OVERVIEW
• An undescended testicle or cryptorchidism is a testicle that has not reached its correct position in the bag of skin hanging (scrotum) below the penis at birth. Usually only one testis is affected, but about 10% of cases, both testes may remain undescended

• During fetal life the testes start developing within the abdominal cavity near the kidneys and descend into their normal position via a tubular passage i.e. the inguinal canal to within the scrotum about a month before birth. Occasionally they may descend into their normal position after birth also but if this does not happen within six months, it is unlikely to happen

• In certain cases, testes that have descended may go back up again into the groin and surgery may be needed to correct this

• Occasionally, in older infants or boys who had normally descended testes at birth, they might appear to be missing later. This can be due to the following reasons

? A retractile testis which moves in and out of the scrotum and can be easily guided back into the scrotum. This is due to a muscle reflex and is not considered abnormal

? An ascending testis which ascends into the groin after normally descending but cannot be easily guided back manually into the scrotum

• Undescended testicles can be classified by physical and operative findings into
? True undescended testicles which exist along the normal path of descent during development and have a normally inserted gubernaculum
? Ectopic testicles, which have an abnormal gubernacular insertion
? Retractile testes which are not actually undescended. It is very important to rule out this condition since no surgery or hormonal therapy is required for this

CAUSES AND RISK FACTORS
The exact cause of an undescended testis is unclear. It is postulated that a combination of genetic and environmental factors including maternal health can affect the hormones, nerve activity and physical changes necessary for the normal development of the testes

Risk Factors
• Low birth weight
• Premature birth
• Maternal smoking or alcohol use during pregnancy
• Family history of undescended testis
• Abnormalities that restrict fetal growth, such as Down syndrome or an abdominal wall defect
• Maternal exposure to pesticides

DIAGNOSIS
By six months of age, infants with undescended testes should be examined by a pediatric urologist or a qualified specialist. Monitoring and observation is not advised beyond one year of age since it reduces chances of successful surgical treatment and can impair spermatogenesis

If on physical examination, the testis is not palpated within the scrotum or guided back into the scrotum,
further investigations will be done to locate the testis.

• Bilateral non-palpable testes after birth – In some cases, where both testes are not felt in the scrotum after birth, other investigations must be done to evaluate for absent testes rather than undescended testes.

A phenotypically male baby with bilateral nonpalpable testicles is considered as a genetic female with congenital adrenal hyperplasia until proved otherwise. It is a life threatening condition and further hormonal evaluation is necessary

During physical examination, evidence of other conditions causing undescended testes such as inherited genetic conditions namely Prader-Willi, Kallmann’s or Laurence-Moon-Biedl syndromes should be
specifically looked for.

Concurrent presence of hypospadias and undescended testis is commonly associated with conditions of intersexuality, such as mixed gonadal dysgenesis and true hermaphroditism.

• Laparoscopy – A small tube with an attached camera at one end is introduced into the abdomen through a small incision. This is done to locate an intra-abdominal testis. Often, the doctor might be able to replace the undescended testis during this procedure, but further surgery might be needed in a few cases. Rarely, laparoscopy may demonstrate absence of testicle, or a tiny piece of nonfunctioning testicular tissue which is removed

• Open surgery – Direct open surgery abdomen or groin through a larger incision may be required in some cases to locate the missing testis

COMPLICATIONS OF UNDESCENDED TESTES
For testicles to develop and function normally, they require a slightly cooler than normal body temperature, which is provided by the scrotum. Complications of an undescended testis include the following

• Increased risk of testicular cancer – The risk is higher if the undescended testis is situated in the abdomen rather than lower down in the groin, and if both testes are involved. Surgical correction of an undescended testis might decrease, but not totally eliminate, the risk of testicular cancer later in life

• Infertility – Low sperm counts, poor sperm quality and decreased fertility are more likely in men with undescended testis, especially if the condition remains untreated for a long time

• Testicular torsion – The risk of testicular torsion is 10 times more in undescended testes. Testicular torsion is the twisting of the spermatic cord, which contains the blood vessels, nerves and the vas deferens, the tube that carries formed semen from the testis to the penis. Torsion can result in loss of the testicle due to cutting off of its blood supply

• Increased risk of injury – A testis located in the groin is more likely to be injured due to pressure against the pubic bone

• Inguinal hernia – If the opening between the abdomen and the inguinal canal is large, a portion of the intestines can enter the groin.

TREATMENT OF UNDESCENDED TESTIS
The goal of treatment is to replace the undescended testis to its normal site in the scrotum.

SURGERY
Treatment before 1 year of age is ideal but surgery should not be delayed beyond 18 months. The surgery is termed orchiopexy, where the surgeon carefully maneuvers the testicle back into the scrotum and stitches it into place. This procedure can be done either laparoscopically or by open surgery

HORMONE TREATMENT
Hormone treatment with human chorionic gonadotropin (HCG) injections may be beneficial in some cases. However, hormone treatment is not routinely advised because it is much less effective than surgery

OTHER TREATMENTS
If one or both testes are absent or were removed during surgery due to abnormal development, testicular prostheses may be introduced during childhood or adolescence to give the appearance of normal looking scrotum

If both testes are absent, an endocrinologist referral is necessary to further evaluate the child and administer hormone treatments to bring about puberty and physical maturity.

KEY POINTS
Undescended testis is an uncommon condition
Testes need cooler temperature of the scrotum for normal development and function
Early diagnosis and treatment (by 1 year) is essential to prevent complications
Complications include testicular cancer, torsion and infertility
Aim of treatment is to identify where the undescended testis is and put it back into place within the scrotum by surgery
Other causes of absent testes should be looked for and further evaluated