MANday: Cryptorchidism in Post Pubertal Men

Cryptorchidism is one of the most common genital problems in pediatric male patients. It is a condition in which one or both testicles do not descend into the scrotal sac. The diagnosis is usually made during a physical exam shortly after birth. If the testicle does not descend on its own after 6 months a referral to an appropriate surgical specialist should be made. Factors that predispose someone to cryptorchidism include prematurity, low birth weight, small size for gestational age, twinning, and maternal exposure to estrogen during the first trimester. Orchiopexy (permanently fixing/repositioning a testicle into the scrotum) is the treatment of choice recommended between the ages of 6-18 months. But there are cases where males do not get surgery at a young age due to circumstances such as underappreciated risk of testicular ascent, lack of provider knowledge, or poor access to care. At The Y Factor we focus on adult males so we will discuss cryptorchidism in relation to late diagnosis in post pubertal men. 

Risk of testicular cancer

Cryptorchidism puts men at a higher risk of developing testicular cancer. The risk of someone with an undescended testicle having cancer is about 2 to 5 times that of someone with two descended testicles. The location of the undescended testis also affects the relative risk of testicular cancer. Undescended testicles can be located in the suprascrotal (high-scrotal) area, in the inguinal canal, in the femoral area, perineal area, or in the intra-abdominal area. Up to 50% of malignant testicular tumors associated with cryptorchidism involve undescended testicles located in the intra-abdominal area. Successful scrotal repositioning of the testis may reduce but does not prevent the potential long-term issues of infertility and testis cancer. Risks of testicular cancer is reduced if surgery is performed earlier but lifelong risks for testicular cancer still remain higher than that of someone born with both descended testicles. And the risk of malignancy increases significantly in the cryptorchid testis treated after puberty.

Risk of testicular dysfunction

The two main functions of the testicles are spermatogenesis and testosterone production. With unilateral cryptorchidism testosterone production is usually not affected when the testicle is outside of the scrotum but spermatogenesis can be impaired. Nonetheless, men with one functioning testicle have almost the same chance of having children as men with two functioning testicles and advances in infertility treatments are improving these odds. Endocrine evaluation with testosterone, LH, FSH, and semen analysis may be considered to determine degree of testicular function.

Diagnosis with history and physical exam

For post-pubertal males, the diagnosis of cryptorchidism is usually made clinically during a physical exam and in most cases the patient is already aware of this issue when they arrive. The scrotum is best examined when the patient is warm and relaxed. The position and size of the testis should be noted along with the position of the urethra – patients affected with both cryptorchidism and hypospadias should be screened with karyotyping for a disorder of sex development. Testicles outside the scrotum can sometimes be palpated elsewhere but nonpalpable testis are not able to be located in the scrotum, inguinal canal, abdominal, femoral, or perineal areas. A good history must also be obtained during the initial evaluation. For example: has the testicle always been absent, does it drop into the scrotal sac and retract intermittently, is it palpable in the inguinal or abdominal areas, has orchiopexy ever been performed, are there scars from this procedure, etc.? 

Diagnosis with imaging

Initially imaging is not ordered until referred to a specialist. Ultrasound is not recommended if the testis is not palpable. It was historically used frequently for evaluation of a cryptorchid testis, but with sensitivity of 45% and specificity of 78%, it is not valuable in surgical planning. Computed tomography is not usually recommended. MRI is the most effective method of identifying the testis, usually with the help of a gadolinium intravenous contrast agent, however it can be costly and can have false-positives and false-negatives. Currently there is no radiologic test that can conclude with 100% accuracy that a testis is absent, which can place one at risk of leaving a malignant intra-abdominal testis in place, therefore, surgical exploration (laparoscopic or open) is recommended for all nonpalpable unilateral testicles and many bilateral cryptorchid patients.

Treatment

Orchiopexy is recommended for prepubertal boys as stated above. But in post pubertal boys and men, as are many of the cases seen at The Y Factor, orchiectomy (testicular removal) instead of orchiopexy is the treatment of choice until age 50. The risks of orchiectomy are significantly increased in comparison to the risk of death from malignancy for those 50 and above, or for those with comorbidities. In these cases, continued observation is recommended instead of surgery. In some cases, orchiopexy with or without testicular biopsy is done depending upon surgeon preference, testicular position (high scrotal, inguinal, intra-abdominal), and appearance of the testis at the time of surgery. But if a mass is present in the undescended testicle, tumor markers should be obtained in combination with radical orchiectomy. 

If there is a concern that you have or have had cryptorchidism and want to be evaluated for low testosterone, to check your fertility status, or for us to fully evaluate you and recommend the best treatment for you, schedule an office visit with one of our providers to get your evaluation started.  

References:

Farrer JH, Walker AH, Rajifer J. Management of the post pubertal cryptorchid testis: a statistical review. J Urol. 1985 Dec. 134(6): 1071-6.

Koh KB. Beware the undescended testis and abdominal mass. Aust N Z J Surg. 1996 Dec;66(12):851-3.

Pettersson A, Richiardi L, Nordenskjold A, et al. Age at surgery for undescended testis and risk of testicular cancer. N Engl J Med. 2007 May 3;356(18):1835-41. 

Savoie KB, Bachier-Rodriguez M, Schurtz E, et al. Health disparities in the appropriate management of cryptorchidism. J Pediatr. 2017 Jun; 185:187-92. e1.

Wong NC, Bansal NK, Lorenzo AJ, et al. Misuse of ultrasound for palpable undescended testis by primary care providers: a prospective study. Can Urol Assoc J. 2015 Nov-Dec;9(11-12):387-90.

Benancio Martinez Jr is a certified Family Nurse Practitioner and one of the newest integral parts of the Y Factor team. Benancio is the medical provider in charge of the Northpointe location and brings to the Y Factor 10 years of nursing experience obtained through the emergency departments of the VA and Kingwood medical centers, as well as clinical experience in family practice, hematology, and oncology.

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