Maldescended Testicles

PEDIATRIC UROLOGY TREATMENTS

Maldescended Testicles

Cryptorchidism is the most common abnormality of the genitourinary tract in male children, with an incidence slightly higher than 1%.

Maldescended Testicles

Table of Contents

Definition

Is cryptorchidism a rare disease ... or is it common in newborns?

Maldescended Testicles is a condition where the testicles abnormally develop inside the abdomen in the embryo/fetus and then fail to descend into the scrotal sac. It is a common genital problem that could greatly affect adult life with regard to both fertility and the risk of tumor development. Hence, it must be treated in the first year of life if possible.

It can occur in isolation or can be a sign of some congenital, endocrine, chromosomal or intersex anomalies (Prune Belly Syndrome, Carpenter Syndrome, Klinefelter Syndrome, Trisomy, etc.). In this section of our website, we will only assess cryptorchidism in isolation.

The importance of this pathology lies in:

Cryptorchidism is the most common anomaly of the genitourinary tract in male children, with an incidence rate slightly above 1%. The prevalence (the percentage of times a disease appears in the total population) at the time of birth is related to gestational age and the weight of the newborn. In premature babies less than 30 weeks of gestation, the percentage rises to 30%, in those under 900 g it is 100%, while the figure drops to 2.5% in those born at full term. Between the first and third month of life, 60% of the maldescended testicles descend in the neonatal period. So the prevalence decreases to 1%, and this percentage is maintained in the first year of life. Testicular descent is hardly ever observed after three months of age, except in premature patients.

It usually affects the right testicle (70%) more than the left (30%). It is bilateral in 10-20% of cases and the most common location is inguinal (72%), followed by penoscrotal and abdominal. In 3% of cases, there is no testicle. Testicular ascent has been observed in one-third of the children whose testes descended postnatally and in between 2% and 45% of children with scrotal testes at birth.

There are a number of predisposing factors: maternal, fetal and even environmental:

Maternal:

Environmental:

Fetal:

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Diagnosis

How do I know if my son has cryptorchidism? What are the ways to diagnose it?

The testicle considered normal is that which is visible and palpable at the base of the scrotum without any manipulation. When it is located outside the scrotum, it is referred to as a maldescended testicle.

Two large groups can be distinguished according to the physical examination:

· Nonpalpable testicle ·

No testicle is found, either because it does not exist or because it is inaccessible to palpation since it would be located in the abdomen (intra-abdominal testicle).

· Palpable testicle ·

A testicle is evident outside the scrotum. It can be:

1 Palpable undescended testicle; located in the normal course of testicular descent but can not descend to the scrotum or if it does, it immediately retracts when released.

Classification of actual testicular descent in boys

Classification of ectopic testicular maldescent in boys

2 Ectopic testicle; located out of the scrotal sac and off the path of normal testicular descent. It can be femoral, perineal, transverse, etc. The most common is the superficial inguinal i.e. a subcutaneous testicle on the fascia of the external oblique.

Classification of ectopic testicular maldescent in boys

3 Retractile testicle; manually manipulated to descend from its inguinal location to the scrotum. However, it ascends when triggered by the cremasteric reflex and then descends spontaneously to the scrotum when the reflex is nullified. It usually occurs between the ages of 1 – 14 years.

4 Acquired undescended testicle (acquired cryptorchidism); It is a testicle that was located in the scrotum in the first years of life and then ascended to the inguinal canal. It occurs in between 3 and 45% of cases with retractile testes.

The clinical history and physical examination constitute the fundamental pillars for the evaluation and management of children with maldescended testicles.

· Information the Doctor will ask during the first consultations ·

Background information is very important in knowing whether there are other cases of maldescended testicles in the family, in addition to details like the duration of pregnancy and birth weight. For the pediatric urology specialist, it is important to ask when the parents first noticed the empty scrotal bag, because if at birth the testes were in the scrotal sac and then later ascended outside the scrotum, the diagnosis will be retractile testicles or ascended testicles.

Physical examination

To carry out the examination correctly, care must be taken with the baby:

Complementary examinations

In general, no further examination is necessary when the testes are palpable.

They are only indicated in special cases such as a “bilateral non-palpable testicle” or when a disorder of sexual differentiation is suspected (ambiguous genitalia, intersexual state, testicular hypoplasia, proximal hypospadias, a micropenis, hypospadias with cryptorchidism, etc.).

A number of indications are evaluated between two and three months of age:

Hormonal study:

Other possible investigations for more complex cases include:

But, many men can suffer from some curvature of the penis without necessarily being a case of Peyronie’s disease. Because of this, there is a medical criteria to determine when a penile curvature is pathological and when it is not: the angle of the penile curve.

It is considered a pathological penile curvature when the organ has an angle of incurvation equal to or greater than 30 degrees. Less than that, it rarely causes discomfort during sex or masturbation and therefore no treatment is necessary.

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solutions

Solutions and treatment: possible options and results

The testicle located out of the scrotum undergoes alterations in its biochemistry and its physiology, with an abnormal maturation: decrease in the number of germ and Leydig cells, absence of maturation of the former, mitochondrial degeneration, smaller seminiferous tubules, peritubular or perivascular fibrosis, and other alterations that are described in the chapter on the prepubertal testicle.

The main objectives of hormonal or surgical treatment are the improvement of future fertility, the prevention of malignant degeneration, ensuring the child grows without aesthetic or functional problems (that allow an adequate psychosocial development), and enabling the early diagnosis of a possible testicular tumor in the future, since it is rather more frequent in these patients than in the general population.

The retractile or undescended testicles generally don’t require any treatment but require at least one annual consultation, since more than 30% of the cases have been reported to be at risk of ascending and requiring orchidopexy.

