BMJ 2019;364:l926 doi: 10.1136/bmj.
l926
Practice
PRACTICE POINTER
Undescended testis
1 2
Alexander Cho paediatric urology fellow , Johanna Thomas consultant urologist , Ranil Perera
3 1
general practitioner , Abraham Cherian consultant paediatric urologist
1
Paediatric Urology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK; 2Royal Berkshire Hospital, Reading, UK;
3
Conway PMS, London, UK
What you need to know
• Examine testicular position in boys at newborn and 8 weeks old to
identify undescended testis
• Review at 3 months of age to check for spontaneous descent of testes;
if still undescended refer to a surgeon
• Urgently refer children with bilateral impalpable testes, penile
abnormalities, or ambiguous genitalia to a tertiary paediatric centre
• There is no role for pre-referral radiological imaging in children with
undescended testes
• Orchidopexy (surgical correction to reposition the testis) is ideally done
between 6 and 18 months of age
Undescended testis or cryptorchidism is a common congenital
anomaly affecting about 2-8% of boys in population studies in
Europe.1 In the UK, about 6% of boys have an undescended
testis at birth.2
Timely referral and surgical correction may improve fertility
and reduce the malignancy rate associated with undescended
testes.3 This article advises the non-specialist on evaluation of
newborns and infants for undescended testis and current
recommended practice in management.
How do patients present?
Testicular position is usually assessed in boys at newborn and
8 week checks. Parents may present with concerns about their
child’s genitalia. Few patients present at a later age if the
diagnosis was missed earlier or with the development of an
ascending testis.4 Box 1 describes a classification based on site
of undescended testis on examination.
Correspondence to: A Cherian abraham.cherian@gosh.nhs.uk
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PRACTICE
Box 1: Classification of undescended testis
• True undescended testis—The testis lies along the expected path of
descent but has never been present in the scrotum
• Ectopic testis—The testis is palpated in a location outside the normal
path of descent, such as the perineum or femoral area
• Ascending testis—A previously descended testis that no longer lies
within the scrotum. This has a peak incidence around 10 years of age
and affects 1-2%.4 It may also occur as a complication of inguinal hernia
surgery in children5
Risk factors include earlier gestational age (<37 weeks’
gestation) or low birth weight (<2.5 kg), with either equating
to a doubling of risk.2 6 Other risk factors include a family history
of undescended testis, associated hormonal disorders such as
congenital adrenal hyperplasia or disorders of sex development,
and previous inguinal hernia surgery or orchidopexy. The
Personal Child Health Record or “red book” is a useful source
for the personal history and initial newborn examination
findings.
How should I examine the child?
Explain to the parent that you will examine the child’s genitalia
as part of the newborn or infant examination. Ask them to
comfort the child while he is examined. Expose the child from
umbilicus to knees. It is best to examine the child in the supine
and frog-legged position on the examination table or parent’s
lap.
Careful inspection is often enough to confirm descended testes
without any palpation. Note any abnormalities such as penile
abnormalities, ambiguous genitalia, or redness (which may
suggest acute testicular torsion if accompanied with pain).
Most (70-80%) undescended testes are palpable, felt during the
sweeping manoeuvre from lateral to medial in the inguinal canal
(fig 1). An undescended testis is determined when the testis
cannot be manipulated, tension-free, into the base of the scrotum.
A retractile testis can be manually manipulated to the base of
the scrotum but re-ascends after manipulation. Palpate with
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BMJ 2019;364:l926 doi: 10.1136/bmj.l926
warm hands. Kneeling to the patient’s right side, start palpation
with your left hand placed lateral to the deep inguinal ring. Press
down with your left hand moving it along the inguinal canal to
the pubic tubercle to “milk” the testis down the inguinal canal.
This will overcome the cremasteric reflex which may naturally
draw the testis away from the scrotum during the examination.
