Commonest cause for empty scrotum is undescended testis. Proper education of physicians and parents regarding timing of surgery is mandatory to avoid serious consequences.

1. CHILD WITH AN EMPTY SCROTUM
A PROBLEM ORIENTED APPROACH

2. CHILD WITH AN EMPTY SCROTUM
A PROBLEM ORIENTED APPROACH
Dr.B.SELVARAJ MS;Mch;FICS;
NEONATAL & PEDIATRIC SURGEON
MELAKA MANIPAL MEDICAL COLLEGE
MELAKA– 75150 MALAYSIA
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3. CHILD WITH AN EMPTY SCROTUM
Recognise various conditions
Clinch correct diagnosis
Appropriate investigations
Timely surgical referral
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A PROBLEM ORIENTED APPROACH
OBJECTIVES

4. CHILD WITH AN EMPTY SCROTUM
UNDESCENDED
TESTIS
ECTOPIC TESTIS
RETRACTILE
TESTIS
POST-TORSION
ATROPHY
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CAUSES

5. Embryology Of Testicular Descend
Primitive gonad in urogenital ridge turns into
testis by gene in short arm of Y
chromosome; Early Testis3 hormones
TestosteroneFrom Leydig cells CSL
regression
Mullerian inhibiting substance from
Sertolli cells Mullerian duct regression
Insulin- like3 hormone Thickening of
caudal gubernaculum holds testis close to
inguinal abdominal wall Relative
descend of testis
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8 to 15 Wks of Gestation- Transabdominal Phase

6. Embryology Of Testicular Descend
28 to 35 Wks of Gestation- Inguinoscrotal Phase
At 25 Wks Processus vaginalis
elongates into gubernaculum
Distal end of gubernaculum elongates
and reach scrotum between 30- 35 wks
Then testis descend through patent
processus vaginalis
Testosterone GFN CGRP
Migration of gubernaculum along with
testis to scrotum
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7. Various Stages Of
Testicular Descend
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8. Classification Of Cryptorchidism
(Hidden Testis)
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9. UNDESCENDED TESTIS
ETIOLOGY
Anatomical
Endocrine
Iatrogenic
• Short spermatic
artery
•Retroperitoneal
Adhesion
•Malfunctioning
Gubernaculum
•Narrow inguinal
ring/ canal
• Pituitary
deficiency
•Testosterone
deficiency
•Post Herniotomy
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10. UNDESCENDED TESTIS
Testicular descend is arrested in it’s normal path
Rt side60%; Lt side30%;Bilateral10%
Premies30%; Full term Neonates 4to5%;
3Month infant1to2%; 1Yr olds0.3%
Empty poorly developed Scrotum
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11. UNDESCENDED TESTIS
Always associated with patent processus vaginalis
Inguinal Hernia
If testis is palpable in groin do Milking Manuver to
R/O Retractile testis
Palpate perineum upper thigh to R/O Ectopic Testis
If testis is impalpable needs further workup to
localise the testis
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12. UNDESCENDED TESTIS
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13. UNDESCENDED TESTIS
Milking Manuver
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14. UNDESCENDED TESTIS
Complications
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TRAUMA
TORSION
TESTICULAR
MALIGNANCY
PSYCHOLOGICAL
PROBLEMS
INFERTILITY

15. UNDESCENDED TESTIS
Postnatal Germ Cell Development
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16. UNDESCENDED TESTIS
Infertility Cancer
Scrotum 4*c than core body temperature Ideal for
spermatogenesis
Transformation of Neonatal gonocyte to type A
Spermatogonium is impaired
This transformation occurs at 3to 6 months of age
Dysplastic gonocyte is the cause for malignant
transformation in early adulthood for infertility
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17. UNDESCENDED TESTIS
Workup
In Bilateral Impalpable Testis: HCG stimulation test to
confirm presence of testis
To localise testis the Gold standard is Laparoscopy
Diagnostic Therapeutic
USG of Groin Abdomen
CT Scan Groin Abdomen
MRI of Abdomen
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18. UNDESCENDED TESTIS
Management
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19. UNDESCENDED TESTIS
INGUINAL ORCHIDOPEXY
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20. UNDESCENDED TESTIS
INGUINAL ORCHIDOPEXY
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21. Algorithm for Impalpable Testis
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22. UNDESCENDED TESTIS
DIAGNOSTIC LAPAROSCOPY
Vas and Testicular vessels
entering the internal inguinal ring
Canalicular UDT
Blind ending Vas and Testicular
vessels
Anorchia (Vanishing Testis)
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23. UNDESCENDED TESTIS
Laparoscopic Fowler Stephens
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24. UNDESCENDED TESTIS
Laparoscopic Fowler Stephens
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Prentiss Maneuver

25. UNDESCENDED TESTIS
Complications of Orchidopexy
Damage to Testicular vessels Testicular Atrophy
Damage to Vas Deferens Infertility
Retraction of Testis out of Scrotum
Hemorrhage
Wound infection
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26. ECTOPIC TESTIS
Testis after coming out of external inguinal ring
has migrated into an abnormal location
Sites of ectopic testis are
- Superficial inguinal pouch
- Perineum
- Pre penile
- Opposite side scrotum- crossed ectopic
- Femoral triangle
Diagnosis is obvious Orchidopexy is easy
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27. Sites of UDT Ectopic Testis
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28. ECTOPIC TESTIS- Perineal
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29. RETRACTILE TESTIS
Testis can be manipulated into
scrotum
Testis is pulled and held high by
overactive cremastric muscle
Descends into scrotum whenever
child is relaxed/ sleeping
By puberty testis grow in size
remain in scrotum
No intervention is needed
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30. CHILD WITH AN EMPTY SCROTUM
www.themegaller
y.com

31. CHILD WITH AN EMPTY SCROTUM
www.themegaller
y.com

32. TAKE HOME MESSAGE
Child should be operated between 6months to 1year
Undue delay in surgery carries the risk of infertility
and malignancy in adult life
Hormone therapy may be tried between 3to 6
months
Retractile testis should not be operated
Intra abdominal testis is best managed with
Laparoscopy
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