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Evaluation

Definitions

• Inguinal hernia: testis not in normal scrotal position, may be palpable
• Agenesis: testis never formed, may have ipsilateral mullerian duct persistence
• Vanishing: testis initially present but lost due to torsion or vascular injury
• Acquired cryptorchidism: initially scrotal, now it's not
• Secondary cryptorchidism: suprascrotal testis after inguinal/scrotal surgery
• Retractile testis: testis that retracts but can be brought down into scrotum
• Ectopic: passed through inguinal ring but not found in scrotum, may be perineal, prepenile, or femoral

Risk factors and prevalence

• Overall prevalence at birth: 1-4%
• Spontaneous descent: 50-87% by 3mo
• Familial risk: 10x in twins, 3.5x in brothers, 2.3x in offspring
• Associated syndromes: Klinefelter, Eagle-Barrett, CP, hernias
• Laterality: right side more common
• Absence: 20% present with a nonpalpable testis, 25% of these patients do not have any testis found during surgery (75% will have intraabdominal or inguinal testis)

Workup

• Testes that do not descend by 6mo are unlikely to descend spontaneously
• Exam tips: most accurate way to diagnose, sitting frog-leg preferred over supine, palpate from ASIS down to scrotum, can use lubricant jelly to help with palpation, may see testis "pop" from scrotum to inguinal region, hemiscrotum may appear abnormal if testis did not descend
• General workup: hormones (T, LH, FSH) and imaging (scrotal US) not recommended/required for otherwise normal patient
• DSD workup: consider if bilateral congenital cryptorchidism, especially if hypospadias also present
• Hormonal workup: consider if bilateral nonpalpable testes in absence of CAH (assess for anorchia)
• Contralateral testis size w/ volume > 2mL is 72% sensitive and 100% specific for vanishing testis
• Risks: 8-30x increased risk of testis cancer (x2 if orchiopexy performed after 12yo), reduced fertility chances (90% if unilateral, 60% if bilateral)

Management

Options

• Timing: give at least 6mo for testis to descend, otherwise pexy by 12mo to allow for spontaneous descent and maintain normal growth while minimizing cancer/fertility risks
• Hormonal therapy: not recommended to treat cryptorchidism
• Surgical findings for nonpalpable testes: abdominal/transinguinal (25-50%), vanishing (15-40%), extraabdominal (10-30%)
• Fowler-Stephens: transection of spermatic vessels and testicular mobilization, can be performed staged 6mo apart
• Empiric contralateral orchiopexy: recommended by some, but risk for torsion appears to be minimal
• Orchiectomy: recommended for abdominal testes diagnosed at puberty due to cancer risk and poor spermatogenesis (minimal benefit to orchiopexy)

	If...	Then...
Palpable	Unable to position in scrotum	Scrotal/inguinal orchiopexy
	Retractile	Annual exam (then observe vs pexy)
Non-palpable	Palpable under anesthesia	Scrotal/inguinal orchiopexy
	Non-palpable under anesthesia	Diagnostic laparoscopy
	Blind-ending spermatic vessels (vanishing testis)	Unilateral testis protection during sports
	Intraabdominal testis	1 vs 2 stage orchiopexy
	Vessels entering inguinal ring	Inguinal exploration, assess for nubbin