We learn about the physiology and management of unilateral and bilateral undescended testicles. We are joined by Yvonne Chan, MD, Assistant Professor of Pediatric Urology at the University of Texas Southwestern Medical Center.
Dr. Neeta Goli:
Welcome to Newborn News, a podcast where we discuss educational topics for medical professionals who care for newborns. I'm your host, Dr. Neeta Goli, a pediatrician in the UT Southwestern Newborn Nursery. Welcome back to the podcast. In today's episode, we will be discussing undescended testicles. We are recording remotely due to the ongoing COVID pandemic. We are joined today by Dr. Yvonne Chan, Assistant Professor of Pediatric Urology at UT Southwestern.
Dr. Yvonne Chan:
Hello?
Dr. Neeta Goli:
Hi, Dr. Chan. Thanks for joining us today.
Dr. Yvonne Chan:
Hi, everybody. Thanks for the opportunity.
Dr. Neeta Goli:
When we're examining a term or late preterm infant in the nursery, we typically expect to be able to feel their testicles in the scrotum on the physical exam. However, this is not always the case. Today, we will discuss the management of neonatal undescended testicles, also known as cryptorchidism. Dr. Chan, to start, please can you remind us of the natural trajectory of the testicles during gestation?
Dr. Yvonne Chan:
Of course. So the testicles in development begin in the abdomen in the lumbar region. And during development, the gubernaculum will guide the testicle down the inguinal canal and into the scrotum. But sometimes this does not always occur. So the testicle can be found anywhere along this trajectory, including intra-abdominal, within the inguinal canal, in the upper scrotum. Sometimes we may have ectopic testes as well, where the gubernaculum is attached abberantly, and we can find the testicle outside the scrotum or even in the perinatal region.
Dr. Neeta Goli:
If we're not able to feel a testicle on our newborn physical exam, what maneuvers can you recommend to make the exam more productive?
Dr. Yvonne Chan:
Sometimes if it's a very challenging exam, I would put some lubricant on the inguinal region and then sweep down from the anterior abdomen down towards the groin. And if it is undescended testes, with the lubricant, you can kind of feel the testicle. You'll feel it under your hands. It's a little bit hard to describe, but you'll feel the testicles jump under your hands with lubricant in place. So some lubricant over the skin may be helpful for the exam.
Dr. Neeta Goli:
And then how can we tell the difference between a retractile versus a true undescended testicle?
Dr. Yvonne Chan:
So typically, retractile testicles, based on history, parents would say that the testes were descended at birth and they’re there when they're changing their diapers. Or during baths when the child is completely relaxed, they'll see the testicle in the scrotum. So that will differentiate it from the undescended testicle, where you typically don't see the testicle in the scrotum. On exam, what you can do is if you feel the testicle and you're able to bring it down to the scrotum, you hold it there and you let go, they should remain in place, as opposed to an undescended testicle, which will typically pop back up into the inguinal canal.
Dr. Neeta Goli:
If we have a testicle which we found to be retractile, but not undescended, what is the outcome or prognosis for those testicles?
Dr. Yvonne Chan:
So retractile testes are normal variants. So there is no bad prognosis. The only thing that we would like to watch out for is instance of testicular ascent. Mainly because if there is such testicular ascent, we would like to make sure that the testicle is in a proper position for the child to be able to perform testicular self-examinations for cancer screening as they reach puberty.
Dr. Neeta Goli:
Do retractile testes typically descend with time, age and puberty?
Dr. Yvonne Chan:
Retractile testicles are descended. It's just that you have very strong cremasteric reflexes that pull them up during examinations when the child is scared or is cold. So for a young child who comes into the examination room and is very nervous, sometimes if you do the genitourinary exam, you may actually see the testicles go up and down. But when they're completely relaxed at home or during baths, they are down. So it's something that we will see in clinics where referrals are concerned for undescended testes, but retractile testes are a normal variant.
Dr. Neeta Goli:
And then what is the management of a unilateral undescended testicle?
Dr. Yvonne Chan:
To manage a unilateral undescended testicle, we would recommend orchiopexy. And depending on whether it's a palpable versus a non-palpable testis, the surgery will vary. In cases of a palpable testicle, we would recommend an open orchiopexy, and they would generally have an incision in the inguinal region and in the scrotum. For older kids, where the testicle can be brought down into the scrotum, some surgeons may elect to go for a scrotal approach. For younger kids, there is typically an associated hernia with the undescended testes, so inguinal approach will be preferred, and the hernia will be fixed at the same time.
Dr. Yvonne Chan:
For cases of non-palpable testes, we recommend a diagnostic laparoscopy, where we take a camera and look inside the abdomen to see if it's an intra-abdominal testis. If it is an intra-abdominal testis, which looks viable, the decision then will be made to bring it down in one versus two stages. And the reason for that is because in certain cases, the testicular artery is very short and it limits the ability to bring down the testis. In these cases, we would perform a procedure called Fowler-Stephens orchiopexy, where we actually divide the testicular artery and vein, but leave the vas deferens and the artery of the vas intact. And we wait six months to allow collateral vasculature to develop, and then come back in and bring the testicle down into the scrotum during the second stage. In certain cases, if the artery looks, and the vasculature, look amenable to be able to bring it down in one stage without division of the vasculature, then we may like to do it. So it depends on how things look.
