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19th of October 2018

Health



The Health Impact of Undescended Testicles

As a male fetus develops, the testes form in the abdomen, just as the ovaries form in a female. During the third trimester, somewhere between weeks 26 and 34, if all goes well, the testicles descend into the scrotum, and they get checked for the first time as soon as the baby is born, as part of the newborn exam done in the delivery room, and again in the nursery.

When the delivery room nurse or the pediatrician tells the parents, “He has 10 fingers, 10 toes,” or the equivalent, that person has also checked the newborn scrotum for two pea-size testes, hanging down. Back in the days when medical notes were handwritten, this was universally denoted by two downward-pointing arrows, side by side: left and right, down and down.

About 3 percent of full-term male infants, though, don’t have both testes descended at birth, a condition called cryptorchidism (crypto means hidden, and orchis is Greek for testicle, and the source of the word orchid, supposedly because of the shape of certain orchid roots). The numbers are much higher in premature infants, who may be born before the testes have moved. In other babies, the testes may be down at birth, but one or both may retract back up later on.

If testes aren’t down in the scrotum as a boy grows, they are less likely to stay healthy and functional — there may be fertility problems later on in life, and there’s even a risk of testicular cancer. That’s why pediatricians check this so compulsively, in the delivery room, in the nursery, and at every checkup, and it’s one reason experts emphasize the importance of including the genital exam every time a boy has a physical.

Many undescended testes do descend all by themselves, in the first months of a baby boy’s life, but if they haven’t come down by the time a child is 6 months old, the baby needs a urologic surgical procedure. This happens in as many as 1 percent of boys, so it’s a relatively common surgery.

A new study published this August in the British medical journal The Lancet used data collected in Australia for more than 40 years, starting in the 1970s, to look at the outcomes for boys born with undescended testes. The researchers looked at their chances of seeking treatment for infertility and of fathering children, and also their risk of developing testicular cancer. The results reinforced the importance of doing that surgery and doing it early, which is what the guidelines in the United States and in other countries recommend — but experts say that it doesn’t always happen that way.

The lead author on the new study, Francisco Schneuer, is a research fellow in child population and translational health at the University of Sydney. The data confirm, he said, that “boys with undescended testes have reduced fertility,” and also the advantage of having surgery when the baby is young: “If you operate early, international guidelines recommend before 18 months, you significantly reduce the risk of developing cancer or being infertile later in life.”

In this huge study, encompassing more than 350,000 boys, they were able to link birth records with hospital admissions, congenital anomalies, cancer, and use of assisted reproductive technology — that is, infertility treatment.

Boys who have undescended testes have 2.4 times the risk of developing testicular cancer, Dr. Schneuer said, and 2.2 times the risk of infertility. Both risks go up if you delay the corrective surgery, he said: For every 6 months’ delay, there was a 6 percent increase in the risk of testicular cancer and a 5 percent increase in the risk of infertility.

“We know guidelines recommend surgery by 18 months, but studies show many boys are not operated on by that time. In our study half were later, in others even more,” he said. The doctors taking care of babies need to be more aware of the guidelines, he said, and parents should expect their sons to be fully examined at every checkup.

“If it doesn’t come down by 6 months, it’s not going to come down on its own,” said Dr. Thomas F. Kolon, a pediatric urologist at Children’s Hospital of Philadelphia and professor of urology at the University of Pennsylvania School of Medicine. He is the lead author on the American Urological Association guidelines for the evaluation and treatment of cryptorchidism. “Start thinking of therapy by 6 months and really do something by 18 months.”

In general, he said, the boys with unilateral cryptorchidism — one testis descends, the other doesn’t — do very well, but “the bilaterals take more of a hit.”

[Related: When parents worry that a baby’s penis is too small.]

Although the risk of testicular cancer is higher in boys with cryptorchidism, it still remains a rare disease; to monitor themselves, adolescents at risk should be taught to do a monthly testicular self-exam, looking for changes that might suggest cancer, Dr. Kolon said.

The surgery, called orchiopexy, is done under general anesthesia and is more complicated if the testes are higher up. If they are up above the scrotum but still palpable, the surgeon will make a small incision in the groin, free the testis, and then another small incision in the scrotum, where it will be anchored in place. If the testis cannot be felt at all, the surgeons may do a laparoscopic procedure, putting a camera in through the baby’s belly button, and if they find the testes in the abdomen, there may be a two-stage operation, first freeing up the testis and then, six months later, in another procedure, bringing it down into the scrotum.

In some newborns, the absence of testes in the scrotum is part of a larger and sometimes more serious syndrome, and those children may need additional medical attention.

On the other hand, many of the baby boys that pediatricians refer to urology because of undescended testicles actually turn out to have what are called retractile testes, which do not need surgery, said Dr. Aseem R. Shukla, a pediatric urologist at the Children’s Hospital of Philadelphia and an associate professor of urology at the University of Pennsylvania School of Medicine. “If you’re in a cold room, the pediatrician’s hands are cold, the baby very ticklish,” he said, then the cremaster muscle, which connects to the cord of the testicle, raises it up.

There are also some cases where boys are born with their testes descended, but they later retract back up, again putting them at risk. Dr. Shukla said that these cases are often missed if pediatricians skip the genital exam in older boys. “It’s too often missed for a long period of time, a boy doesn’t want to be checked down there, the pediatrician doesn’t want to put him through it,” he said. “It needs to be part of every annual physical exam, not something to be forgotten. We find undescended testicles all too often.”

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