QuestionSBA
QuestionChoice
Annual l follow-up is required if the testes descend after 3 months but remain retractile since there is a risk of the testes ascending over time. This baby needs follow up at 3 months to see if the testicles have descended or not; by then, the child will be 4-5 months of age, and if the testicle hasn't persisted, will warrant referral to a urologist for review, as per NICE guidelines.
53270
d
Annual follow-up
QuestionChoice
Urological surgery may be warranted if the testis remains undescended by 6 months. Unilateral undescended testis is common and usually resolves spontaneously within the first 3-6 months of life. Therefore, urological review is not required at this stage or urgently. This baby needs follow up at 3 months to see if the testicles have descended or not; by then, the child will be 4-5 months of age, and if the testicle hasn't persisted, will warrant referral to a urologist for review, as per NICE guidelines.
53271
e
Refer to urology routinely
QuestionChoice
Urological surgery may be warranted if the testis remains undescended by 6 months. Unilateral undescended testis is common and usually resolves spontaneously within the first 3-6 months of life. Therefore, urological review is not required at this stage or urgently.
53269
c
Refer urgently to a senior urologist within 2 weeks
QuestionChoice
Bilateral undescended testes may represent a serious underlying endocrinological or developmental abnormality, such as congenital adrenal hyperplasia, and as such the NICE guidelines suggest urgent review within 2 weeks by a paediatrician.
53268
b
Refer urgently to a senior paediatrician within 2 weeks
QuestionChoice
This newborn has a unilateral undescended testicle which has been noted on the 8-week baby check up. This is a common presentation at the baby check with around 1/25 boys being born with undescended testicles. In most instances, these will descend naturally during the first 3-6 months of life, and no treatment will be required. Therefore, at this stage, follow up in 3 months is all that is required. If undescended by 6 months, then it is unlikely they will descend spontaneously, and as such surgery is warranted, ideally before the child reaches 12 months of age. Referral is usually done around 4-5 months of age if the testicles are undescended, in order to minimise delays. Note that by the first year of life, 2/3 of undescended testes resolve spontaneously.  Note that undescended testes are a big risk factor for testicular tumours which are identified as an inguinal lump later on in life.
53267
a
Review at 3 months
Concept
Chapter
# Summary

Undescended testes, or cryptorchidism, is a condition present at birth where one or both of the male testes have not descended into the scrotum prior to birth. It occurs in about 1-4.5% of term and 30-45% of premature newborns, with around two-thirds spontaneously descending by the first year of life. Key symptoms include the absence of one or both testes in the scrotum. Orchidopexy is a common treatment, and management strategies depend on whether the condition is unilateral or bilateral. Management of this condition is important as undescended testes are a risk factor for testicular cancer.

# Definition

Cryptorchidism, or undescended testes, is a congenital condition in which one or both of the testes fail to descend into the scrotum before birth.

# Epidemiology

Cryptorchidism is present in approximately 1-4.5% of term newborns and about 30-45% of premature newborns. By the first year of life, around two-thirds of these cases will have spontaneously descended.

# Aetiology

The exact cause of cryptorchidism is unknown, but it is thought to be multifactorial, with genetic, maternal, and environmental factors potentially playing roles. Maternal factors may include alcohol consumption, smoking, and exposure to certain medications during pregnancy. Cryptorchidism is also more common in premature and low birth weight infants.

# Signs and Symptoms

The primary sign of cryptorchidism is the absence of one or both testes in the scrotum. This can often be identified during a physical examination.

# Differential Diagnosis

When considering cryptorchidism, other conditions that may present with similar symptoms include:

- **Retractile testes:** The testes may be in the scrotum at times but can retract into the inguinal canal when the cremaster muscle contracts. Key signs include the ability to manipulate the testes into the scrotum and staying in place at least temporarily.
- **Inguinal hernias:** These present with a palpable mass in the inguinal region which can increase in size with crying or straining. They are often associated with discomfort or pain.
- **Ectopic testes:** This condition is characterized by testes that have deviated from the normal path of descent and are located in abnormal positions, such as the perineum or femoral region.

# Investigations

The initial investigation of cryptorchidism involves a thorough physical examination. In some cases, further investigations like ultrasound or MRI may be considered, especially in cases of non-palpable testes. Hormonal testing may also be needed in certain cases.

# Management

The primary management of cryptorchidism is surgical, with the most common procedure being orchidopexy, a surgery designed to bring the undescended testes into the scrotum.

Management strategies vary depending on whether the condition is unilateral or bilateral:

- For undescended testes that are **bilateral** at birth, an urgent referral to a senior paediatrician within 24 hours is needed for potential endocrine or genetic investigation (e.g. congenital adrenal hyperplasia, or CAH). If these conditions are ruled out and the testes remain undescended by 3 months, the child should be referred to surgeons by 6 months of age.
- For undescended testes that are **unilateral** at birth, arrange a review at 6-8 weeks of age. If the testis remains undescended at the 3-month review, re-examine at 4-5 months
- At 4–5 months (corrected for gestational age), if the testis remains undescended, arrange referral to paediatric surgery or urology for specialist management depending on local referral pathways, to be seen by 6 months of age
- The British Association of Paediatric Surgeons (BAPS) recommends that if orchidopexy is indicated, it should be performed around 12 months of age


# NICE Guidelines

[NICE CKS - Undescended Testes](https://cks.nice.org.uk/topics/undescended-testes/)

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2168
Undescended testes
Topic
22
Urology
10714
Unilateral undescended testicles often resolve spontaneously within the first six months, infants should be reviewed at 3 months.
An 8-week-old baby boy presents to the GP with his father for his baby check. He is currently feeding well, opening his bowels and passing urine. There are no concerns regarding his growth and development as he is following the centiles adequately. On examination, he is fixing and following objects and smiling at his dad. The GP notices that he has a right unilateral undescended testicle.

Which of the following is the next best step in the management of this patient?
a