Retractile and Undescended Testis Referral Guidelines

Initial Evaluation based on the American Urological Association Guidelines on Cryptorchidism

• Primary care providers should palpate testes for quality and position at each recommended well-child visit. 
• Primary care providers should not perform ultrasound (US) or other imaging modalities in the evaluation of boys with cryptorchidism prior to referral as these studies rarely assist in decision making. 
• Pediatric urology providers should assess the possibility of a disorder of sex development (DSD) when there is increasing severity of hypospadias with cryptorchidism.
• In boys with bilateral, nonpalpable testes who do not have congenital adrenal hyperplasia (CAH), providers should measure Müllerian Inhibiting Substance (MIS or Anti- Müllerian Hormone [AMH]) level) and consider additional hormone testing, to evaluate for anorchia.
• In boys with retractile testes, primary care providers should assess the position of the testes at least annually to monitor for secondary ascent. 

Initial Management:

• Primary care providers should refer infants with a history of cryptorchidism (detected at birth) who do not have spontaneous testicular descent by six months (corrected for gestational age) to an appropriate surgical specialist for timely evaluation. 
• Primary care providers should refer boys with the possibility of newly diagnosed (acquired) cryptorchidism after six months (corrected for gestational age) to an appropriate surgical specialist. 
• Primary care providers must immediately consult an appropriate specialist for all phenotypic male newborns with bilateral, nonpalpable testes for evaluation of a possible disorder of sex development (DSD). 

Spontaneous descent is seen in up to 90 percent of testes in the first six months of life. Therefore, any testis which is not descended by the seventh month of life should be referred to a pediatric urologist.

Your patient will undergo a physical examination by one of the pediatric urologists. If an undescended testis is discovered, an orchidopexy will be offered to bring the testis down surgically.

The goal is to move the testicle into the scrotum. In most cases, a small groin incision is made about 1/2 to 1 inches long. During the surgery, the blood vessels attached to the testicle are "freed up" so the testicle can be moved to the bottom of the scrotum. A second incision is made in the scrotum and the testicle is stitched to the scrotal wall to keep it in place.

In eight out of 10 boys, hernias accompany undescended testicles and are repaired as part of the procedure. It is rare that these children require more surgery.

Sometimes, the testicle cannot be located upon physical examination of the child. The testicle can be in the abdomen (belly) or maybe absent. Unfortunately, x-rays and other non-invasive tests will not help find the testicle or determine if it is absent. In that situation, a laparoscope may be passed into the abdomen through a small incision below the bely button. If the testicle is found, a second incision is made to bring it into the normal location or the testis may be brought down laparoscopically.

Care After Surgery:

• Your patient will be given home-care instructions after your child's surgery. Plan on the following activity restrictions:
  
  • Only sponge baths for the first two days.
  • No school or day care for the first week.
  • Avoid strenuous activities such as bike riding, wrestling and climbing for two weeks.
  • Children's Tylenol every six hours alternating with Children's Motrin every six hours can be given for pain.
  • The child will be allowed to walk and climb stairs.
  • Call to make an appointment for our child to be seen 10-14 days after surgery. If your child had an undescended testicle repair, there may be one more visit two - three months after the procedure.