Once the left hand is at the pubic tubercle, determine the location
of the testis with your right hand and pull it down gently to the
scrotal base. Repeat the same process to locate the contralateral
testis.
When should I refer the patient?
Box 2 lists red flags on examination that warrant urgent referral
to a tertiary paediatric centre for paediatric urology and
endocrinology review.
Box 2: Red flags that should prompt urgent referral
• Undescended testes with penile abnormality (such as
hypospadias)—Consider disorders of sex development
• Bilateral impalpable testes or ambiguous genitalia—Need to exclude
endocrinology abnormalities, including congenital adrenal hyperplasia
that is associated with life threatening electrolyte disturbances
• Pain with or without erythema—Consider acute testicular torsion
In newborns with unilateral palpable or impalpable undescended
testis and no other abnormality, arrange a review at 3 months
of age to re-examine the child. Explain to the parent that this
would allow for natural descent of the testis. In a prospective
cohort study in the UK (784 male infants) the incidence of
undescended testis decreased from 6% at birth to 2.4% at 3
months of age due to further descent of the testis postnatally.
Refer patients with undescended testis at 3 months of corrected
gestational age and older children to a surgeon. Figure 2
describes referral pathways for unilateral and bilateral
undescended testis.
What investigations are required?
There is no role for routine or preoperative imaging for
undescended testis.8 9 The findings of preoperative imaging do
not influence surgical management. In addition, two
meta-analyses investigating the use of ultrasonography10 and
magnetic resonance imaging (MRI)11 to detect non-palpable
undescended testes have found low sensitivity (45% for
ultrasound, 62% for MRI) and poor reliability in accurately
localising testes. They conclude a lack of benefit for diagnosis
of undescended testis. A retrospective analysis at our institution
over three years identified 40% of 169 paediatric patients who
required surgery for undescended testis had pre-referral imaging.
This meant that 169 ultrasound scans (£111 per scan) and five
MRI (£352 per scan) were unnecessarily performed.12
Other tests such as testicular biopsy and hormonal tests, if
required, will typically be done by a specialist.
How is it treated?
As most boys have a palpable undescended testis, an open groin
orchidopexy is performed to reposition their testis in a sub-dartos
scrotal pouch. Orchidopexy is usually undertaken as a day case
procedure under general anaesthesia. International guidelines
recommend surgery between 6 and 18 months of age based on
testicular biopsy results and testicular volume outcomes.8 13 A
recent meta-analysis found no difference in testicular atrophy
and complication rates following orchidopexy before and after
1 year of age.14
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PRACTICE
Patients with an impalpable undescended testis are re-examined
under anaesthesia to confirm it is still not palpable. If it is still
impalpable, then laparoscopy is undertaken to ascertain what
definitive procedure should be performed. Figure 3 describes
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the surgical pathways for management of unilateral undescended
testis. Hormonal treatment with human chorionic gonadotrophin
or gonadotrophin-releasing hormone is not routinely done
because of concerns about future spermatogenesis.15
Early complications include operative site bruising, infection,
and wound dehiscence. Later complications include testicular
atrophy (up to 5% for a palpable undescended testis, 10-15%
for intra-abdominal undescended testis) and testicular re-ascent
requiring revision surgery (1% for palpable undescended testis,
10% for intra-abdominal undescended testis).16-18
The incidence of testicular cancer is approximately 6.9 per 100
000 men.19 With timely surgery, the potential testicular
malignancy risk is 2.9 times the baseline prevalence for adult
men. Regular testicular self examination is advisable once the
child reaches adolescence.20 In a historic cohort of boys who
underwent orchidopexy between 1955 and 1971, paternity rates
were lower in the group who had had bilateral undescended
testis (62%) compared with those who had had unilateral
undescended testis (89%) and the unaffected population (94%).21
There is good evidence that earlier surgery improves testicular
volume, but the potential fertility benefits from this are still
unknown.22
Sources and selection criteria
We searched PubMed using the terms “cryptorchidism” and “undescended
testis” for relevant English language publications published in the past 10
years. We have included evidence from recent systematic reviews and
meta-analyses.
