Senior Consultant, Department of Urology, Sir Ganga Ram Hospital, New Delhi
What is an undescended testicle?
Undescended testis is a condition in which one or both testes do not lie in the scrotum, the loose bag of skin below the penis. It is a common condition that occurs in nearly 4% of all newborn babies.
The testes originally develop in the back of the abdominal cavity of the foetus. Later they begin to descend to the scrotum. If the testis fails to descend all the way down and gets stuck somewhere along the path of descent it is called an undescended testes. This process of descent occurs during late pregnancy. This is why 30% of premature babies have at least one undescended testes. Some of the testes may descend even after birth, but this usually happens in the first 3-4 months. Testes that do not descend till one year will not descend and need to be treated.
How is the diagnosis made?
The diagnosis is usually apparent. One or both testes may be missing from the scrotum. The condition, however, needs to be differentiated from retractile testis. Sometimes the testes move up and down depending on the temperature of the surroundings. If the child is in a warm bath his testes are normal, but if he is exposed to cold or stroked along his upper thigh, the testes move up towards the abdomen. This up and down movement is normal and these testes are called retractile testes. They do not require any treatment.
The paediatric surgeon or urologist will be easily able to differentiate between a retractile testis and a true undescended testis. By examining the child he will also be able to locate the position of the undescended testis. Tests like ultrasound scan or CT scan to locate the testes are rarely required and are not very helpful. If the testis is not felt on repeated examination, the doctor may advise a laparoscopy examination to determine whether or not the testis is present in the abdomen. Sometimes testes can reach some place other than scrotum, a condition called ectopic testes. On examination, it is important to differentiate between undescended or atrophic testis, in latter condition, the testis is very small and can be difficult to feel.
Why is treatment needed for undescended testis?
It is very important for the boy's psyche to have two normal testes in the scrotum. This is often an underplayed argument.
Testes require a temperature slightly lower than the body temperature for sperm production. If they lie too close to the body, then over time the cells that produce sperms die leading to infertility. To minimize this damage undescended testes need to be brought down to the scrotum by 6 months of age.
Undescended testis are often associated with a hernia which requires surgical correction.
If the testes remain in the abdomen for a long time, they have a slightly higher chance of developing a cancer. If testis is in groin area, it is more easily injured during play or accidents.
What is the treatment?
The best treatment for undescended testis is an operation called orchidopexy. This operation is best done before 6 months of age. It is a safe procedure that is performed under general anaesthesia. Admission to hospital is usually not required. A small cut is made in the groin, the testis is freed from its attachments and its blood supply is preserved. Another small cut is made in the scrotum and a small pouch is made under the skin in which the testis is placed. The operation usually takes about an hour, the child is able to feed shortly thereafter and can walk about from the same evening.
In some cases, the doctor may prescribe injections of a hormone called human chorionic gonadotropin (HCG). The role of this is not defined and may be tried only in some cases where both testes are undescended.
What if the doctor is not able to feel the testis?
There are several possibilities in this case. Either the testis did not form. Or that it did form but underwent damage and has become useless. Or it lies somewhere inside the abdomen. This differentiation is possible by laparoscopy in which a small telescope is inserted into the child's abdomen under anaesthesia and the insides are examined to locate the testis. In the first two cases nothing further needs to be done except removing the useless testis. If the testis is inside, it will need to be brought down. In cases where one testis is missing, an artificial testis may be placed in the scrotum later so that the child does not suffer from an inferiority complex.