Before considering treatments your medical practitioner needs to find where the testicles are. This will determine how the testicle can be treated.
Where can undescended testicles be located?
I was born with an undescended testicle and you can read my story here. If you can’t feel your son’s testicles, don’t panic! The most common reason is they’re just hiding from sight (retractile), and will pop down again soon.
- Retractile testicles are exactly what they sound like 🙂 They pull up into the body at times, particularly when touched or it’s cold. This is normal – 80% of children’s testicles can rise and leave an empty scrotum behind – and usually don’t need operating on, and your doctor will be careful to distinguish them from palpable testes. If a testicle can be milked down to the bottom of the scrotum, it is considered a retractile testis, and no further treatment is needed. If your son has retractile testicles it’s a good idea to monitor them until puberty, when they usually descend naturally as the muscle weakens. Find out more here.
- Sometimes retractile testes may reascend into the body and become ‘stuck’. These are called Reascended testicles (medical name: “acquired cryptorchidism”). Research suggests 50-66% of all undescended testis surgically brought down are testicles which descended at one point (research), but you have to remember this would be based on cases which medical professions saw – and there will be plenty of retractile testicles they never know about. To put it another way: between 25 and 50% of retractile testicles a doctor knows about ascend and require surgery. For this reason you need to keep an eye on your son’s retractile testicles to ensure they don’t reascend.
There may be over-surgicalisation occurring: two studies in the Netherlands reported spontaneous pubertal descent in 57-71% of cases. This is fascinating research.
- Palpable testes are located low-down in the stomach. and can be felt by the GP or consultant, usually right at the top of the scrotum. They are likely to always be here, but you can frequently massage them down and feel them ‘pop’ under your fingers or be grabbed in the scrotum. They include gliding testicles (high scrotal testicles), prescrotal and inguinal testicles.
- Impalpable testes are somewhere in the body, or may not be present at all. Your child will need to undergo an ultrasound or laparascopic surgery to discover where they are.
The medical names given to the places where your son’s undescended testicle(s) are located are:
- High scrotal (gliding) testis
- Superficial inguinal region (prescrotal)
- Inguinal canal
- Ectopic (outside line of normal descent)
Does your child have palpable testicles?
“Testicular examination of the infant and young child requires a two-handed technique. One hand should start at the hip and gently sweep along the inguinal canal, aided by surgical lubricant or warm soapy water, if necessary. A true undescended or ectopic inguinal testicle will be felt to ‘pop’ under the examiner’s fingers during this maneuver. A low ectopic or retractile testicle will be felt by the opposite hand as it is “milked” into the scrotum. The ectopic testicle will immediately spring out of the scrotum when it is released. The retractile testicle will remain momentarily in the scrotum until further stimulation causes a cremasteric reflex. To prevent retraction, the fingers first should be placed across the abdominal ring and the upper portion of the inguinal canal, obstructing ascent. Examination while the child is in the squatting position or in a warm bath is also helpful.”
For Palpable testicles
Hormone therapy was once available (at least outside the UK) but are now appear to be rarely used. According to WebMD:
Hormone therapy alone stimulates the testicles to complete their descent into the scrotum in less than 20 out of 100 cases. Reascent occurs in about 15 out of 100 males who are treated.
Which – when you add in the potential side effects of giving hormones – pretty much says why it’s not widely used!
Surgery is the go-to treatment for an undescended testicle. I know it’s scary to think of your son having an operation, but it’s the best help you can give him.
There’s no definite ‘best age’ to do an operation for cryptorchidism, but it does appear the earlier the better. Over the last 40 years as surgical techniques have improved the average age has decreased from 6-7 years to under 18 months.
The surgical procedure is called and orchiopexy (or orchidopexy – I don’t know why but there are two common spellings) and most commonly involves making a cut in the groin, freeing the testicle (and repairing a hernia if present), making a cut in the scrotum and stitching the testicle in place. If you want to see what happens, these videos give a good overview (not recommended if you’re squeamish and your son’s just about to have the procedure!)
What’s going to happen?
This is the clearest video I’ve found – done on an older boy so you can see what’s going on more easily:
There’s an even better video here, but you have to be logged in to YouTube to view it.
If you are squeamish, here’s a 3D computer generated video of what goes on, which provides a very clear explanation of all forms of undescended testicles.
If you’re lucky your child’s surgeon will use this! In 1989 Bianchi and Squire developed a single incision technique to bring down undescended testicles which could be palpated down and felt at the top of the scrotum (those are ‘high scrotal’ or ‘prescrotal’ mentioned above). This gets rid of the larger incision on the groin and only uses one incision in the scrotum. The technique has been studied (and again) but doesn’t appear to be commonly practiced in the UK – I guess it takes a while for new surgical techniques to catch on.
More photos in this new journal article: https://www.sciencedirect.com/science/article/pii/S2090598X17300049
For impalpable testicles
For boys whose testicles can’t be felt and are located higher inside the body, the surgery is more complicated. Approximately half will have an intra-abdominal testis (a testis that is located high in the inguinal canal and not descended). For the other half, the testicle will have atrophied (died) or will not be present. For all children with testicles that can’t be felt, laparascopy will be used as it allows the surgeon to quickly determine the location of the testis, and do the right operation to fix it.
For impalpable testicles an orchiopexy is successful in most cases, but removing the testicle (orchiectomy) may be necessary in more challenging cases or when the patient has an atropic testis.
Sometimes two operations can be required. If the testicle is undescended because it has short blood vessels attached, and won’t reach the scrotum, your surgeon will need to move the testicle down as far as it will go, attach it and then do another operation to move it to the scrotum about 6 months later when your son (and his pipework) has grown. This is known in the profession as a Fowler-Stephens orchiopexy.
Help, my son has two undescended testicles!
Having a son with bilateral undescended testicles is incredibly scary. All sorts of questions flash through your head – “Is he normal?” “Will he ever be able to have children?”. Well, the good news is that while 30% of boys with this have fertility problems (compared to 7% of the general population), fertility is better the earlier the operation is done. Remember the studies that are quoted (like I just did) consider men who had the operation 10+ years ago, when they would have been 3 or older at the time of the operation.
So don’t worry. I know, easier said than done 🙂 What will be more scary is that unlike the rest of us, you will probably have to go through two (or more) operations.
For good reason, your surgeon is likely to want to bring down each testicle in a separate operation. This is for a good reason – in the unlikely event the testicle got infected after the operation and it had to be removed, your son would only lose one – and not both – of his testes.
For all of this, if you’re after medical reading then this paper covers it all in detail (and dry, doctor’s language!).
Got questions? Get in contact.