Undescended testicles

The term undescended testicle or cryptorchidism describes the condition in which one or both testicles are not within the scrotum and can't be brought into the scrotum with external manipulation. A testicle may be located anywhere along its normal path of descent or in an ectopic location. Cryptorchidism is distinct from the situation when the testicle is "retractile," meaning that it can be brought into the scrotum by external manipulation or is seen in the scrotum sometimes. Young boys often have a strong "cremasteric reflex," which pulls up the testicles with stress or cold.

An undescended testicle may reside in the inguinal canal (the groin), inside the abdominal cavity, or in an unusual and "ectopic" location, such as above the pubic bone.Approximately 80% of undescended testicles can be found within the inguinal canal.Sometimes, the testicle is absent on one or both sides.It can be difficult to distinguish this situation from cryptorchidism, particularly if a testicle is present but inside the abdomen and not apparent on physical examination or even with imaging studies.

Diagnosis

The diagnosis of cryptorchidism is usually made by a child's parents or pediatrician. If a testicle can be brought into the scrotum, even if it retracts again on release, the diagnosis of cryptorchidism has been excluded and the testicle would be expected to assume a normal scrotal position when the endogenous (produced within) male hormone level of the adult is reached.

Sometimes, when a testicle can't be felt within the scrotum or in the groin, an ultrasound exam will be obtained. An ultrasound will sometimes demonstrate a testicle that can't be palpated.

Why do we operate on undescended testicles?

There are several reasons to perform an operation, called an orchidopexy, to bring an undescended testicle into the scrotum.

Fertility

The most important concern of the patient with an undescended testicle and his parents is related to the possibility of impaired fertility. When a testicle is not in the scrotum, it is exposed to higher temperatures than when it is in the scrotum and this is felt to impair the production of sperm. Irreversible microscopic abnormalities in undescended testicles are noted even in the first year of life, so it is believed that orchidopexy must be performed early in order to promote fertility. However, factors other than temperature, such as hormonal irregularities, are also likely to be involved in the abnormal development of undescended testicles. For this reason, the effect of orchidopexy on ultimate fertility is not completely clear. Overall, we feel that if orchidopexy is to have a chance of augmenting fertility it should be performed by 6 to 12 months of age, before microscopic changes develop.

Malignancy

There is an association between the incidence of testicular cancer and cryptorchidism. Approximately 10 to12% of testicular tumors arise in undescended testicles and an undescended testicle is at least 10 times more likely to undergo malignant degeneration than a normal testicle. The normally descended testicle on the side opposite the undescended one is also at increased risk for cancer. Orchidopexy does not decrease the incidence of malignancy, but it allows for the testicle to be properly examined by the patient and his physicians in the future so that cancer may be detected early if it develops.

Trauma

A testicle that resides in a scrotal position is at little risk from trauma in ordinary activity because of its mobility. When a testicle is trapped in an abnormal position it is more likely to be injured. Orchidopexy reduces this risk.

Cosmetic and psychological considerations

Although an undescended testicle is of little concern to the preschool child, body image issues will increase during teenage years. Orchidopexy usually results in a relatively normal appearing scrotum, although the undescended testicle frequently is smaller than the normal one on the other side.

The operation

Orchidopexy is usually performed as an outpatient procedure in the Outpatient Surgery Center (OSC). The operation takes about an hour. An incision of about an inch in length is made just above the groin. Another small incision is made on the scrotum to construct a pouch under the skin of the scrotum where the testicle is sutured in place after being pulled down from the inguinal canal.

Sometimes, when there is concern that the testicle is either within the abdomen or is absent, a laparoscope may be used to look inside the abdomen. Your surgeon will discuss this with you in detail if laparoscopy is considered

The office visit

When your child sees us, he will be seen by either the pediatric surgery nurse practitioner or the surgery resident. They will perform a history and physical examination on your child, answer any questions you may have, and complete all necessary paperwork. They will then discuss their findings with the attending pediatric surgeon. Your child's pediatric surgeon will examine your child and explain the procedure in detail.

Scheduling

If orchidopexy is indicated, once the paperwork has been completed, you will be taken to meet the surgery scheduler. She will be your contact person. She will inform you of the surgery date as well as the date of their PATS (Pre-Admission Testing) appointment.

Postoperative care

Medications

Pain control rarely requires more than over-the-counter pain relievers such as Children's Tylenol or Children's Advil. These may be given every four hours as needed.

Any other medications which your child required before the operation should be continued on a regular schedule afterward.

Diet

Nausea following general anesthesia is uncommon in infants. However, older children may experience nausea after discharge. Initially, liquids may be tolerated better than solids. There are no dietary restrictions once the nausea has passed and your child is alert and hungry.

Activity

Children require no particular restriction of activity following orchidopexy. They may have enough initial discomfort to limit their activity voluntarily for a day or so. However, larger children should avoid body contact sports for at least two weeks.

Wound care

Always wash your hands before touching or cleaning the incision area. Some blood staining of the paper tapes on the incision is common. If the blood is dry and not spreading, the staining is not a problem. If the blood seems fresh, the amount is increasing, or if the paper tape is blood soaked and partially floating above the skin, apply gentle pressure with a clean washcloth for five to six minutes. Then contact the pediatric surgery resident on call at (909) 558-4000. The problem is usually minor but the surgeon needs to know about it.

Bathing

No tub baths should be given for at least two days after the operation. Sponge bathing for infants and showering for older children are permitted the day following the operation. Carefully pat dry the incision tapes after showering.

When to call your child's surgeon

• Fever above 101^oF that does not come down with Tylenol (mild fever is common)
• Difficulty breathing, with or without a croupy cough
• Active bleeding from the incision
• Redness, swelling, or persistent pain in the incision

Follow-up

A clinic appointment needs to be scheduled one to two weeks after the operation. Please call (909) 558-4848 to schedule this appointment.

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