Kourosh Afshar MD, MHSc, FRCSC (biography and disclosures)
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What frequently asked questions I have noticed
What can we do to improve the management of UDT?
UDT is one of the common causes for referral to Pediatric Urologists. 1-2% of boys have UDT at age of 12 months1. UDT is associated with increased risk of malignancy (relative risk 2.75-8). Early orchiopexy may reduce this risk1. Infertility is mainly an issue in bilateral cases. Paternity rates of unilateral cases approaches general population. Earlier orchiopexy is associated with more favorable fertility potential2.
There is a trend to request imaging studies, primarily ultrasound, for diagnosis and management of this congenital problem. Although a minority of these boys may require imaging, for the most part an ultrasound is unnecessary.
Data to support practice change
- Ultrasound is inaccurate in locating a non palpable testis as shown by several studies 3.
- If the testicle is palpable, ultrasound does not change clinical management since the decision to proceed with treatment (surgery) is based on history and physical examination by the surgeon.
- Ultrasound may misdiagnose a retractile testis as an undescended testis. This is due to activation of cremasteric reflex by the ultrasound probe displacing the testis toward the groin. Retractile testis does not require treatment. This misdiagnosis may cause unwarranted parental anxiety.
- Ultrasound may delay surgical referral. Surgical treatment of UDT is time sensitive. The optimal timing is between 6 and 12 months3.
- The optimal method for diagnosis of undescended testis is physical examination, and laparoscopy in the case the testis is not palpable.
- Magnetic Resonance Imaging (MRI) has limited accuracy and is considered invasive in toddlers since it requires general anesthetics 4.
Practice tip
Genital exam should be part of all well child visits. The schedule recommended by Canadian Pediatric Society is a useful framework5. This part of physical examination may be challenging if the child is upset. Distraction, ensuring the examiners fingers are warm and gentle palpation in supine position may be helpful. Both hands should be used to prevent the ascent of the testicle to the inguinal area due to cremasteric reflex. If UDT is suspected before age of six months are examination at 6 months of age is advisable, since some of these gonads may spontaneously descend. To ensure timely management, surgical referral should be initiated no later than 6 months of age or immediately after diagnosis in boys presenting at an older age. The decision to perform imaging should be left to the attending surgeon, who may request this test for surgical planning in a minority of the patients.
References
- Wood HM, Elder JS. Cryptorchidism and testicular cancer: separating fact from fiction. J Urol. 2009 Feb;181(2):452-61. doi: 10.1016/j.juro.2008.10.074. Epub 2008 Dec 13. Review. PubMed PMID: 19084853. (View with UBC or CPSBC)
- Chan E, Wayne C, Nasr A; FRCSC for the Canadian Association of Pediatric Surgeon Evidence-Based Resource. Ideal timing of orchiopexy: a systematic review. Pediatr Surg Int. 2013 Nov 15. (View with UBC or CPSBC)
- Tasian GE, Copp HL. Diagnostic performance of ultrasound in nonpalpable cryptorchidism: a systematic review and meta-analysis. Pediatrics. 2011, Jan;127(1):119-28. doi: 10.1542/peds.2010-1800. (View with UBC or CPSBC)
- Krishnaswami S, Fonnesbeck C, Penson D, McPheeters ML. Magnetic resonance imaging for locating nonpalpable undescended testicles: a meta-analysis.Pediatrics. 2013 Jun;131(6):e1908-16. doi: 10.1542/peds.2013-0073. Epub 2013 May (View with UBC or CPSBC)
- http://www.caringforkids.cps.ca/handouts/schedule_of_well_child_visits
Research shows that ~10% of all testicular tumors arise from UDTs and that individuals with untreated UDTs are at a greater risk (2-6 times more) than those who undergo prepubertal orchiopexy (1).
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Interesting. I work primarily in ER and as a hospitalist so this clinical situation does not often arise in my practice. Essential information for primary care.
If UDT is suspected before age of six months are examination at 6 months of age is advisable, since some of these gonads may spontaneously descend. Is this meant to read “…..an examination at 6 months…..”.
We generally examine the babies at 2, 4 and 6 months as routine including checking for descended testes.
Thank you.
I was told my some peds to wait until 9m of age to refer. Generally, I do refer by 6m as there is a lot of parental anxiety regarding UDT.