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Why is my son’s testis not in the scrotum?
It is important to differentiate an undescended testis from a retractile testis. An undescended testis occurs in 1% of children by the age of 1 year old. It presents as an absent testis from the scrotum. It may be felt in the groin or not palpable at all. The testis and epididymis may be dissociated.
A retractile testis presents with a testis that moves in and out of the scrotum. This is due to a strong cremasteric muscle reflex. The testis is otherwise normal and will reside in the scrotum when the reflex is not stimulated.
An ascending testis occurs when a testis that was once in the scrotum, now resides in the groin. It is thought to be ascending due to a failure of the spermatic cord to grow in proportion to the body.
What is the risk of leaving an undescended testis alone?
When the testis is in the groin, there is increased temperature of 2 to 4 degrees. This degrades spermatogenesis and induces dysplasia.
A unilateral undescended testis (UDT) has 10% risk of subfertility, compared with 7% in the normal population. Bilateral UDT has up to 35% risk of subfertility.
The risk of testicular cancer is up to 10 times more for patients with undescended testis, as compared with the general population. The incidence of testicular cancer in the Singapore population is 1 in 10,000 (1). In undescended testis (UDT) of one side, the incidence of cancer is up to 1 in 2,500. Internationally, the incidence of testicular germ cell cancer has been reported to vary between 0.05% to 1% (3).
Post-surgery (orchidopexy), this risk deceases by up to one–third. The lower the age of orchidopexy, the better the detection of early cancer change. Moving the testis into the scrotum at a younger age may prevent cancer development (2).
Is an ultrasound or other investigations required before surgery for undescended testis / testes?
No, an ultrasound or magnetic resonance imaging does not change the management when the testis is not palpable in the scrotum. Ultrasound is accurate in only up to 76% of patients, false positives include the gubernaculum, lymph node and scar tissue. I do not recommend doing an ultrasound when the clinical findings do not demonstrate the testis in the scrotum. An examination under anaesthesia is diagnostic. When the testis is not palpable, laparoscopy is the gold standard to exclude an abdominal testis. When the testis is palpable, orchidopexy is performed.
What is the best treatment for an undescended testis?
For a palpable testis in the groin, the treatment is an orchidopexy via a groin skin crease incision. I free the undescended testis from the attachments holding it in the groin. The hernia sac (patent processus vaginalis) is divided. The testis is brought down into the scrotum in a tension-free manner and anchored to a space that is created in the scrotum. The incision is closed with absorbable sutures.
When the testis is not palpable, key hole surgery (laparoscopy) is performed. This allows visualization of the testis in the tummy (abdomen). When the testis is low (below the external iliac vessels), I perform a single procedure via key hole (laparoscopy) to divide the attachments holding the testis in the abdomen. The testis is then brought through the abdomen and into the scrotum. The vessels and sperm channel (vas deferens) are also brought down safely with the testis into the scrotum.
When the testis is high (above the external iliac vessels), I perform a staged procedure. The first procedure is via key hole surgery (laparoscopy). I divide the testicular vessels (to gain length) and bring the testis to the deep inguinal ring (where it normally exits the abdomen). The testis is supplied by other vessels and remains alive. The second procedure is performed 6 months later, to allow for good collateral blood supply to form and keep the testis viable. During the second procedure, I perform laparoscopic surgery and bring the testis through the abdomen into the scrotum in a similar fashion as the single stage procedure mentioned previously.
What happen after surgery for an undescended testis (orchidopexy)?
My patients go home on the same day after surgery for an undescended testis (orchidopexy). They have normal showers or baths. The dressing needs to be kept on for 3 to 5 days. Thereafter, if it falls off, there is no need to replace it. The follow up appointment is in 2 weeks’ time. There are no stitches to be removed, because they are all absorbable. When the wounds are well healed, I recommend subsequent reviews in 6 months to 1 years’ time. I teach my patients self-examination of the testis. This monitoring for malignant change in the testis (testicular cancer) is important for life, with age specific incidence rate of testicular cancer from 2 peaks, the first at 10 to 14 years old and the second at 30 to 34 years old.
1. Singapore Cancer Registry Annual Report 2018, National Registry of Diseases Office, 2021 March 31.
2. Pettersson A, Richiardi L, Nordenskjold A, et al. Age at surgery for undescended testis and risk of testicular cancer. N Engl J Med. 2007 May 3;356(18):1835–41.
3. Radmayr C, Bogaert G, Dogan HS, et al. EAU Guidelines on Paediatric Urology 2018. Arnhem (The Netherlands): European Association of Urology; European Society for Paediatric Urology, 2018.
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