Dr. Neeta Goli:
So if we are, as pediatricians, taking care of a baby with an undescended testicle, at what age would we be recommended to refer to you all in urology for further management, if it hasn't descended yet?
Dr. Yvonne Chan:
Yeah. So if the testicle remains undescended by six months, I would refer to urology. We typically recommend intervention between six to 18 months of age.
Dr. Neeta Goli:
What is the risk if the testicle were to remain undescended?
Dr. Yvonne Chan:
So the reason for performing surgery is that there are some studies that indicate that there was a slightly increased risk of testicular cancer in undescended testes. So that's one reason. But the other reason is also because if the testis remains undescended, when the child reaches puberty, it's very hard for them to perform testicular self-exams for screening for testicular cancer. So we also like to bring the testicle down for that purpose. For cases of mostly for bilateral undescended testes, there are concerns regarding fertility. So we would like to bring the testicle down for that reason as well.
Dr. Neeta Goli:
What is the recommended evaluation of bilateral undescended testicles?
Dr. Yvonne Chan:
Evaluation for bilateral undescended testicles will be dependent on whether the testes are palpable or non-palpable. Evaluation of bilateral palpable testes will be the same for unilateral palpable testes, with referral to urology by six months of age for consideration of orchiopexy if they have not descended, will be what's recommended.
Dr. Yvonne Chan:
In cases of bilateral non-palpable testes though, we recommend obtaining a karyotype to make sure that the patient doesn't actually have congenital adrenal hyperplasia with severe virilization. So in these cases of which bilateral testes are non-palpable, or in cases of unilateral undescended testes with events of hypospadias, karyotyping to confirm the karyotype would be recommended. That would be the first step. And if it's confirmed that the child is 46, XY, then we would further evaluate whether these are intra-abdominal testes versus a rare case of anorchia. In those cases, we would recommend getting hormonal testing, including FSH, LH, testosterone, Inhibin B, as well as Müllerian-inhibiting substance, to further evaluate their hormonal profile.
Dr. Yvonne Chan:
And if it is a case of disorders of sex development then you consider getting pelvic ultrasounds to look for gonads. And obviously referral, which in cases of DSD, we recommend both pediatric urology as well as endocrinology consults for further evaluation.
Dr. Neeta Goli:
And then would you ever recommend an ultrasound in the nursery?
Dr. Yvonne Chan:
Do you mean in cases of bilateral non-palpable testes?
Dr. Neeta Goli:
Yes.
Dr. Yvonne Chan:
Okay. We don't typically recommend ultrasounds in cases for retractile or unilateral undescended testes, because management will be dependent on exam rather than ultrasound. In cases of bilateral undescended testes that are non-palpable and there is concern for disorders of sexual development, then consideration can be given to obtaining a pelvic ultrasound to look for gonads.
Dr. Neeta Goli:
What else do you think is important to talk about that we didn't talk about?
Dr. Yvonne Chan:
I think one thing I would mention, if the audience is taking care of older kids with more instances of retractile testes, there is a risk of testicular ascent. So we can talk a little bit about that, if that's appropriate?
Dr. Neeta Goli:
Sure.
Dr. Yvonne Chan:
Depending on your audience, yeah. So in some children who come in with retractile testes, we do recommend yearly genitourinary exam to ensure that the testicles remain in the scrotum. The reason for that is that there is a risk for testicular ascent in this population. And if that does occur, we would like to see them, because orchiopexy will be indicated for these kids. So for all of the children that I see with retractile testes, depending on how challenging the exam is, sometimes I would follow up where I would ask the pediatrician perform yearly exams. And also would just forewarn parents that if they did notice that the testicles would remain mostly in the high scrotum, or remain up, even when they're completely relaxed at home, then they should be evaluated.
Dr. Neeta Goli:
Okay. To end the episode today, do you have any advice for our listeners while they care for newborns?
Dr. Yvonne Chan:
In terms of undescended testes, I think that if the child is premature, then there are higher incidences of these, and we typically would recommend giving them until about six months of age to allow them to descend. But we are happy to see them if there are any concerns. And a lot of times, I think just different tricks with the exam, keeping the child calm and sometimes using a little lubricant on the skin will help with exams too.
Dr. Neeta Goli:
Thanks for joining us today, Dr. Chan.
Dr. Yvonne Chan:
Thank you for the opportunity. Take care.
Dr. Neeta Goli:
Thank you. Thanks for listening to Newborn News. We hope you join us next time. If you like what you hear, make sure to subscribe and leave us a review. If you have questions, comments, feedback, or suggestions for future episodes, please email me at NewbornNews@utsouthwestern.edu. As a reminder, this content is educational and is not meant to be used as medical advice. Views or opinions expressed in this podcast are those of myself and my guests and do not necessarily reflect the views of the University.