Pediatric Surgery: Cryptorchidism, Retractile & Vanishing Testicles

Cryptorchidism (Undescended Testicle)

Basics

  • Can Be Unilateral (Most Common) or Bilateral
  • Timing:
    • Congenital: Extra-Scrotal from Birth
    • Acquired: Intra-Scrotal at Birth & Then Ascend Later
  • Most Common Congenital Abnormality of the GU Tract
  • Most Spontaneously Descend by 6 Months
    • Spontaneous Descent After 6 Months is Unlikely

Testicle Location

  • Superficial Inguinal Ring – 44% (Most Common)
  • Superficial Inguinal Pouch – 26%
  • Inguinal Canal (Canicular) – 20%
  • Intraabdominal – 6%
  • Absent – 3%

Presentation

  • Hypoplastic, Hypopigmented, Empty Scrotum
  • Increased Infertility
    • 10% Risk if Unilateral
    • 38% Risk if Bilateral After Orchiopexy
  • High Cancer Risk (4-6x)

Diagnosis

  • Diagnosed on Physical Exam by an “Experienced Provider”
  • Generally, Imaging Is Not Indicated
  • If No Testicle Palpable on New-Child Exam, Plan Follow Up in 4 Months

Treatment

  • Primary Treatment: Orchiopexy Between Ages 6-18 Months if Does Not Descend
    • Palpable: Scrotal Orchiopexy
    • Non-Palpable: Exploratory Laparoscopy
      • If Found: Laparoscopic Orchiopexy
      • If Not Found: Inguinal Exploration
  • Testicular Arteries are Generally Ligated to Provide More Length, Good Collaterals

Risk Modification After Surgery

  • Cancer Risk is Decreased but Not Completely Resolved
    • *It Was Previously Believed that Cancer Risk was Not Improved at All
  • Fertility Improved

Inguinal Canal 1

Cryptorchidism on US 2

Retractile Testicle

Basics

  • Definition: A Testicle That is Pulled Out of the Scrotum by an Exaggerated Cremasteric Reflex but Can Be Manually Replaced
  • Retractile Testicle is Generally Considered a Variant of Normal
  • Increased Risk for Acquired Cryptorchidism

Diagnosis

  • Differentiated from Cryptorchidism on Physical Exam

Treatment

  • No Treatment Necessary
  • Repeat Exam Every 6-12 Months Until the End of Adolescence or Until Testis Has Completely Descended

Vanishing Testicle (Testicular Regression Syndrome)

Basics

  • Definition: A Testicle That was Initially Present Early in Development but Disappeared In Utero Due to Torsion or Vascular Accident

Diagnosis

  • Initial Physical Exam:
    • Presents with Nonpalpable Testicle, Similar to Cryptorchidism
    • May See Compensatory Contralateral Testicular Hypertrophy
  • Differentiate from Intraabdominal Cryptorchidism at Exploratory Laparoscopy
    • Findings: Blind-Ending Spermatic Cord with No Macroscopic Testicular Tissue

Treatment

  • No Treatment Necessary

References

  1. Gray H. Anatomy of the Human Body (1918). Public Domain.
  2. Haggstrom M. Wikimedia Commons. (License: Public Domain)