E U R O P E A N U R O L O G Y F O C U S 3 ( 2 0 17 ) 1 5 5 – 1 5 7
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Clinical Consultation Guide – Pediatric Urology
Undescended testes: Diagnostic Algorithm and Treatment
Bernhard Haid *, Patrick Rein, Josef Oswald
Department for Pediatric Urology, Ordensklinikum Linz, Hospital of the Sisters of Charity, Austria
1. Introduction and definitions
Undescended testis (UDT) is one of the most common diag-
noses in pediatric urology and the single most common
disorder diagnosed at birth. It is defined as a testis that has
failed to descend to a scrotal position until birth or has
reascended from a scrotal position after birth which is
referred to as acquired UDT [1]. By localization of the testis
it is subdivided into prescrotal, inguinal, abdominal (ranging
from peeping to testis at the internal inguinal ring to high
abdominal testes), and ectopic UDT. Nonpalpable testes,
comprising as well abdominal as vanishing testis (ie, testis
having atrophied before or perinatally) represent a relatively
small proportion of all UDT, nevertheless accounting for up to
20–35%. Retractile testis, lying mostly in a scrotal position,
imply a risk of up to 20% concerning a later acquired UDT and
should be followed-up yearly until puberty.
The incidence of UDT for term-born boys accounts to 2%,
with wide variations dependent on birth weight and a far
higher prevalence in preterm boys (up to 54%). Spontaneous
descent occurs up until the 6th mo of life in 35–43% of all
affected children [2]. Given the orchidopexy rates of around
2–4%, the presumably important role of acquired UDT is
more emphasized recently.
2. Diagnosis and imaging
Diagnosis is mainly made by clinical examination, where a
child-adapted approach as well as a gentle examination
technique are essential. An inspection of the external geni-
talia is the first step; in case of bilateral nonpalpable testes
combined with other malformations of the external genita-
lia (eg, hypospadias) further endocrinological assessment
(testosterone, luteinizing hormone, follicle-stimulating
* Corresponding author. Department for Pediatric Urology, Ordensklinikum Linz, Hospital of the Sisters of Charity, Seilerstätte 4, 4020 Linz, Austria. Tel.
+43-512-583258.
E-mail address: Bernhard.Haid@ordensklinikum.at (B. Haid).
http://dx.doi.org/10.1016/j.euf.2017.05.009
2405-4569/© 2017 European Association of Urology. Published by Elsevier B.V. All rights reserved.
hormone, and anti-Müllerian hormone) as well as a karyo-
gram is to be performed to exclude a disorder of sex
development or anorchia. Palpation is performed with
warm hands, placing the nondominant hand on the boy’s
abdomen in a supine or “frog-leg” position and gently
palpating from cranially in the groin to caudally versus
the scrotum, the inner thigh and the femoral region to
detect ectopic testes. Sonography gel (warmed to body
temperature) can help reducing friction and further
increase the sensitivity of the exam. For nonpalpable testis,
sonography has a distinct role in the assessment with a
potential to guide the surgical approach [3]; however, there
is no consensus on its routine use. In unilateral nonpalpable
testis, the contralateral testis size (16–18 mm, measured
monographically) has been shown to have a sensitivity up to
over 90% to predict the absence of the ipsilateral testis.
Diagnostic laparoscopy remains the gold standard in the
diagnosis of an intra-abdominal testis. Other imaging
modalities such as computed tomography or magnetic res-
onance imaging have been shown to deliver no additional
information and are not indicated.
3. Hormonal treatment
The efficacy of hormonal treatment to bring the testis to a
scrotal position as well with gonadorelin/gonadotropin-
releasing hormone as with human chorionic gonadotropin
has been shown to be of limited efficacy, with only about
20% of treated testis reaching a scrotal position and 20% of
those reascending again thereafter. Especially for human
chorionic gonadotropin, there are data available pointing at
potential harm to the germ cell lines. Concerning paternity
there is a potential benefit, long-term data, however, are yet
lacking. According to the European Association of Urology/
156 E U R O P E A N U R O L O G Y F O C U S 3 ( 2 0 17 ) 1 5 5 – 1 5 7
Table 1 – Recommendations of international guidelines concerning diagnosis and management of undescended testis (UDT).
AUA [1]
Use of imaging Providers should not perform ultrasound or
other imaging modalities in the evaluation of
boys with cryptorchidism prior to referral as
these studies rarely assist in decision making. determination of exact testicular size if needed.
Use of hormonal Providers should not use hormonal therapy
treatment to induce testicular descent as evidence
shows low response rates and lack of
evidence for long-term efficacy.
Timing of surgery In the absence of spontaneous testicular descent Any kind of treatment leading to a scrotally
by 6 mo (corrected for gestational age),
specialists should perform surgery within the
next yr.
Type of surgery for Orchidolysis and orchidopexy, either via an
a palpable testis inguinal or scrotal approach.
Type of surgery for Examination under anesthesia to reassess for
a nonpalpable testis palpability of testes. If nonpalpable, surgical palpable, laparoscopy, if indicated
exploration and, if indicated, abdominal
orchidopexy should be performed.
