BY ROBERT A. MEVORACH, MD, FSPU, FAAP
Case
In this case a 12-year-old boy received a new diagnosis of a right non-palpable undescended testicle, which was discovered on a routine sports physical at an urgent care facility. He had a history of normal physical examinations prior to this, was a full-term birth, had no symptomatic complaints, and reported no trauma. Review of his infant records revealed a question of hydroceles bilaterally up until 10 months old, a note of retractile testis on the right until six years, and only normal exams noted thereafter. After a confirmatory physical examination by his PCP, and prior to referral to pediatric urology evaluation, he was sent for diagnostic ultrasound imaging.
On arrival to pediatric urology he was in no distress, was 25th percentile for weight, and 70th percentile for height. In the past year he reported a four-inch growth spurt, and was otherwise healthy with no surgical history except circumcision at three years of age by an adult provider. A physical examination revealed a normally descended left testis and an ectopically descended right testis to the area of the pubic tubercle, equal in size and consistency to the left with a small right hemiscrotum.
The patient underwent an elective and uneventful operative orchidopexy and at his one-year follow-up has maintained relative size and dependent position for both testes. He has been instructed in testicular self-examination and will have routine primary care follow-up.
Discussion
Undescended testicles, cryptorchidism, occurs in 2-5% of term infants and up to 30% of premature males. During the first three to five months postnatally, testicular descent will be completed in the majority of infants, mediated by a physiologic surge in serum testosterone levels (mini-puberty), leaving 1% still having cryptorchidism. For these males, surgery is recommended by one year of age to hopefully maximize the long-term development of these testicles and provide a scrotal position for consistent examination given a lifelong need to monitor for testicular cancer.
Current literature suggests an overall five-fold increase in testicular cancer risk from an undescended testis, and a clear reduction in the relative risk for patients who undergo orchidopexy before puberty as compared to those males whose surgery is not performed until after the onset of puberty and beyond. Fertility in a male with a history of unilateral undescended testicle and a normally developed and positioned contralateral testis appears to be equivalent to that of the general population by current studies and does not seem to be impacted by age of orchidopexy.
There is often an inordinate and undesirable delay in diagnosis and treatment of the undescended testis. The average age of orchidopexy diagnosis in the U.S. and internationally is nearly seven years old. Two factors likely contribute to this dismal performance of our healthcare system.
First, there is a delay in diagnosing the undescended testis and distinguishing this from retractile testis. Testicles that are not descended after the infant is six months old should be assessed by a specialist. Delaying referral in the hopes that descent will occur with growth and development, or to distinguish the retractile from the undescended testicle, may miss the best therapeutic window for developmental and surgical success. Significantly retractile testicles diagnosed at this age can be monitored to assure no “ascent” with linear growth, that appears to occur in a particular “tethered” subset of these testicles, occurs. Cases like this occur in approximately 6-10% of all cases of retractile testes.
Second, the healthcare network for children has become fragmented. For many of our referred patients there is no consistent primary care provider who examines the infant and child periodically. Instead, patients seek care in either urgent care clinics unaffiliated with their pediatric practice, or alternate providers within their practice for whom only an electronic record is available to convey ongoing concern with a genital exam.
Finally, the utility of ultrasound examination prior to specialty examination for questions of testicular descent is negligible at best. Ultrasound rarely offers information not attained upon examination and often leads to misinforming the family about the child’s diagnosis and care.
Robert A. Mevorach, MD, FSPU, FAAP, is the director of Pediatric Urology at Chesapeake Urology. He can be reached at rmevorach@cua.md.
References:
Agarwal, Piyush, et al. J of Urology 2006
Kanaroglou, Niki, MD, et al. Pediatrics 2015
Pettersson, Andreas, MD, et al. New England J of Medicine 2007
Stec, Andrew, et al. J of Urology 2007
Tasian, Gregory, et al. J of Urology 2011
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