Cryptorchidism Flashcards
What is cryptorchidism?
Congenital abscence of one or both testses in the scrotum due to a failure of descent.
Epidemiology
Found in 6% of newborns but drops to 1.5-3.5% of males at 3 months.
Types of cryptorchidism.
True undescended where testis is absent from scrotum but lies along the line of testicular descent
Ectopic testis where it is found away from the normal path
Ascending testis where the testis was found in the scrotum at one time but has begun an ascension.
Pathophysiology
Normally it should descend from abdomen to the scrotum by being pulled by the gubernaculum within processus vaginalis.
In bilateral cases hormonal causes like androgen insensitivity sndrome or disorder of sex development must be excluded
Risk factors
Prematurity
Low birth weight
Other abnormalities like hypospadias
First degree relative with cryptorchidism
Clinical features
Clarify whether the testes have ever been seen or palpated like on a newborn check.
Soemtimes they may not the testicle in the scrotum in certain situation, like in a warm bath.
Examination findings
It might be found on examination in the scrotum = it might be retractile
Otherwise palpation should begin to locate it.
80% of undescended testis are still palpable.
Explain how to do a thorough testis examination
Have the infant/child laid flat on the bed.
With warm hands palpate laterally with your left hand from inguinal ring and owrk along inguinal canal to pubic symphysis.
If found one should attempt to see if the testis can be gently milked down to the base of the scrotum -> Retractile testis diagnosis.
If it is pulled down but under tension in the base, this is called a high scrotal or high testis.
What are inguinal undescended testis?
It can sometimes be found within the groin, along the inguinal canal and you might not be able to bring it down, this is an inguinal undescended testis.
Around 20% of undescended testis are impalpable.
What are they then?
Either…
Ectopic
Intra-abdominal
Absent
Or impalpably small
What can make it easier to palpate the testis?
Add a little soap to finger tips to remove any friction.
The testis should roll easily under the finger tips and will not feel dissimilar to a raised enlarged LN.
Dx
Normal retractile testis
True undescended
Ectopic
Absent
Bilaterally impalpable
Initial management of undescended testis associated with ambiguous genitalia or hypospadias or bilateral undescended.
Urgent referral to senior paediatrician within 24 hous.
This is because it can be a presentation of congenital adrenal hyperplasia (CAH) and can lead to salt-losing crisis which means it requires high dose sodium chloride therapy and careful glucose monitoring with steroid replacement
Imaging
No imaging has been shown to be of benefit in the diagnosis
Management at birth
Review at 6-8 weeks again
Management at 6-8 weeks.
If fully descended => No further action
If unilateral = re-examine in 3 months
If bilateral => Urgent referral to senior paediatrician within 24 h
Management at 3 mo
If retractile => Annual follow up
If undescended => Refer to paediatric surgery/urology for definitive intervention ideally at 6-12 mo of age
What to do before intervention?
Examination under anaesthesia with laparoscopy to ascertain the location of the impalpable testis.
Management of a palpable non-reducible testis.
Open orchidopexy.
Groin incision is made and the processus vaginalis and cremasteric covering is separated from the cord
The testis is mobilised and fixed in the scrotum.
Management of intra-abdominal testis.
2-stage procedure Fowler-Stephens
Testicular vessels are located and ligated.
This allows for more robust colalteral vessels to allow a second stage to bring the testis into the scrotum at a second operation 6 mo later.
What should be done if there is an atrophic testis?
It should be removed.
What should be done in an absent testis with blind-ending vas and testicular vessels or vas and vessels enter the deep inguinal ring.
Groin exploration
Surgical complications
Infection
Bleeding
Wound dehiscence
Small risk of testicular atrophy and testicular re-ascent.
Complications of an undescended testis
Impaired fertility because it is too hot for spermatogenesis
Testicular cancer (this risk is even double if correction is undertaken after puberty)
Torsion
