undescended testis

1. DR ALLEN DAVID
MODERATOR: DR MONIKA NANDA MENON

2.  congenital absence of one or both testes in the scrotum due to a failure of the
testes to descend during development.
 It is the most common birth defect of the male genital tract
 Derived from Greek word which means “hidden testis”
 Reccurent cryptorchidism: testes non scrotal at birth  descend spontaneously
postnatally  return to a non scrotal position
 Acquired cryptorchidism: testes are intrascrotal at birth  subsequently
identified in an extrascrotal position. Also known as Testicuar ascent

3.  2–5% of full term and 25–30% of preterm male infants are born with undescended
testes
 1% at 1 year of age
 Bilateral in 10–30% of cases
 80% of undescended testes are palpable
 a component of over 390 syndromes.
 Associated conditions: Prune belly syndrome, neural tube defects, etc.

5.  Transabdominal descent complete by 10 weeks
 Traverses inguinal canal between 20-28 weeks
 32nd week – emerges from superficial inguinal ring.
 35-40th week –descends into the scrotum.
 Left testis descends before the right.
 About 96% of testes have descended at birth.

6.  Multifactorial pathogenesis.
 Testicular descent occur as a result of a complex interactions of hormonal and
mechanical factors

7.  Testosterone
 Dihydrotestosterone
 Mullerian-inhibiting Substance(MIS/AMH)
 HCG
 Genital branch of genitofemoral nerve which secret CGRP (elaborated by
testosterone)
 Non androgen–insulin like factor 3(INSL-3)

8.  Shortening and traction of the gubernaculum testis
 enlargement/elongation of processus vaginalis.
 Intra-abdominal pressure from increased visceral size.
 Straightening of fetus.
 Resolution of physiological hernia.
 Enlargement of testes/growth of epididymis.
 Propulsive force of the developing cremasteric muscle.

9.  True undescended testes (UDT): Testes found along its normal path of descent but
not reached scrotum
 Ectopic Testes: Testes found outside its normal path of descent and outside the
scrotum
 Retractile Testes: Normally descended testes, found in a suprascrotal position due
to an overactive cremasteric reflex
 Vanishing testis: present initially in development but lost owing to vascular
accident or torsion
 Agenesis: testis that was never present and therefore associated with ipsilateral
Mullerian duct persistence

10.  With warmed hands
 supine, frog leg position with both legs free
 Scrotum observed for hypoplasia
 Inguinal region examined before scrotum to prevent activation of cremasteric
reflex
 Contralateral testes can show compensatory hypertrophy.

11.  Check in path of descend of testis
 If testes is not found in normal path of
descent, possible ectopic locations have
to be examined
 Common ectopic locations:
 Inguinal region
 Perineum
femoral canal
 penopubic area

12.  There is no role for routine imaging in undescended testes
 Ultrasound has 88% accuracy for localization of undescended testis and is more
accurate than clinical examination
 Ultrasound lacks the efficacy to detect or definitively say there is no intra-
abdominal testes

13.  Undescended testes rarely descends after 6–10 months
 Orchidopexy should be performed as early as possible after 10 months of age to
prevent progressive loss of germ cells.
 UDT can undergo torsion at any age and emergency surgery is warranted in case
of acute pain with redness.

14.  prematurity
 low birth weight
 having other abnormalities of genitalia (i.e. hypospadias)
 having a first degree relative with cryptorchidism.

15.  INFERTILITY: Many men who were born with undescended testes have reduced
fertility, even after orchiopexy in infancy.
 CANCER RISK:
 About one in 500 men born with undescended testis develops testicular cancer
 a four- to 40-fold increased risk
 The peak incidence occurs in the third and fourth decades of life.
 The most common type of testicular cancer occurring in undescended testes is seminoma.
• PSYCHOLOGICAL IMPACT

16.  T- Trauma
 E- Epididymo-orchitis
 S- Sterility
 T- Torsion
 I –Inguinal Hernia
 S - Seminoma

17.  Observation is indicated for the first 6 postnatal months to allow spontaneous
testicular descent.
 If descent does not occur in the postnatal period SURGICAL TREATMENT at 6
months of age.
 Open orchidopexy is the standard of treatment for palpable UDT.
 Diagnostic laparoscopy is recommended for all nonpalpable UDT.

18.  If it reveals absent, dysplastic or atrophic testes, it is excised and sent for biopsy.
 If intra-abdominal testes are identified,
 single stage laparoscopic orchidopexy
 staged Stephen Fowler (FS) procedure based on the length of the vessels.

19.  First stage of FS orchidopexy involves clipping and division of spermatic vessels.
 Second step is done 3 - 6 months later and Testes mobilized and fixed in scrotum.
 This interval is necessary for the improvement of the collateral circulation
 The main aim of surgery in these patients is to make it palpable for early
detection of malignancy and preserve hormonal function.

20.  surgical removal of one or both testicles.
 Done in postpubertal men with a contralateral normally positioned testis.

21.  Haematoma
 Infection
 Unsatisfactory position (requiring revision)
 Ilioinguinal nerve injury
 Damage to the vas
 Testicular atrophy
 Torsion testis.

22.  Boys with undescended testes may suffer from lower fertility rates
 Age at intervention and laterality is an important predictive factor
 2–8 fold increase in risk of malignancy.
 Close follow-up warranted after puberty.