Undescended testis is a very common problem in children. I am going to spread this subject in a few chapters so I don’t bore you. In this section of the pediatric surgeon’s journal, I will explain what an undescended testis is, why it happens, and how it can cause problems.
When the undescended testis is mentioned among the people, it is understood that the testicle is not in the sack. However, we call it cryptorchidism. The testicle does not descend into the sack until the 4th month of life. The term cryptorchidism includes undescended testicle, vanishing testicle, shy testicle, ascending testicle, and ectopic testicle. What do they mean?
Absent testicles, that is, absent or vanishing testicles. They are disappearing or becoming very small as a result of damage to the vessels during the development of the testis, such as the testicular rotation while the baby is in the mother’s womb.
Undescended testicle, the testicle remaining in the path during the natural descent process. This path comes from the abdomen, passes through the inguinal canal and continues to the bottom of the sack. This means that the testis may remain in the abdomen, in the canal, or just at the exit of the canal, on the upper side of the sack.
The shy testis, or the elevator testis. We call them the retractile testis. Actually, this is a normal descended testicle. An extension of the abdominal muscles of males goes down to the sacks. The reason why the testicle is pulled up by the body is the contraction of this muscle, called the cremaster, in very cold weather, or when the inner side of the leg is touched. When the cremaster reflex is very active in young children, the testicles may go up when touched with a cold hand in cold weather, during diaper change. When the diaper is opened, the testicles are sometimes lower in the scrotum, and sometimes higher. This is called shy testis or elevator testis.
The testicle, which was located in the sack, may not positioned in the scrotum in the future due to the cord that cannot elongate at the same ratio as the child’s growth. Thus it may turn into an undescended testis.
Ectopic testis, on the other hand, is the deviation of the testis from its path during the descending process. It may place in the upper inguinal region, femoral canal, pubic bone, perineum, and even inside the sack of the opposite side, rather than descending into the sack after exiting the canal. But this is rare. It occurs in less than 1% of all undescended testicles.
Well, why? It is still not clearly understood. A lot of mechanical factors, hormonal factors are blamed. The changes in intra-abdominal pressure, the opening of the canal that causes the formation of inguinal hernia, that is, the processus vaginalis not closing, the deterioration of the gubernaculum, which acts as a guide in the descent of the testis, and a lot of hormonal reasons are among these factors.
While undescended testis is seen at a rate of 2% to 5% in all newborn babies, it can be detected at a rate of 30% in preterm babies, as can be expected since the descent process has not been completed yet. But the good news is that this process continues after birth, and by the time babies reach the age of 1, the rate of undescended testicles equals the same rate as in adults: 1%.
The fact that the rates I mentioned may vary on country basis, the probability of the father having undescended testicles may increase the incidence, and the association with exposure to drugs such as pesticides and diethylstilbesterol that can cause hormonal disorders during pregnancy makes us think of genetic and environmental factors.
Cryptorchidism is actually a stand-alone problem. However, it can be associated with some endocrine disorders, genetic syndromes and morphological abnormalities, especially if it is bilateral. There’s no point in distracting yourself by listing all of them here. But I repeat, one must be vigilant, especially if it is bilateral. It can be bilateral in approximately 10% of children with undescended testicles.
What happens if the testicle is not in place?
If there is a true undescended testicle, not a absent or shy testicle:
1. I just said that in almost 90% of cases, the processus vaginalis is open, that is, an inguinal hernia may accompany it.
2. The testicle, which has not yet descended into its pouch, can rotate around itself because it has not yet been fixed, that is, torsion may occur, its blood supply may be impaired and it may disappear. This condition is seen almost 10 times more in children with undescended testicles.
3. When the undescended testicle, which remains in the canal, encounters trauma and may be crushed in front of the posterior pelvic bone.
4. It is known that there is low sperm count, low quality and lowere reproductive potential in adults with a history of undescended testicles.
5. Men with undescended testicles have a higher risk of developing testicular cancer than the normal population. This elevation never reaches a prostate cancer or lung cancer level, but is above normal. It is difficult to calculate exactly, but there is talk of an increase of 3 to 10 times. Although less cancer is seen in those with early surgery than those with late surgery, it does not decrease to the level of the normal population.
6. Psychologically, it is accepted that men do not like their bags to be empty.
As a result, we first evaluate children with undescended testicles and then operate.
How and when?
I will continue next time.
Stay happy,
Prof. Egemen Eroğlu
