How do we evaluate the patient with undescended testis?
July 2021
As doctors, we first listen the story with details which means we take anamnesis. If our patient with undescended testicles is a small baby, we question whether there is an endocrine disorder during pregnancy, that is, whether the mother used hormone medication. We are investigating unexpected loss of newborns, genital abnormalities, infertility in the family to reveal a concomitant genetic problem. If our patient is a little older, we learn whether the testicles were in the sack when he was born or whether he has had an inguinal surgery such as a hernia before. All of these can push us to investigate in different ways.
After taking a good anamnesis, it’s time for the examination. Sometimes parents ask what we saw in the two-minute exam.
Let me tell.
First, we look for clues to possible hormonal, genetic, and metabolic problems that are generally noticeable. Then we move on to the genital examination. Patience is very important in the examination of the undescended testis. A crying child can contract his abdominal muscles, pull up the testicles that are normally in his sack, and mislead us. Likewise, it is very important that the room, the place where the child sleeps, and our hands as they should not be cold.
In the examination, we start from the inguinal canal with one hand and make a milking movement towards the sack and try to catch it in the bag with the other hand. With these maneuvers, we understand the location of the testis, its dimensions, its difference with the other testis, its hardness, whether its borders are smooth, that is, whether it contains a mass.
Sometimes the sack is empty during the examination, but we find the testis in the canal, when we milk it, it goes down into the sack, if its dimensions are good and we keep it in the sack for a while, we let him forget the cremaster reflex and if it stays in the bag when we let go, we say “shy testis”. Sometimes the testicle does not reach us at all. This is what we call “nonpalpable testis”. Let me describe these patients in a separate topic. Long explanation can be quite distracting.
Apart from the testis, we also examine the entire genital area. For example, the size of the penis, or the fact that the urinary hole that should be at the tip of the penis is lower, that is, the presence of hypospadias can give us clues about the sexual development disorders that can accompany us. Again, the fact that the sack is too small can give us the idea that the testicle does not descend or will not descend at all, or that the appearance of the structure of the bag is not normal can guide us in the direction of sexual development disorders.
We also look at the inguinal canal. I told you last time that inguinal hernia may accompany these children, and in addition, inguinal examination is indispensable to feel the lymph nodes in the groin and testicles in the groin.
Let’s move on to imaging techniques.
I can frankly state that no imaging technique can take precedence over physical examination and diagnostic surgery. The most commonly used imaging technique is ultrasonography, which works well for the nonpalpable testicles, which I will explain later. For example, we may not be able to feel the testicles in very obese children because of the adipose tissue. In this case, before looking with laparoscopy, performing ultrasonography and learning that the testicles are in the inguinal canal will change the surgical approach technique which is important.
We can also apply to find out the testicles dimensions while following the shy testicles. In fact, this is not a requirement either, but today, having a document for protecting ourselves within the understanding of “protective medicine” strengthens our hand. Otherwise, most of the time, our radiologist friends who do ultrasonography say that what they see is exactly the same as our examination findings. This is not due to a personal skill. We pediatric surgeons do so many genital examinations. So the important thing is our physical examination.
Do you know why I am telling you this?
Messages keep coming. This is the latest fashion. Parents are posting photos, “should there be surgery?” they ask. Or they send the ultrasound result, the report says the testis is in the inguinal canal. However, even in a normal child, a normal testicle may appear above the scrotum with the contact of the cold gel while ultrasound is being performed. How can we decide what to do by looking at a photograph or an ultrasound report?
Well, we finally decided that it was an undescended testis. What will happen?
In newborn babies, the descent journey may continue for another 4-6 months. We will wait patiently with the risk of possible inguinal hernia and testicular rotation, that is, testicular torsion. It is accepted that if it does not go down until 4 months, it will not go down anymore.
If the testis has not descended, there is a risk of torsion which means there is a risk of rotation of the testis,there is a risk of hernia, there is a risk of cancer, there is a risk of trauma, there is a risk of decreased reproduction.
I burned your brain, didn’t I? Let’s answer the question that is the title of our blog: How do we evaluate the patient with undescended testicles? Answer: By physical examination
In the end, we decided on the undescended testis. How will we treat it? When will we treat it?
I will explain the type and timing of undescended testis treatment in the next course, and the nonpalpable testis in another course.
And stay happy.
Prof. Dr. Egemen Eroğlu
