What is an undescended testicle?
Testicular tissue first forms on the posterior abdominal wall when the baby is in the mother's uterus. Then, with several hormonal and mechanical factors, it first moves to the inguinal region and then reaches the scrotum. Sometimes, if these hormonal and mechanical factors that lead to the descent of the testicle develop, and if the testicle remains behind or in an abnormal position on the way it should progress, it is called an undescended testicle. In this case, it is seen that the scrotum does not develop, and the testis cannot be felt there.
Undescended testis is the most common disease requiring surgical intervention in pediatric urology. Due to the uncertainty in its causes, there is no consensus on the priorities of hormonal and surgical treatment in its treatment, and there are different treatment protocols. However, the risk of infertility and testicular cancer in children with undescended testicles is higher than in the normal population, therefore, treatment and follow-up are necessary.
What are the functions of the testicles?
The testicles are two oval organs with an average length of 5 cm in adults. They are located under the abdomen and behind the penis in a leather bag called the scrotum. The testicles begin to make sperm cells to be used for reproduction at puberty and they continue to do so throughout life. For example, even if an 80-year-old man's testosterone (male hormone) production drops to 20% of what it was in his youth, sperm production continues until he dies. In addition to producing sperm, the testicles also secrete the male hormone testosterone. This hormone enters the bloodstream and plays an important role in the development of typical male physical characteristics, beard, mustache, more muscle mass, strength, deep voice etc. as.
What does testicular descent mean?
The testicles complete their development in the first two months of pregnancy and secrete hormones that provide sexual differentiation by settling in the baby's abdomen. While in the mother’s uterus, the baby's testicles are located just below the kidney s, that is, in the abdomen and in front of the back muscles. In the 7th month before birth, they depart from this region, pass through the inguinal canal, and descend into the scrotum close to birth. If this journey does not occur, the undescended testis will appear.
By which mechanisms do the testicles descend into the scrotum?
The descent of the testicles into the scrotum is a complex process, and in addition to hormones such as gonadotropins and testosterone, intra-abdominal pressure also plays a role. The effects of these factors controlling the descent of the testis are not completely clear and there are many hypotheses regarding the descent mechanism of the testis.
What are the causes of an undescended testicle?
Although undescended testis is a very common problem in newborn male babies, its exact causes are not known. Various theories have been put forward as to its causes. When the baby is in the mother’s uterus, a band-like tissue coming out of the lower end of the testis extends to the inner surface of the scrotum. In the lead of this, the testicles descend into the scrotum. Structural reasons such as the absence of tissue to lead, the shortness of the vessels feeding the testis or the duct that will carry the sperm, the narrowness of the inguinal canal, or the lack of hormones play an important role in the emergence of this problem. Undescended testis due to hormone deficiency is usually bilateral.
How common is an undescended testicle in the community?
Undescended testis occurs with a frequency of 33% in preterm babies (premature babies) and 3% in term babies. The lower the birth weight, the higher the incidence of undescended testicles. As the premature babies start to gain weight over time, the testicles begin to descend. Spontaneous descent also occurs in term infants in the first few weeks or months, so approximately 0.8-1% of children at the age of 1 may still have undescended testicles. Most of this subsequent descent, which takes place within the first year, occurs within the first 6 months.
How are undescended testicles classified?
It is classified into 3 groups according to the localization of the testicle:
- True undescended testicle(cryptorchidism): This can also be grouped within itself:
- Abdominal; The testicle is inside the inner inguinal ring (orifice).
- Canalicular; The testicle is between the inner and outer inguinal rings.
- Prescrotal (or higher scrotal); The testicle is located just at the exit of the outer inguinal ring.
- Ectopic testicle: They are in an area outside the normal descent path. They may be located on the anterior surface of the abdomen, just under the skin, on the inner surface of the thigh, in the perineum or far from the normal descent path, such as the root of the penis.
III. Retractile testicle:Retractile testicle also known as shy testicle; It refers to the lowering of the testicles to the base of the scrotum with manual pulling, but the testicles that are in the groin area at other times. Normally, in boys, the testicle is pulled upwards towards the inguinal region because of a reflex activated by touching the thigh region close to the scrotum. This reflex is normally the body's mechanism to protect the testicles. In some children, this reflex mechanism may be more active than normal and cause this condition called retractile testicle. The approach to these is different from undescended testicles. Since this situation is not known by many families, the testicles can be evaluated as if they are not in the scrotum. To fully reveal this situation, it would be appropriate to consult specialist physicians in cases of doubt. Retractile testicles are common in children aged 5-6 years. These cases are often (and not given sufficient care) confused with true undescended testicles. Retractile testes, which are usually bilateral, completely settle into the scrotum in early adolescence without the need for treatment. Retractile testicles often do not affect sperm production when they are in the scrotum.
