Undescended testis

Dr.Santosh Jha
TMU

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A, 5th week Testis begins its
primary descent; kidney
ascends.
B, 8th-9th weeks. Kidney
reaches adult position.
C, 7th month, Testis at
internal inguinal ring;
gubernaculum (in inguinal
fold) thickens and shortens.
D, Postnatal life.

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Introduction

An undescended testis is one which has filed to descend to the scrotum &
is retained at any point along the normal path of descend

Right side: 50%

Left side: 30%
Bilateral: 20%
cryptorchidism

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Types of undescended testis

Lumbar testis
Iliac testis: testis remains just deep to the deep inguinal ring
Inguinal: testis is in the inguinal canal
At the superficial inguinal ring
Scrotal testis:
the testis lies in the upper part of the scrotum

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A, Ectopic testes. Perineal
ectopia not shown.

B, Undescended testes.
Percentages of testes
arrested at different stages
of normal descent
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Undescended testis

Scrotal testis:
The testis lies in the upper part of the scrotum
Also known as a retractile testis
Normal scrotal sac & testis
The testis can be brought down

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Undescended testis: C/F

Symptoms
Underdeveloped scrotum

Infertility

Indirect inguinal hernia

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Undescended testis: C/F

Signs

Empty scrotum

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Undescended testis: complications

Torsion of the testis

Epididymo- orchitis
Atrophy
Sterility
Malignancy

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Undescended testis: management

Hormone therapy
Orchidopexy
Orchidectomy
Laparoscopic surgery

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Undescended testis: hormone therapy

Not used routinely

Indications:
When the surgeon is not sure whether the case is one of retractile
testis or not
Bilateral incomplete descended testis associated with hypogenitalism
& obesity

The hormone mostly used is human chorionic gonadotrophin

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Undescended testis: orchidopexy

Treatment of choice

Usually should be done by the age of 5 years but it is unnecessary to do

this operation before completion of second birthday of the child

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Ectopic testis

The testis fails to descend into the scrotum & is deviated from its normal
path of descent

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Position of the ectopic testis

Superficial inguinal pouch

Pubopenile ectopia
Perineal ectopia
Crural or femoral ectopia

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 Comparison between ectopic & undescended
testis
Undescended testis
The testis is arrested in its normal
path of descent
Usually undeveloped
Undeveloped & empty scrotum
on the affected side
Shorter length of spermatic cord
Poor spermatogenesis after 6 yrs
Usually associated with indirect
inguinal hernia
Treatment: surgery & HT
Associated with a number of
complications
Ectopic testis
The testis deviates from its
normal path of descent
Fully developed testis
Empty but usually fully developed
scrotum
Longer length of spermatic cord
Spermatogenesis is perfect
Never associated with indirect
inguinal hernia
Treatment: basically surgical
Complications: liability to injury
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 Workup
Preterm and maternal history, including the use of
gestational steroids

Perinatal history, including documentation of a

scrotal examination at birth

The child's medical and previous surgical history

Family history of cryptorchidism or syndromes

All boys with nonpalpable testes and normal serum gonadotropin levels must
undergo surgical exploration regardless of the results of the hCG stimulation test.
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 Management of Cryptorchidism
Proper identification of the anatomy, position, and viability of the
undescended testis

Identification of any potential coexisting syndromic abnormalities

Placement of the testis within the scrotum in timely fashion to prevent

further testicular impairment in either fertility potential or endocrinologic
function

Attainment of permanent fixation of the testis with a normal scrotal position

that allows for easy palpation

No further testicular damage resulting from the treatment

Definitive treatment of an undescended testis should take
place between 6 and 12 months of age
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 Hormonal Therapy
Exogenous hCG and
Exogenous GnRH or LHRH.

Increases serum testosterone production by stimulation at

different levels of the hypothalamic-pituitary-gonadal cascade

Successful results are more commonly reported in older

groups of children and in testes that were retractile or below
the external inguinal ring. E.g. the lower the pretreatment
position, the better the success rate

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A transverse skin incision is made in an inguinal skin crease
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 The overall efficacy of hormonal treatment is less
than 20% for cryptorchid testes and is significantly
dependent on pretreatment testicular location.

Therefore, surgery remains the gold standard for the

management of undescended testes.

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 Standard Orchiopexy.
The key steps in this procedure are ---
(1)complete mobilization of the testis and spermatic cord,
(2) repair of the patent processus vaginalis by high ligation of the
hernia sac,
(3) skeletonization of the spermatic cord without sacrificing
vascular integrity to achieve tension-free placement of the
testis within the dependent position of the scrotum, and
(4) creation of a superficial pouch within the hemiscrotum to
receive the testis.

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 A transverse inguinal skin incision is made in the midinguinal canal, usually in a skin
crease in children younger than 1 year
The dermis is opened with electrocautery, and subcutaneous tissue and Scarpa's
fascia are opened sharply.
The skin and subcutaneous tissue are quite elastic in younger children and allow for a
tremendous degree of mobility by retractor positioning for viewing the entire length of
the inguinal canal.

One should be careful to

observe that the testis is
in the superficial

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A,The external ring is opened.

B, Cremasteric fibers are dissected from the cord

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A, High ligation of the processus
vaginalis at the internal inguinal ring.

B, The ligated processus and the cord

structures

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Separation of the internal spermatic fascia
from the cord structures after ligation of the
processus vaginalis 30
Formation of a dartos pouch
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A, Formation of a
passage to the scrotum.

B and C, Passage of the

testis into the scrotal
pouch

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 Complications of Orchiopexy
Testicular retraction,
Hematoma formation,
Ilioinguinal nerve injury,
Postoperative torsion (either iatrogenic or
spontaneous),
Damage to the vas deferens, and
Testicular atrophy
Devascularization with atrophy of the testis can result from skeletonization
of the cord, from overzealous electrocautery
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