Undescended Testes (Cryptorchidism): What is it and how to treat in Malaysia

Dr Nada Sudhakaran

Dr Nada Sudhakaran

Paediatric Surgeon & Urologist

Undescended Testes or Cryptorchidism in Malaysia

“Why is my son’s testis missing?” 

This is a question that Malaysian parents ask when their baby’s scrotum looks flat or when touched, this may be a congenital deformity called undescended testes or cryptorchidism. This condition is more common in premature babies.  Timely, early intervention can prevent your child’s testicular function from being effected.

The difference between Retractile Testis vs Undescended Testis (Cryptorchidism)

According to some reports, 3 out of every 100 newborn full-term male babies suffer from cryptorchidism, but this data has an overestimated component because most of the cases are actually retractile testis. When a child surgeon examines the baby’s testicles, he may be able to bring it into the scrotum. When the baby cries, feels cold, or is afraid, the testicles retract. This is typical of a retractile testis. However, one in every 100 baby boys, will have a true cryptorchidism. The child surgeon will not be able to bring baby’s testis into the scrotum or is absent and requires surgery to fix the testes.

Cryptorchidism or undescended testis means that the baby’s testicles did not descend from the abdominal cavity, through the groin and into the scrotum. It could have been restricted by fibrous tissue during the process of descent into the scrotum or it may be due to endocrine (hormone from testis) abnormalities. If the testicles were outside the normal path of descend, such as the abdominal cavity or other locations, it is called an ectopic testis. In short, in all of these, the testicles do not reach its true ‘home’.

Whether it is bilateral or unilateral cryptorchidism, it will affect the baby’s testicular function. About 85% are unilateral, only 15% are bilateral, and most of the unilateral ones are on the right. This is because the right testis descends after the left.

As for retractile testis, the cremaster muscle (which wraps around the sperm tube and blood vessels to the testis), is active and it pulls the testicles up, when the child is anxious, fearful or in a cold room. This is a normal physiological reaction, which is sometimes seen in male animals about to encounter dangers such as a fight, when their testicles are pulled up into their body for protection and is ‘hidden’. Therefore, retractile testicles are regarded as normal.

The cause of cryptorchidism in babies is generally unknown, but thankfully there has been no increase in incidence over the years. This is unlike the case of hypospadias, an abnormality in the development of the penis. The latter is thought to be also related to environmental pollution. However, it is worth noting that although the incidence of cryptorchidism has not increased significantly, it will have a profound impact on the baby’s sexual function, and even affects his fertility. Intervention at the right time is imperative, and surgery is the only treatment.

According to animal studies by Professor John Hutson, a professor of paediatric urology at the University of Melbourne, Australia, early surgery to fix the testicles can help improve the sperm quality.

The operation for cryptorchidism is done at at 6 months of age.

It is worth noting that if the testicle does not drop to the scrotum by 6 months of age, it will never drop, so surgery is necessary.

Risks and problems of an undescended testis:

1) Testicular torsion

2) Insufficient sperm (may effect both the quantity and quality)

3) Testicular cancer is higher than normally positioned testis

4) Appearance is abnormal (causing psychological issues)

The testicles are like apples hanging on its stalk (here the testis has the stalk made of the sperm tube and it’s blood vessels). An undescended testis has a higher chance of twisting (torsion of testis) and with this cutting off its blood supply. If this situation is not treated rapidly, within 6 hours, the testicle can be lost. In addition to pain experienced by the child, it will also cause permanent damage and shrinkage of his testis. A child with testicular pain, especially if undescended, need to see a child surgeon immediately.

About 10% of all undescended testis have an impalpable testis. Of this, half of them are absent testes, probably twisted and lost as a foetus. The other half the testis that may be found by laparoscopy in the abdomen.

After surgery for a unilaterally cryptorchidism, the patient’s fertility in the future is not too effected compared to men with both normal testicles. However, if it is a bilateral problem, the sperm quality may be inevitably poorer than normal men.

