Cryptorchidism, also known as "undescended testicle," is one of the most common congenital abnormalities in newborn males. It is characterized by the failure of one or both testicles to descend into the scrotum before birth. While in many cases the testicle may descend spontaneously during the baby's first months of life, in other cases, medical treatment or surgery is necessary to avoid long-term complications, such as infertility or an increased risk of testicular cancer.
In this article, you'll find a comprehensive review of cryptorchidism, analyzing the different types, causes, symptoms, diagnostic methods, available treatment options (both surgical and hormonal), associated risks if cryptorchidism is not corrected, and the possible prognosis and follow-up process. You'll also find answers to the most frequently asked questions about this condition.
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What is Cryptorchidism?
Cryptorchidism (a term that comes from the Greek kryptos: hidden, and orchid: testicle) is a malformation that occurs when one or both testicles do not complete their descent from the abdomen to the scrotum during fetal development, resulting in the baby being born in this way.
We must understand the physiology of normal testicular descent. During embryonic development, the testes form in the abdominal cavity and then descend into the scrotum in two phases. The first is the transabdominal phase, which occurs between weeks 8 and 15 of gestation, in which the testes migrate toward the pelvis. The second phase is the inguinoscrotal phase, which occurs between weeks 25 and 35 of pregnancy, in which the testes descend through the inguinal canal into the scrotum.
This process depends on various hormonal factors, such as testosterone and anti-Mรผllerian hormone, and mechanical factors (gubernaculum testis). If this mechanism is altered, the testicle may become retained in the abdomen, in the inguinal canal, or in some ectopic position.
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Unilateral
Unilateral cryptorchidism affects only one testicle and is the most common, accounting for approximately 80% of cases. The left testicle is the most common undescended testicle.
Bilateral
Bilateral cryptorchidism occurs when both testicles fail to descend into the scrotum. It is less common (only 20% of cases), but also carries a higher risk of infertility and hormonal complications.
Classification
Cryptorchidism is usually classified according to the location of the undescended testicle. If it's inside the abdomen, it's called abdominal retention; if it's located in the inguinal canal, it's called inguinal retention. If it's located outside the normal route, such as in the perineal region, it's an ectopic testicle. If the testicle initially descends but then retracts, it's called ascended or acquired testicle.
Causes and risk factors
The main causes of cryptorchidism usually involve hormonal disorders, such as a deficiency of testosterone or gonadotropin, or a resistance to androgens (androgen insensitivity syndrome).
It can also occur due to anatomical abnormalities such as defects in the gubernaculum testis or fibrosis or adhesions in the inguinal tract. It can also be caused by genetic factors such as mutations in the INSL3 or GREAT genes, and it has a higher incidence in those with syndromes such as Klinefelter or Prader-Willi.
Risk factors often include prematurity (it affects 30% of premature babies), low birth weight, exposure to endocrine disruptors, a family history of cryptorchidism, or multiple pregnancies.
Symptom
The main sign of cryptorchidism is the palpable absence of one or both testicles in the scrotum. Other possible findings include an empty or asymmetrical scrotum, a palpable testicle in the inguinal canal (in some cases), abdominal or groin pain (although this is a rare symptom in boys and is more common if there is testicular torsion), and asocial inguinal hernias, which occur in 90% of cryptorchidism cases.
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Diagnosis
Diagnosis of cryptorchidism begins with a physical examination that involves inspection and palpation of the scrotum and inguinal canal, as well as a gentle traction maneuver to differentiate a retractile testicle (which is normal) from an undescended one.
Imaging studies are also commonly performed, such as a testicular ultrasound, which is useful for locating inguinal testicles but less effective for intra-abdominal testicles; an MRI, which is more accurate for finding non-palpable testicles; or a diagnostic laparoscopy, which is the standard for abdominal testicles.
In selected cases, hormonal studies of testosterone, LH, FSH levels, or hCG stimulation tests are also often required to evaluate testicular function.
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How and when does testicular descent occur?
In full-term fetuses, 95% of the testicles descend at birth. In premature babies, up to 30% may present with cryptorchidism at birth, but in many cases, the testicles descend spontaneously after 6 months. And if cryptorchidism is still present after the first year, then the likelihood of descent is already very low and treatment is necessary.
The key time to intervene is between 6 and 12 months of age, and it should always be before 18 months, to ensure the preservation of fertility.
Treatment
Surgery
It's called orchidopexy, and its purpose is to secure the testicle in the scrotum to prevent tissue damage. It can be performed using an open technique for testicles that are palpable in the inguinal canal, or laparoscopically for testicles that are intra-abdominal. It is recommended to perform it between 6 and 12 months of age (always before 2 years of age) and has a high success rate of 90 to 95%.
Hormonal treatment
This is indicated only in certain cases, to stimulate testicular descent with hormones. Its effectiveness is limited, with a success rate of only 20 to 25%, and it can be used as a preoperative supplement in certain cases.
What happens if it's not corrected? Risks and complications
Infertility
Abdominal temperature damages sperm-producing tissues, and in bilateral cases, the risk of sterility is 50 to 70%.
Increased risk of testicular cancer
There is an estimated 5 to 10 times greater chance of developing germ cell tumors, and the risk persists even after surgery.
Testicular torsion
The undescended testicle is more susceptible to torsion, causing ischemia.
Associated inguinal hernia
This occurs in 90% of cases, they have a patent peritoneal duct.
Psychological impact
This condition often causes anxiety about the appearance of the scrotum, especially from adolescence onwards.
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Forecast and Monitoring
What to expect after surgery?
Recovery is usually rapid, with a period of 1 to 2 weeks of relative rest, and then annual monitoring should be maintained to evaluate testicular growth.
Monitoring future fertility
A semen analysis can be performed in adolescence and adulthood if bilateral cryptorchidism has occurred, and assisted reproductive techniques may be necessary.
Oncological surveillance
Patients who have suffered from this condition should perform a monthly testicular self-examination starting at puberty and should undergo periodic ultrasounds if they are at high risk.
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Frequently Asked Questions
How common is cryptorchidism in newborns?
This condition occurs in 3 to 5% of full-term newborns, and in up to 30% of premature babies.
Is an undescended testicle the same as an absent testicle?
No, anorchia is the congenital absence of one or both testicles. It is different from cryptorchidism and requires a hormonal diagnosis.
Can there be abdominal pain due to cryptorchidism?
This condition rarely causes pain in children, but in untreated adults, it can cause pain due to testicular torsion or the development of a tumor.
Can it affect sex life?
Not directly, but it can cause infertility or anxiety that can impact sexual health.
What happens if cryptorchidism is not detected in childhood?
There may be a higher risk of cancer and infertility. Furthermore, surgery in adults is more complex.
When is surgery urgent?
Surgery is urgent if testicular torsion or an incarcerated hernia is present.
Can cryptorchidism return after surgery?
This is very rare, but it can happen if the fixation was not adequate.
Conclusion
Cryptorchidism is a condition that requires early diagnosis and timely management to prevent future serious complications such as cancer and infertility. Surgery should be performed before 18 months, as this is the best standard for recovery, with excellent results in most cases. Long-term follow-up should include fertility evaluation and ongoing oncological surveillance, which is essential to ensure a healthy adult life.
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