We have considered recommendations from the National Institute for Health
and Care Excellence (NICE) Clinical Knowledge Summary9 and the British
Association of Paediatric Surgeons commissioning guide for undescended
testis.8
Education into practice
• How might your current referral pathway for patients with undescended
testis (including time of referral and use of radiological imaging) be
modified on the basis of this article?
• Think about the last time you examined a child for testicular position.
How might you alter your examination next time?
How patients were involved in the creation of this article
We asked parents of patients at our practice who had had pre-referral imaging
about their thoughts regarding imaging. Their experiences of having an
investigation that was not necessary and possibly mis-informative resulted in
this article.
Contributors: All authors contributed substantially to the text and were involved in
the drafting and final approval of the work. A Cherian is the guarantor.
Competing interests: We have read and understood the BMJ policy on declaration
of interests and have no relevant interests to declare.
Provenance and peer review: Commissioned, externally reviewed.
1 Boisen KA, Kaleva M, Main KM, etal . Difference in prevalence of congenital cryptorchidism
in infants between two Nordic countries. Lancet 2004;363:1264-9.
10.1016/S0140-6736(04)15998-9 15094270
2 Acerini CL, Miles HL, Dunger DB, Ong KK, Hughes IA. The descriptive epidemiology of
congenital and acquired cryptorchidism in a UK infant cohort. Arch Dis Child
2009;94:868-72. 10.1136/adc.2008.150219 19542061
3 Kollin C, Granholm T, Nordenskjöld A, Ritzén EM. Growth of spontaneously descended
and surgically treated testes during early childhood. Pediatrics 2013;131:e1174-80.
10.1542/peds.2012-2902 23530172
4 Keys C, Heloury Y. Retractile testes: a review of the current literature. J Pediatr Urol
2012;8:2-6. 10.1016/j.jpurol.2011.03.016 21497555
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BMJ 2019;364:l926 doi: 10.1136/bmj.l926
5 Baird R, Gholoum S, Laberge JM, Puligandla P. Prematurity, not age at operation or
incarceration, impacts complication rates of inguinal hernia repair. J Pediatr Surg
2011;46:908-11. 10.1016/j.jpedsurg.2011.02.059 21616251
6 Damgaard IN, Jensen TK, Petersen JH, Skakkebaek NE, Toppari J, Main KMNordic
Cryptorchidism Study Group. Risk factors for congenital cryptorchidism in a prospective
birth cohort study. PLoS One 2008;3:e3051. 10.1371/journal.pone.0003051 18725961
7 Kolon TF, Herndon CD, Baker LA, etal. American Urological Assocation. Evaluation and
treatment of cryptorchidism: AUA guideline. J Urol 2014;192:337-45.
10.1016/j.juro.2014.05.005 24857650
8 British Association of Paediatric Surgeons. Commission Guide: Paediatric Orchidopexy
for undescended testis. https://www.baus.org.uk/_userfiles/pages/files/Publications/
Commissioning%20guide%20for%20orchidopexy%20final%20v7.pdf.
9 National Institute for Health and Care Excellence. Clinical Knowledge Summaries:
Undescended testes. 2014. https://cks.nice.org.uk/undescended-testes#!scenario.
10 Tasian GE, Copp HL. Diagnostic performance of ultrasound in nonpalpable cryptorchidism:
a systematic review and meta-analysis. Pediatrics 2011;127:119-28.
10.1542/peds.2010-1800 21149435
11 Krishnaswami S, Fonnesbeck C, Penson D, McPheeters ML. Magnetic resonance imaging
for locating nonpalpable undescended testicles: a meta-analysis. Pediatrics
2013;131:e1908-16. 10.1542/peds.2013-0073 23690512
12 Cho A, Thomas J, Nathan A, et al. Pre-referral radiological imaging for undescended
testis—wasteful and potentially harmful [abstract]. In: 28th Congress of the European
Society of Pediatric Urology; 2017 Apr 19-22; Barcelona, Spain: ESPU; 2017. Abstract
nr S9-10.
