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  • Shaken Baby Syndrome

    Tuesday, 21 July 2015 16:28
  • Amniotic fluid problems

    Thursday, 14 May 2015 12:54
  • Choosing a pre-school

    Friday, 10 April 2015 17:50
  • Newborn reflexes

    Tuesday, 03 March 2015 15:49
  • Mastitis

    Tuesday, 03 March 2015 15:41
  • Pelvic floor exercises

    Wednesday, 11 February 2015 17:20
  • Colic

    Wednesday, 11 February 2015 17:11
  • Antenatal Classes

    Monday, 03 June 2013 09:34
  • Strap-in-the-Future

    Thursday, 30 June 2011 13:52

Undescended Testes

The testes or male sex glands are responsible for producing sperm and the male sex hormone testosterone. The testes are located in the scrotum (a small pouch of skin that hangs at the base of the penis). The testes initially develop in the foetal abdomen and then move through the inguinal canals in the groin, into the scrotum before or just after birth. If the testes fail to migrate into the scrotum, the result is undescended testicles.

Undescended testes can be unilateral or bilateral. The condition, also called cryptorchidism, is present at birth when one or both testicles remain in the abdomen or only move partially into the scrotum. Approximately 5% of all boys are born with the condition. This number tends to drop to 2-3% by six months of age, with the testes often descending into the scrotum on their own during this time. It is common for the testes to descend on its own before the child is 3 months old. If the testes has not moved into the scrotum by 6 months of age, it is unlikely to do so and will require treatment.

Cause

The cause of undescended testes is sometimes unknown. It is believed that a combination of genetic, maternal health and environmental factors play a role in disrupting the hormonal, physical changes and nerve activity involved in testicle development.

Premature babies tend to be more prone to the condition because the testes do not descend from the abdomen into the scrotum until 8 months gestation. Physical abnormalities at birth and genetic conditions (such as Klinefelter’s syndrome), can also lead to undescended testes. Similarly, the condition is more prevalent in babies born with spina bifida and Down syndrome.

Risk factors therefore include:

  • Premature and low birth rate babies
  • Tobacco consumption and smoking by the mother during pregnancy
  • Familial history of problems involving genital development, including
  • Cryptorchidism. A baby, whose older sibling has undescended testicle (s), is twice as likely to be born with the condition.
  • Babies of diabetic mothers are also at increased risk.

Signs and symptoms

You should be able to see or feel two distinct testicles when examining a baby’s scrotum. The scrotum may appear empty or bag-like in infants with undescended testicles. The scrotum may appear smaller than normal or uneven. An undescended testicle causes no pain or difficulty with urination.

Diagnosis

Undescended testes are often discovered on physical examination. A warm bath is used to help newborn babies relax and simultaneously expand the skin around the scrotum, to make the examination easier. This initial evaluation is followed by periodic examinations at child wellness visits. There are a number of reasons why testes are not in the scrotum. The testicle failed to develop or died in utero (absent testicle), the testicle shrank before birth due to a twist or blockage in its vessels (atrophic testicle), or it may have failed to descend into the scrotum (undescended testicle).

Due to the migratory habits of testicles, it may be challenging to determine if one or both has not descended. The testes usually hang away from the body, as they require a slightly cooler environment than the normal body temperature for optimal functioning, especially sperm production. If the testes are exposed to cold or handled, they tend to slip back up into the body as a protective mechanism. In some boys, the testes are particularly sensitive and spend a great deal of time in the body. In most boys, the left testicle tends to hang lower than the right, possibly causing concern that the right is undescended. A diagnosis is only made, if one or both testicles have never been seen in the scrotal sac, or fail to appear when baby is placed in warm water.

Types of undescended testes

Doctors generally distinguish between palpable and impalpable undescended testicles. In 80% of cases the testicles can be felt during a physical examination (palpable). The testicle (s) are usually lodged in the inguinal canal. The inguinal canal is a tubular opening found in the lower anterior abdominal wall. In males, it is the passage through which the testes descend into the scrotum and it contains the spermatic cord.