IV.Acquired undescended testicle: Testicles that are initially examined in the normal scrotal localization but are then permanently located in the inguinal canal position are called acquired undescended testicles. In children with initially retractile or descended testicles, they may migrate out of the scrotum towards the inguinal canal in advanced ages due to the limited development of the spermatic cord, the formation of fibrous bands and the change in some growth factors. Retractile testicle is the group in which testicular ascending is most common in advanced ages. In a series, it was reported that 32% of the cases of acquired undescended testis were retractile, but it was also reported that this situation could reach 50%. In the case of retractile testis, the rate of undescended testis was reported to be 56% in cases with an inelastic spermatic cord and under the age of 7 years. During the examination, close follow-up is recommended considering the high probability of undescended testis in cases of tense cord in cases of retractile testis.
Of the undescended testicles, 70 percent can be found in the inguinal canal or the neck of the scrotum, 25 percent in the abdomen, and 5 percent in a different place from the normal place. 70% of undescended testicles are on the right side. 10% of cases are bilateral.
With what symptoms do families apply?
The main symptom that causes the patient to apply is the absence of one or both testicles in the scrotum. Unfortunately, most of the patients apply late, perhaps because of previous treatment modalities, misinformation from the environment that they can come off on their own. However, the true undescended testicle does not descend after the 6th month, and histopathological changes begin after this period and sperm producing cells are damaged over time.
Why is it necessary to surgically lower the testicles into the scrotum?
There are 4 reasons, each of which can be an answer to this question on its own.
- Prevention of infertility: Normally, the testicular temperature is 0.5-2°C below body temperature. This is essential to produce sperm. It has been experimentally shown that serious disorders occur in the ducts where sperm are produced in the undescended testicle, which is constantly at body temperature. Structural examinations that are possible with the introduction of electron microscopy show that sperm production disorders begin to appear around the age of 2 years. For this reason, undescended testicular surgery to be performed after the first two years is for the continuation of hormone production rather than sperm production. Fertility is rare in untreated adults with bilateral undescended testicles, and only 35-45% are fertile even after surgery of the testicle (orchiopexy). Fertility is often impaired in patients with unilateral undescended testicles, and approximately 75-80% of them are fertile.
- Prevention of cancer formation: The increased incidence of testicular cancer in cases with undescended testicles is a controversial issue. The diversity in scientific publications causes disagreements on this issue. However, the risk of developing testicular cancer is 7-10 times higher than the normal population. Among these patients, the highest risk of developing cancer is those with intra-abdominal testicles, and approximately half of the patients who develop cancer are those with this type of testicle. Today, it is thought that this risk will decrease in children who are operated at the age of 2 years. Although undescended testis is a childhood disease, cancer that may occur later is an adult disease. While testicular cancer develops lately in the twenties, its appearance is mostly in the thirties. With the surgical intervention, the patients can be aware of such problems that may occur in their testicles in an earlier period.
- Prevention of torsion: Torsion (rotation of the testicles around itself) may occur in undescended testicles located in the abdomen. Testicular torsion should also be included in the possible diagnoses in children presenting with abdominal pain and found to have undescended testicles.
- Psychological reasons: Even if there are no other complications, it is certain that the psychological trauma of this will be great for a child in the developmental age who thinks that one of his testicles is missing. For this reason, the testicle should be surgically lowered to the scrotum before he reaches sexual consciousness. It is argued that the insertion of testicular prosthesis in children whose testicles have been removed and in cases where there is no congenital testicle is a psychological aid.
What should a family do with a baby with an undescended testicle?
Families should check from birth whether their baby's testicles are in place. If one or both testicles are missing or if the family has any doubts about this, the baby should be taken to a physician, preferably a pediatric urologist. Babies with undescended testicles must be examined before the age of 1 year. Thus, it is ensured that physicians investigate whether there is another problem with the undescended testis in the early period, especially if there is a problem that causes suspicion in the gender of the baby.
What are the treatment options?
