If one or both testicles are not in the scrotum after a child is born, it is a developmental disorder called undescended testis. Such undescended testicle almost always requires medical treatment.
What is undescended testis?
About 1-3% of all male infants and 30% of all premature infants are affected by undescended testis. Undescended testis is a developmental disorder in which either one or both testicles have not migrated into the scrotum. Usually, the testicles migrate into the scrotum around the seventh month of pregnancy. It is possible for delayed, independent migration of the testes into the scrotum to occur within the first year of life. Generally, a distinction is made between 3 forms of undescended testis:
Inguinal testis: Abdominal cavity and scrotum are connected by the inguinal canal, this is where the testis is located in this case
Sliding testicle: The testicle is always pulled back into the inguinal canal based on the fact that the spermatic cord of the testicle is too short
Abdominal testicle: It is not possible to feel the testicle, because it is located in the abdominal cavity.
The pendulum testis should be distinguished from these forms. The pendulum testicle is not a disease but the reflexive displacement of the testicle from the scrotum into the inguinal canal, here it is not an undescended testicle.
Causes
Undescended testis can have both an anatomic and a hormonal cause. For example, there may be an inguinal hernia or the inguinal canal may be too narrow, preventing the testicle from moving into the scrotum. Hormonal causes may include delayed development of the child in the womb, which also affects the migration of the testicle. In principle, the development of testicles in unborn babies takes place in the kidney region. Since the temperature outside the body, in the scrotum, is optimal for sperm production, the testicles migrate to the scrotum during development. Often, however, no definite cause is found in undescended testicles.
Symptoms, complaints and signs
The main symptom of undescended testis is incompletely descended testicles from the abdominal cavity after birth. This may affect one or both testicles. In this case, the testicles can be noticed either in the entrance area of the scrotum or not at all. There may be different forms of undescended testis, the symptoms of which may vary. The abdominal testicle (cryptorchidism) usually cannot be palpated at all. A pendulous testicle is located in the scrotum, but migrates back to the groin when it is cold, for example. An inguinal testicle can be palpated in the groin but cannot be passed into the scrotum. In contrast, a sliding testicle can be guided into the scrotum, but returns from there to the groin. It is particularly rare to have a testicular necropsy. This means that the testicle is not on its natural path, but is located, for example, in the thigh or perineum. Usually, the testicles are not located properly, but they are normally formed and developed. In childhood, undescended testicles are not associated with any other symptoms. If it persists beyond this age, it can lead to a number of late consequences. First and foremost, there is a risk of infertility. It can also lead to testicular cancer. Affected adults also complain of pain in some cases.
Diagnosis and course
During the U1 examination of the newborn, undescended testis can be diagnosed by a pediatrician. To make a diagnosis, the doctor palpates the scrotum while the child is in a standing, sitting, and lying position in succession. If the doctor is unable to palpate the testicle, a hormone stimulation test is performed to detect testicular tissue. Further diagnostic methods are performed with the help of laparoscopy, MRI and ultrasound. However, these procedures are not regularly performed in the case of undescended testicles. An undescended testicle that is treated too late can have various serious consequences in the course of time. Already damaged testicular tissue can lead to infertility. This occurs in about 30% of those affected. In addition, undescended testicles increase the risk of inguinal hernia and later testicular cancer.
Complications
If undescended testicles are not treated medically in a timely manner, there is sometimes a risk of serious complications as the condition progresses. These mostly become apparent from adolescence onwards. Babies and children rarely suffer the immediate effects of undescended testicles, such as hormonal imbalances or pain. Although the testicles do not attach correctly, they are formed normally. However, adolescents who are developing sexual awareness are at risk of psychological distress if one or both testicles are not in the scrotum. Usually, however, undescended testicles are treated before the first birthday, so this is rarely the case. Without therapy, there is a risk of secondary symptoms in adulthood, which include testicular torsion (rotation of the testicle). The rotation of the testicle on the spermatic cord is often caused by the wrong position of the testicle. Due to this, the vessels supplying the testicle are at risk of being cut off, so that the testicle may die without prompt treatment. In the case of an inguinal or sliding testicle, weak spots form inside the inguinal canal in some affected individuals. This, in turn, can conceivably cause intestines to burst from the abdominal cavity, which is referred to by medical professionals as an inguinal hernia. Another complication is infertility. If maldescensus testis is present in only one testicle, it has little effect. However, if both testicles are affected, sometimes significantly fewer children are conceived. Furthermore, undescended testicles can have a favorable effect on testicular cancer. Thus, without treatment, the risk of cancer increases twentyfold.
When should you go to the doctor?