If the testes are said to be impalpable it means that they cannot be felt during a physical examination. There are three main types:

  1. Abdominal or intra-abdominal – In 40% of cases the testicle is inside the abdomen, usually near the upper opening of the inguinal canal.
  2. Inguinal – In the other 40%, the testicle has moved into the inguinal canal (as it should), but has not descended enough to be detected by touch.
  3. Atrophic – Atrophic testicles are very small and account for 20% of cases of impalpable testes.

Treatment

If the testes have not descended by the age of 6 months to one year, treatment will be recommended. Boys whose testes remain in the body are unable to function effectively due to overheating, possibly resulting in fertility difficulties, if left untreated. Locations outside the scrotum place the testes at risk of injury. Undescended testes have also been associated with hernias. If the testes are undescended, there is a higher risk of developing testicular cancer in adulthood. Testicular cancer has a high cure rate, if discovered and treated early. Early identification is only possible if the testicle is located in the scrotum.

The goal of treatment is to bring the undescended testicles down into the correct place in the scrotum. This is usually done surgically, with general success and safety. In rare cases, hormone therapy may be recommended.

The type of surgery your child needs depends on the location of the testicle. If the undescended testicle is low in the abdomen or in the groin and the blood vessels are long enough to reach into the scrotum, a surgery called orchiopexy is required.

If your child’s undescended testicle is high in the abdomen and the attached blood vessels are potentially too short to reach the scrotum, a different type of surgery is necessary. This surgery is called “Fowler-Stephens” or FS orchiopexy. It can be done in two ways: either as a single surgery (one-step surgery), or as two, separate procedures 6 months apart (two-step surgery).

Both orchiopexy and FS orchiopexy can be performed by means of open or laparoscopic surgery. If your child’s undescended testicle is situated in the groin, the surgeon will probably do open surgery. If the surgeon is unsure where the testicle is situated or cannot find it, he is likely to use tool called a laparoscope. A laparoscope is a thin tube with a tiny camera that can be inserted through small cuts in the body. In this case, the procedure aims to locate the testicle and surgically move it into the scrotum without making large incisions.

Recovery

Every anaesthetic comes with a risk of complications and your child is likely to feel unwell for the first 24 hours after surgery. Nausea is a common side effect of general anesthesia. You should encourage but not force your child to drink plenty of fluids. Every surgery carries a small risk of bleeding and infection. Your child will need regular pain relief postoperatively, for at least three days. Swelling, bruising and tenderness in the affected area are normal. Activities such as watching TV, playing games and reading together may help keep his mind off the pain. Your child should refrain from riding his bike or use “sit-on” toys for a few weeks after the operation. Follow your surgeon’s advice in this regard to prevent the testicles from travelling back up into the abdomen. The same applies to washing and bathing directives. Wearing a nappy is fine and may help protect the area. Your child should rest for a few days at home before returning to their regular activities.

Contact your surgeon immediately if:

  • Your child’s pain is unmanageable and the medication does not seem to help
  • Your child is not drinking any fluids and appears dehydrated
  • Your child has a fever
  • The operation site is red and feels hotter than the surrounding skin
  • The wound is oozing or appears infected


Hormone treatment

Another, less popular treatment option for undescended testicles, involves the use of a hormone called hCG (human chorionic gonadotropin). Hormone therapy may be recommended if your child’s testicle is close to the scrotum and blood tests reveal an underlying problem with their hormones. The hormone is administered by means of injection 2-4 times per week, for 4 or more weeks. The aim of treatment is to get the testicle to drop down into the scrotum.

Prognosis

Hormone therapy is less commonly used because of its limited effectiveness and the possible risks of long-term complications. When the undescended testicles are surgically treated in early childhood, the outlook is good. Your child will have normal fertility, unless there were problems with the testicles themselves.