What is Cryptorchidism?

The Descent of the Testes from the Abdomen to the Scrotum

Cryptorchidism is the absence of one or, more rarely, both testes in the scrotum.

During the last two months of pregnancy, the testes normally "descend" from their original location in the abdominal cavity to the scrotum. During descent, each testicle "drags" with it the spermatic cord, a kind of "cord" containing nerves, blood vessels, and the cremaster muscle, necessary for the proper functioning of the testes.

Therefore, at birth, during the first pediatric examination at the hospital, in most cases, the testes are both present and palpable in the scrotum. This does not occur in 2 to 3% of newborns. It is even more common in premature babies. In most cases, in both full-term and premature babies, the missing testicle(s) spontaneously reach the scrotum within a few weeks and remain there for life. If this is not the case by the age of 3 months, treatment is necessary to prevent complications in the testes themselves.

Retractile Testes

It is also possible that a testicle normally descended at birth may not be palpable in the scrotum in an older child. This is only rarely "true" cryptorchidism. Almost always, it is instead a so-called retractile testicle or an accentuated cremasteric reflex. The involuntary contraction of the cremaster muscle contained in the spermatic cord causes the intermittent ascent of the testicle itself out of the scrotum.

What are the causes of ectopic testicle?

The causes of ectopic testicle must be studied by analyzing the in utero development period of the newborn. In the fetus, the testicle does not form in the scrotum, i.e., in its "final" position, but at the abdominal level, near the kidney. From the abdominal cavity, it then descends through the inguinal canal thanks to a complex, partly not fully understood, hormonal stimulation, to finally arrive in the scrotum, where it naturally fixes itself.

The exact mechanisms that alter this process are not fully understood. Some risk factors may include:

• Low birth weight;
• Prematurity;
• First-degree relatives who have suffered from cryptorchidism or other genital development problems;
• Fetal conditions associated with growth retardation, such as Down syndrome; abdominal wall anomalies;
• Smoking;

Another variant of cryptorchidism is testicular ectopy. During the migration process, the testicle regularly descends downwards but takes a "wrong" path, positioning itself not in the scrotum but outside, for example in the inguinal canal.

How to detect cryptorchidism

Cryptorchidism diagnosis is made after the first 3 months of life

Diagnostic suspicion is obviously placed at birth for the absence of the testicle in its natural location, but the definitive diagnosis of cryptorchidism is only made after waiting 2 to 3 months from birth, a time interval during which one or both testes not palpable in the scrotum may spontaneously descend.

What does the diagnosis of cryptorchidism consist of?

Anamnesis and precise palpation of the genitalia are usually sufficient to make a diagnosis. In some cases, it is advisable to use ultrasound (when, for example, the location of the testicle is particularly high) and more rarely magnetic resonance imaging or laparoscopy. The doctor, thanks to appropriate checks, will also be able to verify that it is not a case of testicular ectopy, or anorchia (congenital or acquired absence of the testicle).

Treatment of Cryptorchidism

The Role of Hormone Therapy

Hormone therapy with chorionic gonadotropin or LH-RH was widely used in the past to try to promote testicular descent. The results were so variable, ranging from 80% success to almost total failure, that they justify the suspicion that a significant proportion of physiologically retractile testes were included in the most optimistic cases. Some authors also consider partial migration as a success of medical therapy. Under the effect of hormonal stimulus, the testicle moves along the peritoneal canal without reaching the scrotum. At the end of the therapeutic cycle, the testicle may even be palpable in the upper part of the sac, but it is not possible for the normal anatomical elements of testicle fixation, the scrotal ligament and the mesovarium, to have formed from nothing, and for the peritoneal canal, which is permeable in about 80% of truly retained testes, to have been obliterated.

Surgical Treatment of Cryptorchidism

Surgical treatment is recommended between the ages of 6 and 12 months, as a late intervention increases the risk of developing infertility and testicular cancer. It generally consists of an orchidopexy, in a day hospital: the testicle is positioned in the scrotum and anchored there. More rarely, a more complex operation is necessary, for example when cryptorchidism is associated with an inguinal hernia, but in this case also without particular problems. Complications of the operation are extremely rare and do not involve significant risks of long-term infertility, which depend rather, as mentioned, on the time during which the testicle remains in its abnormal position.

What are the complications associated with cryptorchidism?

In case of cryptorchidism, complications can occur over time:

• Testicular cancer: It usually develops from germ cells, from unknown causes. However, cryptorchidism increases the risk of developing testicular cancer, especially if the undescended testicle remains in the abdomen and if both testes are affected;
• Infertility: Cryptorchidism also increases the risk of infertility, which is all the more important the longer the time elapsed before treatment;
• Testicular torsion: This is the torsion of the spermatic cord, which contains blood vessels, nerves, and seminiferous tubules connected to the testicle. Torsion causes, in addition to testicular pain, interruption of the blood supply to the testicle, which can lead to its definitive loss. The risk of testicular torsion is 10 times higher in case of cryptorchidism;
• Traumatic testicular suffering: The undescended testicle contained in the inguinal canal can be compressed against the pubis, thus suffering;
• Inguinal hernia: Cryptorchidism is generally associated with the persistence of the inguinal canal, which normally closes after the descent of the testicle into the scrotum;