Undescended testicles are usually diagnosed by a pediatrician immediately after birth and treated promptly. Medical treatment is required at the latest when the malposition of the testicles causes pain or other discomfort. Parents who notice such signs in their child are best advised to talk to the pediatrician. If serious complications develop, the child must be treated in the hospital. Parents should arrange for an examination immediately to minimize the risk of late complications such as infertility or testicular cancer. Individuals who have been diagnosed and treated for undescended testicles in childhood should continue to see their primary care physician or a urologist regularly later in life. A comprehensive examination will ensure that the testicle is properly positioned and not causing any problems. In addition, any triggers such as hormonal fluctuations can be identified and corrected at an early stage before undescended testicles occur. If the malposition is due to a serious disease, close monitoring by a specialist is required. Treatment is usually carried out in a specialist urology clinic.
Treatment and therapy
If the testis does not descend on its own within the first six months of life in the case of undescended testis, treatment by a urologist is recommended. However, before surgical intervention is performed, hormone therapy should be administered. Hormone therapy involves the administration of the hormone gonadotropin. Its purpose is to ensure that the testicle moves (further) into the scrotum. The hormone can be absorbed through the mucous membrane in the form of a nasal spray or injected intramuscularly. Hormone therapy for undescended testis is successful in 20% of all cases. There are exceptions in which surgery should be performed. These exceptions include:
- Undescended testis during puberty
- Simultaneous inguinal hernia
- Unsuccessful hormone therapy
- Abnormal positioning of the testis
During surgery, the testicle is surgically transferred to the scrotum and sutured there at the lowest point. If the testicle is already atrophied so it is removed to avoid further consequential damage. In any case of undescended testis, regular check-ups are necessary from the age of 15.
Outlook and prognosis
Within the first year of life, in rare cases, the affected testis may move into the scrotum on its own without treatment. However, as the patient ages, this becomes less likely. The earlier the undescended testicle is treated surgically or hormonally, the lower the risk of long-term complications or secondary diseases. The prognosis with hormone therapy is significantly better if the affected testicle has already previously migrated towards the scrotum. Hormonal therapy is successful in about 20 percent of those affected.However, about 25 percent of testicles that are initially successfully treated move back up out of the scrotum after hormone therapy. With surgical treatment, the prognosis is significantly better. In five percent of those affected, the treated testicle nevertheless migrates upwards again after the operation. Rarely, there is consequential damage due to the undescended testicle or the operation. For example, the testicle may already have been damaged before successful treatment and may be dysfunctional. After surgery, the testicle may also atrophy. If neither hormonal nor surgical treatment shows success, surgical removal of the testicle is often advised because of an increased risk of cancer. Even after successful treatment, the likelihood of developing testicular cancer is slightly higher.
Prevention
Since undescended testis is a developmental disorder, there are no preventive measures. Only late effects can be avoided by treating undescended testicles through early control examinations.
Aftercare
If the undescended testicle is treated surgically, a grace period must always be observed after the procedure. For optimal wound healing, the patient should stay in bed and rest for two days for this purpose. Physical activities should be avoided during this time. Bed rest can take place as an inpatient in the hospital or as an outpatient at home. Even after successful surgical or hormonal treatment, the testicles may become erect again. So-called atrophy, atrophy of the testicles, is also possible. In order to be able to detect these possible complications, close monitoring is recommended. For this purpose, follow-up examinations should be performed every three months. This involves an ultrasound to assess the size and position of the testicles. If the status of the testicles is not satisfactory six months after completion of therapy, the patient must usually present again to the treating surgeon. If the findings are normal, further follow-up examinations are necessary every three months to one year after surgery. In addition, patients over the age of fifteen should return for follow-up care. At this time, patients are examined for malignancies of the testis. The examination can take place at the pediatrician in charge. Alternatively, family physicians and urologists can also provide this care. Furthermore, according to the S-2 guideline, it is recommended that adolescents examine themselves at regular intervals. Any enlargement of the testicles should be reported to a physician immediately. This is especially the case if the enlargement occurs without pain.
What you can do yourself
If the child has been diagnosed with undescended testicles, medical treatment is required. The hormone therapy that takes place first can be supported by alternative methods from naturopathy and homeopathy in consultation with the doctor. However, the most important measure is the observation of the child. The child’s behavior can tell relatively quickly whether the hormone therapy is successful, because a lowering of the testicle is often noticeable by a reduction in pain. The affected testicle should be checked regularly by a doctor, as this is the only way to ensure that lowering is actually taking place. If the undescended testicle persists despite hormonal treatment, surgery must be performed. Since this is a routine procedure, the child does not need to be specially prepared for it. It is important to ease any fears the child may have and to make the time in the hospital as pleasant as possible. With older children, the developmental disorder should be discussed, preferably together with the pediatrician, who can explain the reasons for the disorder to the affected person and at the same time allay any fears regarding a surgical procedure. After the operation, the child should stay at home for a few days and take it easy. Especially sports activities should be avoided in the first period after an operation.
