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UNDESCENDED TESTICLE (CRYPTORCHIDISM)

An undescended testicle, also referred to as cryptorchidism, is a testicle that has not moved down into the scrotum, influenced by several hormones the testicles begin developing deep within the abdomen early in pregnancy. At 32 to 36 weeks' gestation, the testicles begin to descend into the scrotum. In about a third of premature and approximately three out of a hundred of full-term male infants, one or both of the testicles would have not completed their descent at the time of birth. Most of these will then descend spontaneously during the first three to six months of life. Either one or both testicles can be affected.

An undescended testicle increases the risk of not being able to have children (infertility). An empty scrotum also can cause significant psychological stress as the boy gets older. For these reasons, early treatment is very important.

Some boys may have a normal descended testicle at birth but that testicle then appears to move back up into the abdomen when they are between 4 and 10 years old. This condition is called an acquired undescended testicle. It is believed that this occurs when, for unknown reasons, the spermatic cord attached to the testicle does not grow as quickly as the rest of the child does.

There are other times when, a temporary situation called a retractile testicle is mistaken for an acquired undescended testicle. This is a condition in which a testicle that has descended fully into the scrotum occasionally retracts into the abdomen. The retraction is occasioned by an overactive reflex in the cremasteric muscle that pulls the testicle out of the scrotum. Boys who are anxious or ticklish during a testicular exam may have this overactive reflex. A retractile testicle does not increase the risk of infertility or testicular cancer, indeed it poses no problem at all because it always comes back down into the scrotum.

CAUSES

In the early stages, all fetuses have structures that can develop into male or female reproductive organs.

The child receives sex chromosomes from its parents. Sex chromosomes are a pair of DNA molecules. The chromosomes will be XX in a female fetus, and XY if the fetus is male.

As the fetus develops, the XY gene promotes the development of the testes. These produce hormones that end up encouraging the growth of the male reproductive tract, and thus effectively preventing female development.

Scientists maintain that the testicles might begin to develop incorrectly.

Abnormal genital development may also stem from a genetic disorder in which XY fetuses do not respond to male hormones, such as testosterone (Androgen Insensitivity Syndrome AIS).

A newborn with AIS may have attributes of a female, such as a short, pouch vagina, but no uterus, ovaries, or fallopian tubes. The testes may be present in the abdomen or the canal that serves as a pathway by which structures pass from the abdominal wall to the external genetalia (inguinal canal).

Experts believe that most cases of undescended testicles occur when a combination of maternal health, genetics, and some environmental factors mess up the hormonal function, cause physical changes, and interrupt the nerve activity involved in the development of testicles'.

The exact cause of cryptorchidism however, remains unclear.

SYMPTOMS

The main sign of an undescended testicle would be when a testicle is not seeing or felt where it is expected it to be (in the scrotum).

Testicles form in the abdomen during fetal development. During the last couple of months of normal fetal development, the testicles gradually descend from the abdomen through a tube-like passageway in the groin canal that serves as a pathway by which structures pass from the abdominal wall to the external genetalia (inguinal canal) into the scrotum. With an undescended testicle, that process stops or is delayed.

RISK FACTORS

The following factors may increase the risk of cryptorchidism:

  • A premature birth (this would increases the risk of cryptorchidism).
  • Smoking and consumption of tobacco products by a mother during pregnancy
  • Parents' exposure to some pesticides
  • Low birth weight, (may double or even triple the risk)
  • Down's syndrome and some other conditions that slow fetal growth
  • A family history of issues with genital development

Other factors that might increase the risk of an undescended testicle in a newborn would include:

WHEN TO SEE A DOCTOR

Normally, an undescended testicle is detected when the baby is examined shortly after birth. If the male child has an undescended testicle, parent would do well to ask the doctor how often the child will need to be examined. If the testicle hasn't moved into the scrotum by the time your son is 4 months old, it would be safe to conclude that the problem probably would not correct itself.

Treating an undescended testicle when the child is still a baby might lower the risk of complications later in life, such as infertility and testicular cancer.

It is possible for older boys (from infants to pre-adolescent boys) who have normally descended testicles at birth might appear to be 'missing' a testicle later.

This condition might indicate:

A retractile testicle, which may not be a problem because it moves back and forth between the scrotum and the groin and might be easily guided by hand into the scrotum during a physical exam. This is not at all abnormal. It is only due to a muscle reflex in the scrotum.

An ascending testicle, or acquired undescended testicle, that may have gone back into the groin. This, unfortunately cannot be easily guided by hand into the scrotum.

Should parents notice any changes in their sons' genitals or are concerned about his development, they should talk to their sons' doctor.

DIAGNOSIS

To diagnose an undescended testicle, the doctor would usually place the infant in a warm place to help him relax. He might expand the skin around the scrotum to facilitate easier performance of the examination.

In a lot of the cases, doctors are not able to locate the undescended testicle until the child is no longer an infant.

If the testicle is not profound, an ultrasound scan can often show its location. However, a doctor usually may deem this step unnecessary. In some cases, a specialist called a pediatric urologist would requests for further testing.

The tests may include:

An MRI scan with a contrast agent:

The doctor will inject the contrast agent into the bloodstream to give a clearer picture of whether the testicle is in the groin or abdomen.

A laparoscopy:

The doctor will insert a tiny tube with an attached camera through a small incision in the abdomen. If it becomes necessary, they can also perform corrective surgery using the same tool.

