Editors

SeppoTaskinen

Undescended Testicle

If left untreated, the amount of germ cells in an undescended testis decreases as the child grows. Even when treated, the undescended testes are usually smaller at adult age than testes that have descended normally.
Approximately one half of undescended testes observed at birth descend spontaneously during the first six months of life.
In pre-school age, a movable testis (testis saltans) is very common. The underlying cremaster reflex usually subsides by school age, but in some cases the testis may retract again. Possibly as many as one half of operations on undescended testes are performed because a previously descended testis has retracted back up. Testes that have descended at a rather late stage or that are hypermobile appear to be at particular risk for this.
Examine the testes at every health check in pre-school and school age.
Ultrasonography is usually not useful in estimating the need for treatment.
Refer to a paediatric surgeon a child with
- undescended testis or testes when the child has reached the age of six months
- earlier if absence of both testes is suspected (particularly if there is any abnormality in the external genitalia)
- also later if the testis is constantly out of the scrotum.
If the testes are at least occasionally in their proper place, e.g. when having a bath or a shower, no treatment is needed. In problematic cases the state of the testes should be checked annually.

Inspect the testes calmly with the child standing or sitting on a parent's lap in the tailor's position with the legs crossed. (The testis often bounces up when the examining hand approaches).
The testes are palpated either in the tailor's position or in supine position. The testis is ”milked” down from the inguinal fold with one hand and taken hold of with the other hand.
Note whether the testis can be pulled to the bottom of the scrotum and whether it remains there. If the testis retracts back up as if pulled by an elastic band as soon as the grip is released, referral to a paediatric surgeon should be considered.

The aim is to treat an undescended testis preferably already at the age of 6-12 months but not later than at the age of 18 months to minimize testicular damage 1.
Uncertain cases may require follow up before a decision on treatment can be made.
The treatment of a true undescended testis is surgical.
Even if positive results have been reported with hormonal therapy, it is suited mainly for mild cases when it is possible to pull the testis with effort to the scrotum but it does not remain there. The safety of hormone treatment especially in children below 2 years of age as regards to the development of the testes has been questioned, even if benefits have also been described. According to the current guidelines applied e.g. in the Nordic countries, hormone therapy is suitable only in exceptional cases if at all 2.

Toppari J. Paediatrics: New cryptorchidism guidelines reach a consensus. Nat Rev Urol 2014;11(8):432-3. [PubMed]
Ritzén EM, Bergh A, Bjerknes R, et al. Nordic consensus on treatment of undescended testes. Acta Paediatr 2007 May;96(5):638-43. [PubMed]