Cryptorchidism - Undescended Testes :
Urology And Urosurgery
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What is Cryptorchidism?
During development of the male embryo in the womb the testicles grow and develop inside the abdomen. They move down into the scrotum towards the end of pregnancy. In some babies this does not happen properly and one or both testicles are not in the scrotum. Many of these will descend after the child is born. As the child gets older this becomes more unlikely and some treatment to bring them down is needed. Some boys have testicles which have come down into the scrotum but can move up and down easily. Often they are pulled back up into the abdomen when the child is cold. These are not truly undescended testes and are called retractile testes. They do not need any treatment.
Complications and associated conditions
A Hernia is always associated with undescended testis and is common with an ectopic testes
Torsion of the teste and incarceration of the hernia
- Malignancy - there is a 20 fold increase of malignancy in the undescended teste and the further away from the scrotum, the greater the incidence. Seminomas are the most common cancers and early repair may be associated with a decreased incidence of malignancy. Most studies have shown that repairing the undescended teste does not decrease the incidence of malignancy but these were done on boys who had their repair at a later time. At the least, the placement of the teste in the scrotum allows for easier self examination and earlier detection.
- Infertility - The longer the teste is out of the scrotum, the greater the incidence of infertility. There is questionably an increased infertility in unilateral cryptorchidism and almost 100% of men with unrepaired bilateral cryptorchidism will be infertile. 2/3 of bilateral cryptorchidism repaired later in childhood will be infertile. Histologic changes include loss of germ cells, Leydig cells, and increased fibrosis. Most of the follow-up studies on fertility were done on boys who had orchiopexy at later ages than presently recommended.
Physical examination will diagnose cryptorchidism. It is most commonly misdiagnosed because the infant has retractile testes secondary to a hyperactive cremasteric reflex. Must have a warm environment to examine properly and parents can often find both teste in the bath. As the child gets older, the cremasteric reflex causes less retraction because the teste gets heavier.
Ultrasound may be helpful
FSH and LH levels that are increased may indicate absence of testicular tissue. Poor testosterone response to hCG may also aid in diagnosing the absence of functional testicular tissue.
- hCG- may be successful with bilateral cryptorchidism, especially if the testes are near the scrotum. Don't use if unilateral
- Surgery- best performed near the end of the first year of life. Locate the testes and bring into the scrotum (orchiopexy) or remove atrophic tissue. May consider testicular prostheses. Must also fix the indirect inguinal hernia.
How does Cryptorchidism occur?
For most boys there is no reason for undescended testes. Sometimes the canal they descend through is blocked. Very rarely a problem with the testis or a hormone problem will cause undescended testes.
What causes undescended testes?
Undescended testes may occur for several reasons. While prematurity is a leading cause, other causes may include hormonal disorders, spina bifida, retractile testes (a reflex that causes a testicle to move back and forth from the scrotum to the groin), or testicular absence.
Who is affected by undescended testes?
- Undescended testes occurs in 100 percent of premature male infants weighing 900 grams (2 pounds) or less.
- Undescended testes occurs in 17 percent of premature male infants weighing 2 to 2.5 kg (4.4 pounds to 5.5 pounds).
- Undescended testes occurs in 3.4 percent of full-term infants.
- There is also a genetic component: 6 percent of fathers of males with undescended testes also had the condition.
- In rare cases, boys who undergo an inguinal hernia repair may develop undescended testes.
Treatment Involved for Cryptorchidism
It is important to tell if the testicle is truly undescended. If you can feel both testicles when the child is warm and happy, such as in a warm bath, they are not undescended. If the testicle is undescended, the baby should see a doctor who will decide if an operation is needed. An ultrasound scan may help in telling where the testicle is. In a few cases hormone injections can help the testicle to come down. If the doctor thinks that the testicle is not likely to come down on its own an operation is needed. This is done through a cut above the groin under a general anaesthetic. During the operation the surgeon will find the testicle, bring it down to the right place and put a stitch to keep it there. This operation will be more difficult if the testicle is inside the abdomen than if it is partly descended and already nearly in the right place.
Specific treatment for undescended testes will be determined by your child's physician based on:
Treatment may include:
- Your child's age, overall health, and medical history.
- The extent of the condition.
- Your child's tolerance for specific medications, procedures, or therapies.
- Expectations for the course of the condition.
- Your opinion or preference.
- Hormonal therapy - administration of certain hormones may stimulate the production of testosterone, which helps the testes descend into the scrotal sac. This is not routinely used for treatment of truly undescended testes.
- Surgical repair - a surgical repair to locate the undescended testicle and advance it to the scrotal sac may be recommended by your child's physician. This surgery, called orchiopexy, is usually performed between months 6 and 18 and is successful in 98 percent of children with this condition.
During Treatment for Cryptorchidism
This is a sensitive part of the body and there will be some discomfort after the operation. He may need painkillers. He may need to stay in hospital, and will take a short while to get back to normal activity.
After Treatment for Cryptorchidism
The surgeon will see the child as an outpatient to check that everything has settled down. It is very rare for the testicle to slip back up after an operation. For most boys there will be no more problems and the testicle will work normally. Very rarely there is a hormone problem or the testicle itself is not normal. These boys may need further tests or treatment. If a testicle is not normal it may not be able to produce male hormone (testosterone) or sperm. Problems are more likely to arise if both testicles are undescended, because only one testicle is required for fertility and for normal sexual development.
If Cryptorchidism is Left Untreated
Testicles only work properly if they are slightly cooler than the rest of the body. In the scrotum they are at the right temperature. Undescended testicles are too warm and will not be able to produce sperm properly : even male hormone production can be affected. This would result in problems developing in puberty and possibly infertility. Undescended testicles are more likely to become malignant (cancerous). If they are inside the abdomen the lump caused by any cancer would not be seen. This is important because the treatment for cancer of the testicle, once diagnosed is very effective.
Effects on Family of Cryptorchidism
Even a very young boy is sensitive about his private parts. He can be distressed when people examine him. Tell him about what will happen before you go to hospital and try to be calm and relaxed yourself. Staff at the hospital can help you prepare him for an operation.
Many men who were born with undescended testes have reduced fertility, even after orchiopexy in infancy. The reduction with unilateral cryptorchidism is subtle, with a reported infertility rate of about 10%, compared with about 6% reported by the same study for the general population of adult men.
The fertility reduction after orchiopexy for bilateral cryptorchidism is more marked, about 38%, or 6 times that of the general population. The basis for the universal recommendation for early surgery is research showing degeneration of spermatogenic tissue and reduced spermatogonia counts after the second year of life in undescended testes. The degree to which this is prevented or improved by early orchiopexy is still uncertain.
Later cancer risk
One of the strongest arguments for early orchiopexy is prevention of testicular cancer. About 1 in 500 men born with one or both testes undescended develops testicular cancer, roughly a 4- to 40-fold increased risk. The peak incidence occurs in the 3rd and 4th decades of life. The risk is higher for intra-abdominal testes and somewhat lower for inguinal testes, but even the normally descended testis of a man whose other testis was undescended has about a 20% higher cancer risk than those of other men.
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