There are two treatment methods in the treatment of undescended testis: drug (hormonal) treatmentand surgical treatment. For the testicles to continue their normal development, they must be in their normal anatomical position. First, if they are not included here, their development deteriorates, and they gradually become smaller (atrophy).
What is hormonal therapy?
There is a difference of opinion regarding the efficacy and safety of hormonal therapy. The use of Human Chorionic Gonadotropin (HCG) or Gonadotropin Releasing Hormone (GnRH) alone or in addition to surgery is a generally accepted method. It has been reported that the testes can be lowered by 15-45% with the use of these hormones alone or together in the treatment of undescended testicles. However, it is known that hormonal therapy is more effective in cases located close to the scrotum and in older children. It should be noted that hormonal therapy should not be done haphazardly.
What is surgical treatment?
Surgical treatment is essential in undescended testis. The aim of surgical treatment is to lower the testis to its normal scrotal position in one or sometimes two sessions. When faced with structural anomalies and atrophic testicular tissue, it is more appropriate to remove the testicle instead of lowering it. Today, undescended testis surgery is recommended to be performed between 6 months and 1 year of age. In the newborn period, male babies should be evaluated in terms of undescended testicles.
How to prepare for the surgery?
General anesthesia is used for the surgery. For this reason, about 3-4 days before the operation, the necessary analyzes and examinations are requested for anesthesia approval. If these tests are evaluated by the anesthesiologist and there is no problem, the oral intake of the child is stopped at least 6 hours before the surgery.
How is the surgical procedure done?
The success rate of undescended testicle operation is very high. The surgery can be performed from the inguinal (inguinal orchidopexy) or scrotal region(scrotal orchidopexy). The location of the surgery may vary depending on the location of the undescended testis and the experience of the physician. In cases of undescended testicle close to the scrotum, the testis is reached with a 2-3 cm incision made in the scrotum, and after the testis is separated from the tissues that may prevent its descent, it is placed back in the sac. If the testis is too high to be reached through the scrotum, an incision of 3-5 cm is made from the inguinal region and after the testis is reached and the testis is completely released, the inguinal hernia, which is often seen together, is also repaired. The scrotum is then fixed into the scrotum with sutures. During the operation, the structure of the testis is evaluated by the physician. If the testis is shrunken (atrophic), the testis is removed against the possibility of cancer.
In some cases, the testis may not be seen either by physical examination or by examination methods. In this case, the inside of the abdomen should be examined with a closed method (laparoscopy) to detect the testis that may be in the abdomen and to make the necessary intervention. Because the testis may have remained in the beginning of the descent path to the scrotum. If the testis, which is seen laparoscopically, is not shrunk, it is first released, then it is lowered laparoscopically to the inguinal region and through the incision to be made in the inguinal region it is observed and placed in the testicular sac. This surgery can be performed in a single step, or it can be performed in stages. If the testis is small (atrophic), it is removed laparoscopically in case of future cancer.
Haw is the early post-operative follow-up?
After the surgery, nothing is given by mouth until the child's bowel sounds begin or until the gas is produced (approximately 4-6 hours). During this period, intravenous fluid support is given. He is discharged in the evening or the next morning on the same day. Under normal conditions, the catheter is not inserted in the patient after undescended testicular surgery, but if it is inserted due to the requirements of the surgery, it is usually removed the day after the operation. After discharge, daily dressing is applied for 1 week and prescribed antibiotics and painkillers are used. The stitches will dissolve on their own within 10 days, but if non-melting stitches are used, the stitches should be removed one week after the operation. Bathing is not recommended for a week.
What is the late period care after surgery?
Follow-up should be done on the seventh day after the operation (to see the wound site and remove the sutures), at the first month, and at the first year. Afterwards, families are taught about the control examination, and it is recommended that they consult a physician in case of doubt.
What are the complications and treatment of undescended testicle surgeries?
Apart from the complications of anesthesia itself, early and late complications may occur in the surgery to lower the undescended testicles. If the incision in the inguinal region is insufficient to lower the testicles during surgery, it may be necessary to open the abdomen with a larger incision. In the early period, visible swelling, and bruising (hematoma) can be seen in the testicular bag, most of which disappear over time. In some cases, fluid collection may develop between the testis and the membrane surrounding it (hydrocele), which may require further surgery in the later period. Sometimes, despite the success of the surgery, the testicles may go up and then surgery may be required. Rarely, the testicles may become smaller and lose their function due to surgery.