This document discusses three cases of testicular maldescent in infants seen by Dr. Hassaan Ali. For the first case, the doctor examines a 6 month old infant with an empty hemi-scrotum and determines it is a unilateral undescended testis without other anomalies. The second case involves another 6 month old with a bilateral empty scrotum, requiring diagnostic tests and possible one or two-stage surgery. The third case is a 6 month old with a bilateral empty scrotum since birth, necessitating a clinical exam to locate the testes and potential laparoscopy. The document also reviews factors, exams, investigations, treatments including hormones or surgery, and reasons for managing undescended testes.

1. Testicular Maldescent
cases discussion
GadHassaan Ali Ahmed
Assistant lecturer of urology and Andrology
Dr. Hassaan Ali 2014

2. Dr. Hassaan Ali 2014

3. Case no.1
Male infant 6 months old came to outpatient clinic
by her mother , she notes that he has abnormal
external genitals in the form of empty hemi
scrotum.
Dr. Hassaan Ali 2014

4. Dr. Hassaan Ali 2014

5. would you like to ask the mother
any questions before examine the
infant ?
Predisposing factors
prematurity,
birth weight,
small for gestational age,
twinning,
maternal exposure to estrogens in the first trimester,
Time of presentation.
Dr. Hassaan Ali 2014

6. How to examine this infant?
Dr. Hassaan Ali 2014

7. How to examine this infant?
the patient needs to be warm, relaxed and in frog leg position.
The state of the scrotum is important.
Presence or absence of features like hypoplasticity,
bifidity, rugae,
transposition,
hypospadias and chordee should be noted.
Serial examinations may be required.
Dr. Hassaan Ali 2014

8. what did you find?
Dr. Hassaan Ali 2014

9. what did you find?
1-unilateral palpable undescended testis without associated
genital anomalies.
2-unilateral non palpable testis without associated genital
anomalies.
3-UDT with associated genital anomalies.
Dr. Hassaan Ali 2014

10. What investigation
European Association of Urology Guidelines
Physical examination is the only method of differentiating
palpable and non-palpable testes.
There is no benefit from ultrasound (US), computed
tomography (CT), magnetic resonance imaging (MRI) or
angiograph
Diagnostic laparoscopy
is the only reliable examination to confirm or exclude
an intra-abdominal, inguinal and absent/vanishing testis
Dr. Hassaan Ali 2014

11. Management
1- Hormonal Therapy effectiveness less than 20%
HCG stimulates Leydig cells directly to produce testosterone,
The schedule is 1500 IU/m2 given by intramuscular
injection twice a week for 4 weeks. doses not exceeding
15,000 IU.
GnRH stimulates the pituitary to release LH and thereby
promote testicular production of testosterone.
in a dosage of 1.2 mg/day divided into three dosages per day
for 4 weeks using a nasal spray.
Dr. Hassaan Ali 2014

12. Management
Standard Orchidopexy for inguinal testes .
Laparoscopic exploration that will determine whether there is a
testis, or not
and if it can be brought down in one or two steps
Dr. Hassaan Ali 2014

13. If we see this child in age of 6yrs
old, what the lines of treatment ?
European Association of Urology Guidelines
Remove an intra-abdominal testis in a boy > 10 years with
a normal contralateral testis.
A one-stage or two-stage Fowler-Stephens procedure can be
performed in a bilateral intra-abdominal testes or in a boy <
10years.
Microvascular auto-transplantation has a 90% testicular survival
rate, but requires very skillful and experienced surgical techniques.
Dr. Hassaan Ali 2014

14. If you see this child in age of 18 years old?
Orchiectomy is typically reserved for post pubescent males
with a contralateral normally descended testis
Dr. Hassaan Ali 2014

15. Case no.3
Male infant 6 months old came to outpatient clinic by his father
due to empty scrotum since birth.
Dr. Hassaan Ali 2014

16. What are you looking for on clinical
examination?
Location of the both testes.
Penile size.
Urethral abnormality.
Scrotal condition.
Dr. Hassaan Ali 2014

17. Location of the both testes.
Bilateral inguinal testis.
left inguinal and right NPT.
Bilateral NPT.
Bilateral NPT with other congenital anomalies.
Dr. Hassaan Ali 2014

18. Investigation
For bilateral NPT.
-Is this child a boy? Karyotype;
-Are the testes present? human chorionic gonadotrophin
(HCG) test/anti-Müllerian hormone (AMH)/follicle-stimulating
hormone-luteinizing hormone (FSH-LH)
-Where are the testes? Laparoscopy: one- or two-stage
orchidopexy
Dr. Hassaan Ali 2014

19. Medical ttt.
HCG stimulates Leydig cells directly to produce testosterone,
GnRH stimulates the pituitary to release LH and thereby.
Dr. Hassaan Ali 2014

20. Surgical
Bilateral inguinal testis.
standard orchiopexy in tow cessation
left inguinal and right NPT
orchiopexy first then laproscopyleft standard
Dr. Hassaan Ali 2014

21. Surgical
Bilateral NPT.
Diagnostic laparoscopy.
one-stage or two-stage Fowler-Stephens procedure can be
performed.
Dr. Hassaan Ali 2014

22. If this child come in adult age.
Dr. Hassaan Ali 2014

23. Why we should treat undescended
testes?
1. To increase likelihood of fertility
2. Facilitation of testicular examination for cancer
3. Correction of the associated persistent processus vaginalis.
This is found in 90% of the cases.
4. To prevent testicular torsion.
5. Prevent trauma. The undescended testis is more likely to be
pressed against the iliac bone.
6. Reduce the psychological trauma associated with an empty
scrotum.
Dr. Hassaan Ali 2014

24. THANK YOU
Dr. Hassaan Ali 2014