Cancer risk reduced to about 0.4% after surgery

Parents can identify an undescended testis by feeling their baby when calm, whilst they are asleep or when taking a bath. If you do not feel the testicles when you touch it, or if the scrotum is empty, do take your child to a child surgeon for consultation. Your baby’s surgeon will do a detailed examination. Rarely is ultrasound scan useful and if the doctor cannot feel the testis, then the use of laparoscopy to look for an intra-abdominal testis is more accurate.

It is worth noting that the temperature in the scrotum is about 1 degree Celsius different from the groin. This minor difference is adequate to determine the healthy development of your child’s testes. Therefore, if the parents do not detect it, your child’s testicles will be outside the scrotum for a long time. A few years being not in the scrotum could significantly increase the cancer risks of that testis.

The risk of normal men suffering from testicular cancer is about 1 in 1,000. This risk for a child with cryptorchidism who has had surgery before 2 years of age, is about 0.4% (that is, 4 in 1000) in his lifetime. This risk rises to about 1% (10 in 1000 men) if surgery is done after the age of 12.

What’s most important with an operation to fix the testis into the scrotum is that the testis will then be easily self-palpated to look for any abnormal lumps or growth in future and to identify any potential tumour growth early.

Laparoscopy (keyhole surgery) for Impalpable Testis

There are two situations for cryptorchidism surgery. The first is traditional surgery and the other is laparoscopic surgery. If the testicles can be palpated in the baby’s groin, traditional surgery can be performed here, but If the testes cannot be found by palpation, then laparoscopy is required to look for it in the abdomen.

For traditional surgery, the incisions are in the groin and the scrotum, each about 1 – 1.5 cm. First, the testis is identified, then released form any structures that may be holding it back, then its tunnelled and fixed into the scrotum. The operation is quick and is is done as a day procedure, usually the procedure is in the morning and your child will be discharged after lunchtime. The follow up is usually 1 week later, to check on the wounds and again 3 months later to check on the position and the quality of the testis.

If the testis is not palpable, keyhole or laparoscopic surgery is required. Upon laparoscopy, if an atrophic testis (not viable), which has shrunk significantly is seen, then it is removed. This was possibly due to an antenatal torsion of testis, before the child was born. It is removed to avoid any risk of tumour formation in future of the already abnormal and non-functional testis.

If the testis is reasonably healthy looking and the length of the blood vessels to it is long enough for the testis to reach the scrotum, it will be brought down and fixed there in one sitting. However, if the blood vessels are not long enough, a two stage procedure under anaesthesia is required. The second and final procedure 3 months after the first. Again, like the open surgery for palpable undescended testis, this again is a day procedure with no need to stay overnight after the procedure.

No stitches on the testis

The technique most paediatric surgeons (but not all adult surgeons) practice to fix the testis in the scrotum is to place the testis in a pocket that is created in the scrotum without much injury of stitches into the testis. Doing this will not breach the thick natural barrier of the testis.

Whether it is traditional surgery or laparoscopic surgery, the treatment outcome is the same, that is:

1) Avoid the risk of twisting and injury to the testicles

2) Improve sperm quality

3) Reduce the risk of cancer and enable self-examination

4) Make it look good

Risks of cryptorchidism is higher in preterm infants

Premature infants have a higher risk of cryptorchidism than term born babies. Doctors will take this into consideration before deciding that the testis will not descend by itself and plan for surgery. The incidence of cryptorchidism is uniform throughout the world in terms of ethnic groups or familial background.

Lastly we in Malaysia all recognise October as the “Women’s Health Month”, from the Pink Ribbon Campaign. It emphasizes the value and importance of the self-examination for women. Many here unfortunately don’t know that November is Men’s Health Month. Here we emphasize the importance of self-examination of the testicles. The health and awareness of prostate problems are also highlighted.

Men should also pay as much attention to their own health as women are. On the part of fathers, they need to firstly do their own examinations and being aware themselves and in addition, to explain about this basic self-awareness and practice to their boys when the time comes, usually in their late teens.  Paying attention to the testicles of your baby from the start will also help identify and treat any problems at the appropriate time.

 Originally published in Easily Sin Chew on 2020-03-20
https://easily.sinchew.com.my/node/2537/ in Mandarin.


View the Chinese version on this blog HERE

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Dr Nada Sudhakaran

Paediatric Surgeon & Urologist

Paediatric Surgeon


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