of paediatricsurgery.London:Heinemann,
1966: 212-219.
3. Jones PG: Undescended testes:In: Jones PG, ed. Clinical paediatric surgery.2nd ed.
Oxford: Blackwell, 1976: 286-292.
4. Wyllie GG. The diagnosis of undescended testes. Med J Aust 1978; 1:639-641.
5. Scorer CG, Farrington GH. Congenital deformities of the testis and epididymis.
London: Butterworths, 1971.
6. Farrington GH: The position and retractibility of the normal testis in childhood
with reference to the diagnosis and treatment of cryptorchidism. J Pediatr Surg
1968: 3:53-59.
surveys. The mean number of decayed, missing, and fill-
ed teeth (OMfT) per child declined from 8.49 in 1963 to
1.37 in 1982, a reduction of 84%. An analysis of the OMfT
index showed that the greatest reductions occurred in
the decayed tooth (OT), and missing tooth (MT) com-
ponents (95% and 94%, respectively). In 1982, in contrast
to the situation in 1963, the backlog of unmet restorative
dentistry needs was low.
(Med J Aust 1984; 140: 405-407)
prevalence and patterns of dental disease. In recent years,
the collection of such data has been facilitated by taking the
oral health status of a specific age group as an indicator of
more general changes in a community. The 12-year-old age
group is now regularly used as an indicator for school-aged
populations both in developed and in underdeveloped
countries.':'
In 1982, data on the caries experience of 12-year-olds were
collected as part of a larger survey to determine the dental
treatment needs of high-school children in the Northern
Metropolitan Health Region, Sydney. A similar survey of
the dental health of 12-year-old children was carried out in