13 Kutasy B, Thorup JM, Wester T. Comments to recent guidelines on undescended testis.
Eur J Pediatr Surg 2016;26:432-5. 10.1055/s-0036-1592195 27631724
14 Allin BSR, Dumann E, Fawkner-Corbett D, Kwok C, Skerritt CPaediatric Surgery Trainees
Research Network. Systematic review and meta-analysis comparing outcomes following
For personal use only: See rights and reprints http://www.bmj.com/permissions
Page 3 of 5
PRACTICE
orchidopexy for cryptorchidism before or after 1 year of age. BJS Open 2018;2:1-12.
10.1002/bjs5.36 29951624
15 Cortes D, Thorup J, Visfeldt J. Hormonal treatment may harm the germ cells in 1 to
3-year-old boys with cryptorchidism. J Urol 2000;163:1290-2.
10.1016/S0022-5347(05)67763-4 10737531
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16 Yu C, Long C, Wei Y, etal . Evaluation of Fowler-Stephens orchiopexy for high-level
intra-abdominal cryptorchidism: A systematic review and meta-analysis. Int J Surg
2018;60:74-87. 10.1016/j.ijsu.2018.10.046 30408514
17 Elder JS. Surgical management of the undescended testis: recent advances and
controversies. Eur J Pediatr Surg 2016;26:418-26. 10.1055/s-0036-1592197 27631723
18 Alagaratnam S, Nathaniel C, Cuckow P, etal . Testicular outcome following laparoscopic
second stage Fowler-Stephens orchidopexy. J Pediatr Urol 2014;10:186-92.
10.1016/j.jpurol.2013.08.005 24045121
19 Office for National Statistics. Cancer statistics registrations: Registrations of cancer
diagnosed in 2008, England. Series MB1 no 39. National Statistics, 2010.
20 Lip SZ, Murchison LE, Cullis PS, Govan L, Carachi R. A meta-analysis of the risk of boys
with isolated cryptorchidism developing testicular cancer in later life. Arch Dis Child
2013;98:20-6. 10.1136/archdischild-2012-302051 23193201
21 Lee PA, O’Leary LA, Songer NJ, Coughlin MT, Bellinger MF, LaPorte RE. Paternity after
bilateral cryptorchidism. A controlled study. Arch Pediatr Adolesc Med 1997;151:260-3.
10.1001/archpedi.1997.02170400046008 9080933
22 Kollin C, Karpe B, Hesser U, Granholm T, Ritzén EM. Surgical treatment of unilaterally
undescended testes: testicular growth after randomization to orchiopexy at age 9 months
or 3 years. J Urol 2007;178:1589-93, discussion 1593.
10.1016/j.juro.2007.03.173 17707045
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PRACTICE

Figures

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Fig 1 The expected path of descent of the testis (A) is via the inguinal canal into the scrotum. For palpation of an undescended
right testis, place your left hand lateral to the deep inguinal ring (B). Press down with your left hand, moving it along
the inguinal canal to the pubic tubercle to “milk” the testis down the inguinal canal (C). Once the left hand is at the
pubic tubercle, determine the location of the testis with your right hand and pull it down gently to the scrotal base (D)

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PRACTICE

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Fig 2 Referral pathway for unilateral and bilateral undescended testis (adapted from American Urological Association
guideline,7 British Association of Paediatric Surgeons commissioning guide,8 and National Institute for Health and
Care Excellence (NICE) recommendation9)

Fig 3 Surgical algorithm for unilateral undescended testis (adapted from American Urological Association guideline7 and
British Association of Paediatric Surgeons commissioning guide8)

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