Cryptorchidism

Question 1

What is cryptorchidism?

Answer 1

• Congenital absence of one or both testes in scrotum
• Due to failure of the testes to descend during development

Question 2

3 subgroups of cryptorchidism

Answer 2

• True undescended testes - absent from scrotum but lies along the line of descent
• Ectopic - testis found away from normal path of descent
• Ascending - testes previously identified in scrotum undergoes secondary ascent out of scrotum

Question 3

Pathophys of cryptorchidism

Answer 3

• In normal embryological development the testis descends from abdomen to scrotum
• Pulled by the gubernaculum within the processus vaginalis
• If bilateral, should exclude hormonal causes too eg androgen insensitivity or disorder of sexual development

Question 4

RF for cryptorchidism

Answer 4

• Prematurity
• Low birth weight
• Abnormalities of genitalia eg hypospadias
• First degree relative with cryptorchidism

Question 5

Clinical features of cryptorchidism

Answer 5

• Check if testis are ever palpable in scrotum - sometimes present when in warm bath for example
• Inspect to see if in scrotum - if are then retractile or normal testes
• If not - try and palpate

Question 6

How to try and palpate for testis within scrotum

Answer 6

• Patient lie flat on bed
• Keep child comfortable and relaxed
• Warm hands, palpate laterally with left hand from inguinal ring, along canal to pubic symphysis
• Use other hand to palpate testis in scrotum
• If difficult, can use soap on hands to reduce friction, testis will feel like lymph node and role under finger tips

Question 7

What to do if you find teste along pathway when palpating?

Answer 7

• See if testes can be milked down to the base of the scrotum - if can = retractile testis
• If it is pulled down but under tension at the base = high testis
• If testes within inguinal canal and cannot be milked down = inguinal undescended teste

Question 8

What are the terms used if you cannot palpate testis in scrotum or along pathway?

Answer 8

Could be any of these:
* Ectopic
* Intra-abdominal
* Absent
* Impalpably small

Question 9

Normal retractile vs true undescended testis

Answer 9

• Retractile - seen intermittently in scrotum, with minimal traction can be pulled to base of scrotum
• True undescended - palpable or impalpable, located along normal decent pathway but cannot be manipulated to the base of scrotum

Question 10

Initial management cryptorchidism - when to refer

Answer 10

If:
* Disorder of sexual development is suspected OR
* Undescended testis associated with ambigious genitalia OR
* Bilateral undescended testis

–> referral to senior paediatrician within 24hrs
Could be congenital adrenal hyperplasia - risk of salt losing crisis - high dose NaCl therapy and glucose monitoring with steroid replacement

Question 11

Imaging for cryptorchidism?

Answer 11

• No imaging has shown to benefit

Question 12

Long term management cryptochidism based on age

Answer 12

• Birth - review at 6-8 weeks
• 6-8 weeks - if unilateral, re-examine at 3 months
• 3 months - if retractile annual follow up, if undescended refer to paeds surgery/urology for intervention ideally at 6-12 months

Question 13

Intervention for cryptorchidism

Answer 13

• If unable to find testes on examination - EUA followed by laparoscopy
• If palpable testis - open orchidopexy
• If found to be intra-abdominal - 2 stage procedure
• Atrophic testis - removed

Question 14

Complications of cryptorchidism

Answer 14

• Short term - Infection, bleeding, wound dehiscence
• Atrophy and re-ascent
• Impaired fertility - testes 2-3 degrees warmer if intra-abdominal, affects spermatogenesis, esp if bilateral
• Testicular cancer - 2-3x more common
• Torsion - undescended at higher risk