Treatment of acquired UDT –
AUA = American Urological Association; DSD = detrusor sphincter dyssynergia; EAU = European Association of Urology; ESPU = European Society for Paediatric
Urology; GnRH = gonadotropin-releasing hormone.
European Society for Paediatric Urology guidelines, gonad-
otropin-releasing hormone analogues can be used on an
individual basis, for example, in boys with bilateral unde-
scended testes [4], according to the American Urological
Association guidelines, their use is not recommended [1]
(Table 1).
4. Surgical treatment
Orchidopexy, usually in general anesthesia with local nerve
blockade and usually as a day case surgery, should be
performed in boys with persistent UDT at the 6th mo of
life (corrected for gestational age) during the following
12 mo. Preferably the treatment should be finished around
the 1st birthday [1,4]. Technically, for palpable testes, an
inguinal or—as convincingly shown by some authors—a
scrotal approach with funiculolysis up to the level of the
internal inguinal ring as well as dissection and ligation of an
open processus vaginalis peritonei (present in up to 30% of
cases) is recomended. If a tension free mobilization of the
testis is to a midscrotal level is not possible, a Prentiss
maneuver (pull-through of the funiculus under the inferior
epigastric vessels) as well as vascular dissection (either
close to the testis, Koff procedure, or farther away, single
or two staged Fowler-Stephens operation) might prove
helpful, especially if a long-looping ductus deferens is pres-
ent. The testis should be secured at a scrotal level by placing
it, free of any tension into a subdartos pouch. For nonpalp-
able testes, diagnostic laparoscopy with the option of a
laparoscopically assisted orchidopexy is the mainstay of
treatment. If a viable abdominal testis can be identified,
according to its position and anatomy, microsurgical mobi-
lization of the vessels as well as the ductus deferens allow in
many cases allowing an orchidopexy using the inguinal
EAU/ESPU [4] Nordic consensus [10]
Only recommended in specific and selected –
clinical scenarios (eg, identification of Mullerian
structures in cases with suspicion of DSDs) and
Do not routinely offer hormonal therapy, either Considering the poor efficacy
-in an adjuvant or neo-adjuvant setting for -of hormonal treatment and
testicular descent. Patients have to be evaluated its possible adverse effects on
on an individual basis. Endocrine treatment spermato- genesis, the
with GnRH analogues with bilateral consensus group concluded
undescended testes to preserve their fertility that surgery is generally to
potential. be preferred.
6–12 mo
positioned testis should be finished by 12 mo,
or 18 mo at the latest.
Scrotal or inguinal orchidopexy. –
Examination under anesthesia, if still not –
abdominal orchidopexy.
– Soon after diagnosis
canal. If the testis cannot be mobilized appropriately an
extra-anatomical routing medially to the medial umbilical
ligament as well as vascular dissection (Koff/Fowler-Ste-
phens) are options. If vessels and/or ductus deferens are
entering the inner inguinal ring, an inguinal exploration
should be performed in order to remove a possibly present
testicular remnant. For high intra-abdominal testes, a
staged Fowler-Stephens procedure might be an option. In
case of intra-abdominal testis with a nonviable aspect upon
exploration or in postpubertal patients, removal—always
taking into account the status of the contralateral testis—
is an option, a testicular biopsy is recommended.
5. Follow-up
The two main long-term risks in boys with UDT are sub-
fertility and the possible development of testicular cancer
later in life. Respective to both, parents and patients have to
be counseled adequately. As to subfertility, especially
patients with bilateral UDT are concerned, in whom also
paternity rates are reported to be as low as 65%. Conversely,
in those with unilateral UDT paternity rates range around
89%, comparing favorably to around 95% in the average
population without a history of UDT [5]. The increase in
risk for developing testicular germ cell cancer is dependent
from the time of surgical intervention, showing a relative
risk of 2.23 for those who underwent orchidopexy before
the age of 13 yr and 5.4 yr for boys having been operated
after age 13 yr [6]. By earlier treatment, cancer risk could be
reduced further, as shown in a recent meta-analysis
[7]. However, genetic changes also play a role in testicular
oncogenesis as proven by the increased rate in contralateral
testis. Therefore, patients with previous UDT should be
counseled to perform a regular self-exam.
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6. Importance, diagnosis, and treatment of
acquired UDT
The possibly high incidence of acquired UDT has been
highlighted in several reports [8,9]. Furthermore, it has been
convincingly shown, that the acquired UDT shares histo-
pathological features with the congenital UDT, putting the
affected children presumably at the same risk for subferti-
lity and testicular cancer compared with those with con-
genital UDT. Its etiology is still unclear with inhomogeneous
surgical findings reporting mostly a position in the subin-
guinal pouch. Acquired UDT has to be looked for actively
and treated at the earliest possible after diagnosis, that
might be deferred due to a lack of attention and less access
to a regular physical exam in older boys as opposed to
infants.
Conflicts of interest: The authors have nothing to
disclose.
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