Boys with an undescended testis also have a slightly higher incidence of testicular cancer, compared to other boys, when they reach adulthood.
“Doctor, please look at my son. His kindergarten teacher noticed when she was changing him, that on one side there wasn’t any testicle.
“My wife and I tried to remember if we’d noticed this before, but we hadn’t. When he was born in the hospital, the doctor told us he was normal and healthy.”
This is a common scenario often encountered by paediatric surgeons. Parents or teachers would notice that there is no apparent testis on one or (rarely) both sides.
The retractile testis
A retractile testis is one that moves back and forth (like a yo-yo) between the scrotum and the groin.
This would be the case where parents would have seen the testis when the child was a baby, and do see it on and off when bathing the child or when he is sleeping. However, sometimes, the testis can’t be seen.
This happens because of a muscle called the cremaster muscle. The main purpose of this muscle is to control the temperature of the testis.
In order for a testicle to develop and function properly, it needs to be slightly cooler than normal body temperature. When the environment is warm, the cremaster muscle is relaxed; when the environment is cold, the muscle contracts and draws the testicle towards the warmth of the body. This is a normal reflex seen in all males.
When the doctor sees the child, she will try to try to put him at ease, and examine his groin and scrotum in a warm, relaxed environment.
If the testis is retractile, she would be able to easily bring it down into the scrotum, and it should remain there without any tension (i.e. without holding it in place).
Sometimes, manoeuvres like making the child squat on the examining table, may help. If the child is distressed and uncooperative, sometimes a repeat visit when the child is calmer, is necessary.
If the diagnosis is confirmed to be a retractile testis, no treatment is necessary, but regular (yearly) follow-up would be wise to check that the testis remains in the scrotum.
Some may go up as the child grows (ascending testis) and would eventually need surgery.
The tendency for the testis to yo-yo becomes less once the child undergoes puberty.
Undescended testis
The testes start developing near the kidneys in a foetus and slowly migrate downwards as the foetus develops. By the time the baby is born, the testes should have reached the scrotum.
An undescended testis is a testis that hasn’t moved into its proper position in the scrotum before the baby’s birth.
Most of the time, the testis does continue to move down after birth and should reach the scrotum by the time the baby is six months old.
If the baby was born prematurely, then this would be six months after its projected due date, to give allowance for its prematurity.
However, if the testis is still not down after six months of age, the little boy will require surgery to correct its position.
This operation is called an orchidopexy (meaning fixing of the testis). This operation is usually done as a day-care procedure. It is usually carried after the child turns six months old.
What if the doctor cannot feel a testis? There are a few possibilities:
• If the other testis is well felt in its normal position in the scrotum, then it could be that the testis is hidden under the skin fat (especially in chubby babies) and is located in the groin.
• It could also be one of the rarer cases in which the testis is high up and in the abdominal cavity.
Usually, in such cases, the other testis may be also undescended.
• The baby may not have a testis on one side. The testis may have twisted when the baby was still a foetus in the womb, or may not have developed at all.
In such cases, during the operation, a very small vestigial testis would be found. This organ would serve no purpose and could potentially become a tumour if not removed.
• The testis may be in a place other than the scrotum. This is called an ectopic testis. The testis may be found at the lower abdomen near the pubic bone, the upper inner thigh, the genital area near the anus or other sites.
Why is an operation necessary? My son is active and healthy.
As mentioned before, the testis needs to be at a slightly lower temperature than body temperature to grow and function normally. This is the case if the testis is in the scrotum.
In other sites, the testis will not develop well.
The testis in abnormal locations is also prone to injury or may get twisted. Most of these cases also have an associated inguinal hernia.
Boys with an undescended testis also have a slightly higher incidence of testicular cancer, compared to other boys, when they reach adulthood (30-40 years of age).
The orchidopexy procedure does not prevent the occurrence of this, but makes any changes in the testis more easily detectable because the testis is now in the scrotum. Patients (and parents) are advised to be aware of this.
What if my son has only one testicle? Will he be normal?
The testis has two main functions: male hormone production and sperm production (which starts at puberty).
If the boy has one normal testis (a testis that is in the scrotum), it will produce all the hormones necessary for a normal male and the boy will develop normally into an adult man.
Sperm counts should be near normal and fertility should be normal.
The issue only arises if the boy has undescended testes on both sides. Hormonal production is usually unaffected, but fertility could be an issue later in his life.
Explaining an orchidopexy
An orchidopexy is usually scheduled after the child has turned one, although many very experienced surgeons may do the operation earlier – between six months to one year of age.
Studies have shown that after the age of two years, an unoperated undescended testis starts to undergo microscopic changes because of the warmer surrounding temperature.
The procedure varies according to the type of undescended testis:
• An undescended testis that can be easily felt on one side, with a normally-located testis on the other side.
This is the most common presentation.
The surgery in these cases is the most straight-forward. It is done as a day-care procedure under general anaesthetic.
There will be two incisions, one in the groin and another on the scrotum. The testis is mobilised from the groin incision, then brought down to the scrotum and fixed there.
• For ectopic testis, the procedure will be exactly the same.
• Cases where the testis is not clearly felt, but the other testis is normal and in the scrotum.
The doctor may find that the testisis very small and non-functional (less than the size of the normal side). This type of testis should be removed.
If this is the finding at the operation, the doctor may decide to remove the abnormal testis and no scrotal incision will be made.
This operation is called an orchidectomy (removing the testis).
However, if the testis is a reasonable size, it will be brought down and fixed in the scrotum.
• Undescended testes on both sides where one or both sides cannot be clearly felt.
In such cases, the surgeon may choose to do a laparoscopic orchidopexy under general anaesthesia. This involves using a telescope to look into the abdominal cavity via a small incision near the navel.
If the testes are located inside the abdominal cavity, they can be mobilised downwards.
There are many varieties of orchidopexies to bring these types of high testes down, some of them done in two stages (i.e. two separate operations). The type of operation done will depend on each patient’s unique situation and the surgeon’s discretion.
According to a 1998 study, undescended testis affects about 5% of Malaysian newborn boys. About 1% will require referral to a surgeon and eventual corrective surgery.
Parents should be aware of the slightly increased risk their son has of testicular cancer when he is a young man, and he should be told to do self-examinations and seek urological consultation should he detect any changes in his testicle.
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