Undescended Testes
What is undescended (cryptorchidism) testes?
When a male child is born, both the testes should be felt down in scrotum where they should be normally. When either one of them or both testicles cannot be felt in scrotum it is called as undescended testes.
What is the cause of undescended testes?
As of now we don’t know exact cause, there are various theories why this happens. It may involve multiple factors like genetics, environmental factors which disrupts maternal hormones, physical changes, nerve activity etc.
Some of the risk factors associated with undescended testes:
- Prematurity
- Low birth weight
- Other sibling having undescended testes
- Maternal Ingestion of some pesticides
- Associated with other disorders like Downs syndrome
- Alcohol use or cigarette smoking by mother during pregnancy
Basically when we are in mommy’s tummy (antenatally) testes are inside abdomen. Slowly as our growth happens inside mommy’s tummy these testes start going down towards scrotum. At birth (when child has completed nine months in mommy’s tummy) both testes should be down into scrotum. This process of testes going down in scrotum gets stopped or slows down and testes doesn’t come into scrotum. It may remain inside the abdomen of baby or may remain little higher than usual.
What are the symptoms of undescended testes?
Undescended testes is more common in premature boys. Generally after birth you will see scrotal sac is empty and you cannot feel the testes. When your son in born in hospital your paediatrician or attending physician will notice absence of testes in scrotal sac.
When should I see the doctor?
When your son in born a paediatrician or attending physician will notice undescended testes. They will advise you to be seen by pediatric surgeon or pediatric urologist. You can schedule consultation with them before leaving hospital.
In majority of cases the testes come down in to scrotal sac themselves. This process can happen till age of 3 months after birth. Afterwards if doesn’t come down there is very less chance that it will come down in scrotum. You should plan your visit around 4-5 months age if testes haven’t come down in scrotum by that time.
Why my son needs surgery now when he is absolutely normal and has undescended testes? Can’t I wait till he grows more?
Once the testes doesn’t come in scrotum, they may be felt in groin or may remain inside abdomen by age of 6 months your son will need surgery to fix testes in scrotum.
Testes need temperature less than normal body temperature, scrotum provides this cooler temperature so that their function and growth happens normally. Two main function of testes are production of testosterone a male hormone and spermatogenesis which helps in fertilization. Complications that can happen in an undescended testes are:
Testicular cancer: It is well known in medicine literature that men who have undescended testes have increased chances of testicular cancer. Testicular cancer develops in testicles producing immature sperms. Why this happens exactly we don’t know. Risk of developing testicular cancer is greater further away is testes from its normal position. So a testes in abdomen has higher chances of developing cancer as compared to testes in groin.
Fertility issues: Fertility issues are more likely to happen in a man with undescended testes. This may be because of low sperm count, low quality of sperms. This is mainly related to abnormal growth and development of testes in men with undescended testes.
Torsion of testes: when testes are not in the scrotum than they are not fixed and twist around the spermatic cord called as testicular torsion. This compromises the blood supply and testes is cut off. This condition is very painful and if not treated promptly will lead to permanent loss of testes. Testicular torsion is almost ten times more common in boys with undescended testes.
Inguinal hernia: Having an inguinal hernia, where contents of abdomen like intestine, omentum protruding through a defect in muscle on abdomen is common with undescended testes.
Trauma to testes: Trauma to testes is common in boys with undescended testes, probably they are less protected as compared to when the testes are in scrotum.
Above all are potential issues that can happen if we don’t operate. So it is always better to do a planned procedure to avoid all above complications.
How to diagnose undescended testes?
Undescended testes diagnosis is based clinical examination only. Pediatric surgeon won’t be able to feel the testes inside the scrotum. Testes may be felt in groin or surgeon may not feel it at all in which case they may be in abdomen. Laparoscopic (keyhole) surgery is diagnostic as well as part of treatment when testes are not palpable.
Sometimes immediately after birth when either of testes are not felt by surgeon your baby may have to undergo more blood test, radiological investigation to diagnose some serious medical problems. You can talk to your doctor about this.
Generally ultrasonography, CT scan or MRI scan are not recommended for diagnosing undescended testes.
What is hormone treatment?
Hormone treatment involves giving injections of human chorionic gonadotropin hormone. This hormone could cause sons testicles to move towards scrotum. Hormone treatment is not much effective so standard care is to do surgery.
Hormone therapy will be required when your sons both testes are not felt and he has some other serious medical problems. When surgeon or your paediatrician will recommend to involve pediatric endocrinologist for further treatment.
How to prepare for surgery?
You will be given instructions regarding feeding of child before surgery. All these instructions are universally followed in institutions all over the world. You can get your child’s favourite toy with him so that it will make him a bit comfortable.
What are different surgical options?
Let your pediatric surgeon decide what the best surgical approach is for your son. Surgery could be laparoscopic (keyhole) or open surgery. Surgeon carefully manipulates testes to bring them in scrotum and fix it over there. Surgery will be done when your son is around 6 months of age. Operation should take around one hour.
Open Surgery: Surgeon will do open surgery when surgeon can feel the testes in groin. A small cut is made over groin and testes is manipulated down in scrotum. One more cut is made on scrotum and testes is fixed in it. Stitches will be dissolvable and dressing is placed over it.
Laparoscopic Surgery: Surgeon will make a small cut near belly button and instrument with camera is passed in the abdomen. Two smaller holes are made on either side of belly button and other instruments are passed and looking at monitor surgery is done.
In majority of boys testes can be brought down in one surgery, occasionally surgeon may have to do this in two separate surgeries. Surgeon will take this decision so as not to damage testes by trying to get it down in one surgery.
Rarely surgeon may not find any testes inside the abdomen.
Occasionally testicles may be small, poorly developed or a dead tissue, surgeon will remove this testicular tissue.
What are complications of surgery?
Orchiopexy for single undescended testes has high success. Infection, which will be taken care with antibiotics is still most common complications.
Bleeding, swelling or bruising at the site of incision is common.
Rarely testes may go up a bit or can shrink in size. Overall further away testes from scrotum complication is more.
Fertility for a male who has operation for single undescended testes is almost 100%, same when operated on both sides falls to 65%.
Surgery may decrease chances of testicular cancer in future, it doesn’t eliminate it.
How should I take care of my son after surgery?
These surgeries can be done either as a day care or one day admission. All post-surgery instructions will be given in discharge summary.
Generally your son will be uncomfortable for a day or two. You can give him shower after 3 days, when soaked in water steri strips or dressing will fall off.
Activities such as playing games, watching television and reading together may help to keep his mind off the pain.
Restricted activity and not to use toys like bicycle or tricycle is recommended for next few days.
Stitches are self-dissolvable, no need to remove it.
You can schedule an appointment with your surgeon in a week.
Child should be ready to go to day care or school in a week time.