Open surgery:

In rare, complicated cases, surgeons will use open surgery to explore the abdomen directly.

The doctor could recommend a genetic test to determine the sex chromosomes if both testicles are undescended.

Some genetically female babies have external male genitalia or ambiguous genitalia. In this case, a doctor may use:

  • Ultrasound imaging to check for undescended testicles or ovaries
  • Genetic testing to identify sex chromosomes
  • Blood and urine tests to measure hormone levels

TREATMENT

The goal of treatment will be to move the undescended testicle to its proper location in the scrotum. Treatment before the child attains 1 year of age might lower the risk of complications of an undescended testicle, such as infertility and testicular cancer. The earlier the better, but it's highly recommended that surgery takes place before the child is a year and half old.

Surgery

It is usual for an undescended testicle to be corrected with surgery. The surgeon carefully manipulates the testicle into the scrotum and stitches it into place (orchiopexy). This procedure can be done either with a laparoscope or with open surgery.

The best time to undergo this surgery will depend on a number of factors, such as his health and how difficult the procedure might be etc. The surgeon will most likely recommend that the surgery is done when the male child is about 6 months old and before he is 12 months old. Early surgical treatment appears to lower the risk of later complications.

In some cases, the testicle might be poorly developed, abnormal or dead tissue. The surgeon will remove this testicular tissue.

It may also happen that the child also has an inguinal hernia associated with the undescended testicle, the hernia would also be repaired during the surgery.

After surgery, the surgeon will monitor the testicle to track its continued development, its proper function and its stay in scrotum.

The monitoring might include:

Physical exams

  • Ultrasound exams of the scrotum
  • Tests of hormone levels
  • Hormone treatment

Hormone treatment would involve the injection of human chorionic gonadotropin (HCG). This hormone could cause the testicle to move to your son's scrotum. However, hormone treatment is not usually recommended because it is much less effective than surgery.

Other treatments

If the child ends up without one or both testicles (whether it is because one or both are missing or didn't survive after surgery), consideration might be given to saline testicular prostheses for the scrotum. This can be implanted during late childhood or adolescence. These are prostheses that are designed to give the scrotum a normal appearance.

If the child does not have at least one healthy testicle, his doctor will refer him to a hormone specialist (endocrinologist) to discuss future hormone treatments that would be necessary to bring about puberty and physical maturity.

TREATMENT FOR CHILDREN

Treatment will depend on the child's symptoms, his age, and general health. It will also depend on how severe the condition is. In many cases, the testes would descend on their own into the scrotum by age 3 months. In most cases, the testes pass down by age 6 months without any treatment.

In other cases however, treatment may be needed. This may include:

Surgery.

The undescended testicle may be moved into the scrotal sac with surgery. This surgery is called orchiopexy. It's often done between ages 6 and 18 months and it works for most children.

Hormone therapy.

Certain hormones may trigger the body to make testosterone. This hormone will help the testes to descend into the scrotal sac. This treatment is only used in some cases. The child's healthcare providers will determine the risks, benefits, and possible side effects of all medicines and advise appropriately.

LIFESTYLE AND HOME REMEDIES

Even after corrective surgery, it will be important to check the condition of the testicles to ensure they develop normally. Parents can help their sons by being aware of the development of their body. Parent must check the position of his testicles regularly during diaper changes and baths.

When the child is about to reach puberty and parent talk about what physical changes he should expect, the male children must be taught how they can check their testicles themselves. Self-examination of testicles will be an important skill for early detection of possible tumors.

COPING AND SUPPORT

A male child who does not have one or both testicles, he might be sensitive about his appearance. He might have anxieties about looking different from friends or classmates, especially if he has to undress in front of others in a locker room. The following strategies might help him cope:

  • The child must be taught the right words to use when talking about the scrotum and testicles.
  • It must be explained that there are usually two testicles in the scrotum. If he's missing one or both, explain what that means and that he's still a healthy boy.
  • Such children must be reminded that he's not ill or in danger of illness.
  • Parents must talk to such children about whether a testicular prosthesis is a good option for him.
  • Parents must help them practice a response if they are teased or asked about the condition.
  • Parents must buy him loose fitting boxer shorts and swim trunks that might make the condition less noticeable when changing clothes and playing sports.
  • Parents must be aware of signs of worry or embarrassment, such as not participating in sports that he'd normally enjoy.

COMPLICATIONS

If a testicle does not descend, its temperature can rise high enough to cause a low sperm count or poor sperm quality.

Another complication of an undescended testicle is testicular cancer, though the risk is lower than 1 percent. The link between the two conditions remains unclear.

Cryptorchidism also increases the risk of testicular torsion. This occurs when the spermatic cord becomes twisted.

The spermatic cord contains nerves, blood vessels, and tubes that carry semen between each testicle and the penis. Without quick treatment, they could lose the twisted testicle.

Also, if an undescended testicle is located in the groin, pressure from the pubic bone can damage it.

Finally, as with any surgery on the testicles, an orchiopexy carries a risk of damaging the vas deferens, which is the tube connecting each testicle to the urethra.

BOTTOM LINE

Cryptorchidism is a common and treatable condition in which one or both testicles does not drop into the scrotal sac while a male fetus is developing.

50 percent of cases of this condition resolves without treatment. However, some infants with an undescended testicle may require a procedure called an orchiopexy to correct the issue.

If an undescended testicle does not receive treatment soon enough, there is a risk of infertility later in life.

Bottom line; while the surgery carries risks, its general outlook is positive.

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