Hormonal treatment

Within the last decade, hormonal treatment has not been recommended due to its low effectiveness, since it only achieves testicular descent in 20% of cases and a fifth of them reascend six months later. The effectiveness seems to be greater the lower the testicle is located.

The results with the two types of hormonal treatment that exist in the European market (HCG and gonadotropin-releasing hormone [GnRH]) are practically similar. HCG has side effects, and this has been another reason why its use has been abandoned.

In our practice in Seville, we do not use this treatment, except in some very specific cases (simple) in which the results are expected to be optimal and we also want to avoid surgery.

Surgical treatment

Currently, in the last decade, hormonal treatment is not recommended due to its low effectiveness, since it only achieves testicular descent in 20% of cases and a fifth of them reassemble six months later. The effectiveness appears to be greater the lower the testicle is located.

The results with the two types of hormonal treatment that exist in the European market (HCG and gonadotropin releasing hormone [GnRH]) are practically similar. HCG has side effects and this has been another reason its use has been discontinued.

In our Seville office, we do not use this treatment, except in some very specific (simple) cases whose results are expected to be optimal and we also want to avoid surgery.

Surgical treatment

The recommended age of orchidopexy has been progressively decreasing to improve fertility in adulthood.

Currently, many articles suggest that maldescended testicles is an endocrinopathy triggered by its anomalous location, rather than an anatomical abnormality of the testicles’ location and, therefore, recommend that orchidopexy be performed between the ages of 6 and 12 months, and at most before 18 months.

The surgical technique is different depending on whether the testicle is palpable or not. The palpable testes are approached by inguinal incision or by high scrotal incision (Bianchi technique), while the non-palpable are scanned and treated with laparoscopy.

 It is recommended to follow the following surgical principles: 

  1. a) treatment of the associated inguinal hernia; b) mobilization of the testicle and spermatic vessels; c) section of cremaster fibers; d) non-dissection between the vessels and the vas deferens, and e) place the testis in a dartos pouch so that it sits in the scrotum without tension.

First, under general anesthesia, a physical examination of the inguinal canal will be performed. If there is a testis, orchidopexy is carried out through the inguinal route. On the other hand, laparoscopy is performed if the testicle is not palpated.

Some centers recommend prosthetic placement for psychological reasons to allow the development of a normal body appearance

complications

Prognosis, problems, and complications of this disease

Most of the existing non-surgical treatments are considered conservative therapies (with little or no corrective effect) because they do not directly manipulate the lesion of the tunica albuginea of ​​the penis where the curvature is occurring.

These treatments consist of the administration of drugs designed to stop and reverse the scarring process of the corpora cavernosa. They are indicated in the initial stages of the disease (acute phase) when there is pain

Results of the surgery

If performed by an expert pediatric surgery or urology team, the results are usually good with very low risks of possible complications. It has a success rate of 95% in palpable testes and between 85 and 90% in non-palpable testes. When using the Fowler-Stephens technique, the single-stage procedure has a success rate of 74%, compared to 85-90% with the two-stage procedure.

Postoperative control

It is advisable to carry out periodic and prolonged controls: During the first year after surgery, control is done at 1, 6 and 12 months; then the control is every 1 or 2 years, to assess testicular development. It is useful to teach the patient to do self-examination because although the risk of malignancy (tumor) is low, it can occur from the second decade of life.

Spermiogram

The spermiogram of adults with maldescended testicles is better in unilateral cases (only one testicle) and is increasing in relation to those who underwent surgery at an early stage. The initial concrete location of the malignant testis does not seem to influence fertility.

Malignant degeneration

Currently, the chances of cryptorchidism predisposing to a testicular tumor in the future are estimated to be between 2 to 6 times more than in the general population, depending on the age at which the orchidopexy was performed. If the surgery was performed before 12 years of age, the chances are 2 times more than in the general population, and if it was performed after the age of 13, it rises to about 6 times more. There is a greater risk of tumor in the bilateral and intra-abdominal cases and when associated with genital anomalies.

Postoperative control;
It is advisable to carry out periodic and prolonged controls: During the first year after surgery, control is done at 1, 6 and 12 months; then the control is every 1 or 2 years, to assess testicular development. It is useful to teach the patient to do self-examination because although the risk of malignancy (tumor) is low, it can occur from the second decade of life.

exploración física genital

Frequent questions

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Is there a remedy or solution other than surgery? Massages? Physiotherapy? Medications and hormones?

Unfortunately, it is not so simple. Entering the operating room is the necessary solution for the restoration of testicular normality. There is no other method. As we have seen above, hormonal treatment is often complementary and prior to surgery, but not a substitute for it. Of course, you should not manually manipulate the area with massages or physiotherapy, since it would not only achieve nothing but could be harmful as well.

My baby has a testicle that appears and disappears from his scrotum. Does he have a maldescended testicle?

If it presents that variable behavior, it is very likely a retractile testicle, not a maldescended testicle. As we discussed earlier on this page, retractile testicles don’t require surgery, but observation and patience, because it is a condition that tends to solve by itself when the male is approaching puberty.

Dr. Pedro Lopez Pereira, a renowned urologist who has treated hundreds of children in his long experience at the Hospital La Paz in the Community of Madrid is the head of our Pediatric Unit and he performs all the interventions in addition to following up the results.

Dr. Natalio Cruz

Author

Dr. Natalio Cruz


El Dr. Cruz, con 25 años de experiencia médica, ha sido hasta 2016 Jefe de la Unidad de Andrología en el Servicio de Urología del Hospital Virgen del Rocío de Sevilla, Coordinador Nacional de Andrología de la Asociación Española de Urología (AEU) y Secretario General de la ESSM, cargos que ha delgado para centrarse de lleno en el ilusionante proyecto de ofrecer una consulta médica privada de alto nivel en Sevilla.

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