Ask an expert: How serious is an undescended testicle?

In this informative guide, highly respected consultant paediatric urologist and surgeon Mr Alex Turner shares his expert insight on how undescended testicles are diagnosed and which procedures are needed to treat the differing subsets of this condition. The renowned specialist also details the importance of treatment and explains how an undescended testicle may affect babies and children as they grow.

What is an undescended testicle?

Testicles develop up near the kidneys. As we are developing in the womb, the testicles should make their way downwards to pass through the groin and into the scrotum. An undescended testicle is a testicle that does not achieve its final, correct position in the scrotum. It may stop at any point along its path of descent.

Undescended testicles are very common generally but even more so amongst premature boys. Up to ten per cent of boys will have an undescended testicle at birth but by the age of one, only around one per cent of boys will still have this issue. For some, therefore, it remains a significant problem that we need to investigate and solve.

At what age do the testicles normally descend?

Normally, both testicles should be in the scrotum at birth. In some cases, however, the testicles may not be in that position and there are a number of different phases of testicular descent. This is more common when babies are born prematurely but can also occur in other children.

It is possible that during the first year of life, a testicle can come further down towards the scrotum. However, generally speaking, if a testicle is not in the scrotum after six months to a year of life, it will not descend any further on its own.

Can both testicles be undescended?

Yes, both testicles can be undescended. It’s important to clarify the difference between palpable undescended testicles (ones we can feel high in the scrotum or in the groin) and impalpable undescended testicles (which can’t be felt at all).

When both testicles are undescended and they are palpable, they can be treated them in the same way, by being brought down with an operation. However, if both testicles are undescended and impalpable, that raises other possibly more serious issues relating to disorders of sexual development (DSD) and further investigation is necessary.

How serious is an undescended testicle?

The main risks of testicles being outside of the scrotum are three-fold.

Firstly, we know that sperm development is affected very early if the testicles are not in the scrotum. This is because the scrotum is a cooler environment for the testicle, as opposed to the groin or the abdomen, and so sperm may not develop in the normal way later on in cases where the testicle is outside of the scrotum.

The second risk is that a testicle sitting in the groin is actually at greater risk of injury – consider a lap belt in a car. The testicle is safer and less likely to be injured in the scrotum.

Lastly, and most seriously, because of the development of the primitive sperm, we know that certain precursors to sperm do not disappear in the normal way if the testicle is undescended. If these precursors persist, there is an increased risk of them becoming malignant (cancerous) and so undescended testicles do carry with them an increased risk of testicular cancer.

When is an undescended testicle usually diagnosed?

Additional to undescended testicles which are diagnosed at birth, there are two more subsets of issues in this area to be aware of, ascending and retractile testicles, which come on later in life.

A true undescended testicle will be diagnosed at birth. As part of the baby check performed by a doctor after birth, the testicles are examined and if they are not in the correct position, the child will be referred to a paediatric urologist.

In cases of an ascending testicle, there is discrepant growth of the spermatic cord and the child in the groin. As the child gets older and has a growth spurt, should the cord not grow in a similar way, it can be pulled up into the high scrotum or groin. Although this is not technically an undescended testicle, it has to be treated in the same way with an operation.

Additionally, retractile testicles is another issue. This occurs when the testicles have a very brisk cremasteric reflex. The cremaster is a muscle which surrounds the spermatic cord and commonly, the testicles may shoot up and down. Sometimes you don’t see them but they can be easily manoeuvred or “milked” down. We normally just need to keep an eye on cases such as these but in a small proportion of patients, some tension develops and the testicles may go up into the groin, meaning an operation is needed.

How is an undescended testicle corrected?

For a palpable testicle that is not in the scrotum, the treatment is called orchidopexy. In this procedure, which is performed under general anaesthetic, an incision is made in the groin and the testicle and its structures are mobilised and freed up. This means they can be brought down in to the scrotum and the testicle is fixed in place through a second incision in the scrotum. This operation takes around forty minutes for one side.

In cases of an impalpable testicle, the treatment is more complicated. The first step is to perform an examination under anaesthetic to see whether the testicle become palpable. If this is not possible, we then need to put a camera through the belly button (laparoscopic surgery) to locate the testicle.

At this stage, we can establish whether the testicle is present and where it is located. Sometimes testicles don’t develop at all or something occurs as they are developing, such as twisting, which can mean they don’t survive because of poor blood supply. Therefore, occasionally we don’t find a testicle there whatsoever but if there is a small, poorly developed testicle, we would remove it. In cases where we do find a testicle which is undescended and in a high position, we need to decide whether it can be brought down in one stage or a two stage treatment is needed.

If we are able to bring the testicle down in one stage, the procedure is similar to that used for palpable testicles. If two stages are required, the first step is to divide some blood vessels to the testicle, which are its main blood supply. We then wait six months for the testicle to pick up its alternate blood supplies before going back in using laparoscopy to mobilise the testicle and bring it down in an orchidopexy procedure, similar to previously described.

If your child requires treatment for an undescended testicle and you wish to schedule a consultation with Mr Turner, you can do so by visiting his Top Doctors profile.