24.7 Clinical Features and Diagnosis

Fig. 24.18 A clinical intraoperative photograph showing a small atrophic testis

24.7Clinical Features and Diagnosis

•The patient should be warm and relaxed for proper examination.

•The patient can be placed in the frog-leg position for examination. This is especially useful in obese children and makes it easier to palpate the testis.

•The diagnosis of undescended testes is clinical.

•The scrotum is hypoplastic and in those with palpable undescended testes, the testes can be felt in the inguinal canal or upper part of the scrotum.

•In cryptorchidism, the most important factor is whether the testes are palpable or not.

•Approximately 80 % of undescended testes are palpable and 20 % are nonpalpable.

•Nonpalpable testes may be:

–Intra-abdominal

–Absent

•Palpable testes may be:

–Undescended

–Ectopic

–Retractile

•Most intra-abdominal testes are found within a few centimeters of the internal ring.

•Absent or vanishing testes are thought to be due to an intrauterine or perinatal vascular event, most likely during late gestation since most of these testicular nubbins are found below the internal inguinal ring.

•Only 20–40 % of nonpalpable testes are absent upon surgical exploration.

•Ectopic testes exit the external inguinal ring and are then misdirected along the normal course of the testis.

•Ectopic testes can be found in the:

–Superficial inguinal pouch

–Femoral triangle

–Prepenile are

–Perineal area

–Contralateral hemiscrotum

•Retractile testes:

–These may be palpated anywhere along the natural course of the testis, although most of them are inguinal.

–Although not truly undescended, these testes may be suprascrotal secondary to an active cremasteric reflex. This reflex is usually weak in infants and most active in boys aged 5 years.

–These testes can be manipulated into the scrotum, where they remain without tension.

–This condition is considered a variant of normal; however, the risk of ascent may approach 50 %.

–Ascent probably represents an undescended testis that was almost in normal position. The distinction can be difficult, even to an experienced pediatric urologist. Therefore, children with retractile testes should be monitored regularly, at least until puberty.

•The clinical anatomic position of cryptorchid testes are as follows:

–Nonpalpable (33 %)

–Palpable above the pubic tubercle (12 %)

–Palpable at the pubic tubercle (35 %)

–Palpable in the upper scrotum (15 %)

–Ectopic testes (5 %)

•The anatomic position of cryptorchid testes at the time of surgery are as follows:

–Intra-abdominal testis (9 %)

–Peeping testis (20 %)

–Palpable at the pubic tubercle (42 %)

–Palpable at upper scrotum (8 %)