Paediatric urology · KIMS Secunderabad
Undescended Testicles (Cryptorchidism) — Why Timing of Treatment Matters
Cryptorchidism (undescended testicle) is the most common congenital genital abnormality in male infants — occurring in approximately 2 to 4% of full-term male births and up to 30% of premature male infants. During normal foetal development, the testicles form in the abdominal cavity and descend through the inguinal canal into the scrotum by 28 to 32 weeks of gestation. In cryptorchidism, one or both testicles fail to complete this descent — remaining in the abdomen, inguinal canal, or just outside the scrotum at birth. By 3 to 6 months of age, spontaneous descent occurs in approximately 70% of undescended testicles — after 6 months, spontaneous descent is unlikely.
The clinical importance of cryptorchidism lies in its two serious long-term consequences if untreated: impaired fertility (from the higher-than-normal temperature within the abdomen or inguinal canal damaging sperm production) and increased risk of testicular cancer. Both consequences are significantly reduced by timely surgical correction — orchidopexy (bringing the testicle into the scrotum and fixing it there) — performed before 18 months of age at KIMS, following European and American Urology Association guidelines.
Classification — where is the testicle?
| Position | Frequency | Clinical approach |
|---|---|---|
Palpable undescended testicle In the inguinal canal or high scrotum, palpable on examination. | Most common (70–80%) | Inguinal orchidopexy — open or laparoscopic · Single-stage procedure. |
Non-palpable undescended testicle Cannot be felt — in the abdomen, vanishing, or ectopic (not in the usual descent pathway). | 20–30% | Diagnostic laparoscopy first to locate the testicle · Two-stage Fowler-Stephens orchidopexy for high abdominal testes · Single-stage laparoscopic orchidopexy for low abdominal testes. |
Retractile testicle Normally positioned in the scrotum but retracts into the inguinal canal with a strong cremasteric reflex · Brought to the scrotum by gentle manipulation. | Very common — the most common cause of 'missing testicle' on neonatal examination | Not a true undescended testicle · Observation until puberty when the reflex diminishes · Some develop ascending testicle — annual review. |
Ectopic testicle Descended but not in the normal scrotal position (superficial inguinal pouch, femoral, perineal, or contralateral scrotal). | Rare | Orchidopexy to bring to the scrotum. |
Why timing matters — the case for orchidopexy before 18 months
The normal testis in the scrotum is maintained at 2 to 3 degrees Celsius below core body temperature — the scrotal skin's cooling function is essential for normal spermatogenesis. An undescended testicle exposed to core body temperature sustains progressive testicular germ cell damage from approximately 6 months of age. Studies show:
Orchidopexy before 12 months — best fertility outcomes, closest to normal sperm production in the affected testicle.
Orchidopexy between 12 and 18 months — good outcomes, still within the optimal window per current EAU guidelines.
Orchidopexy between 2 and 5 years — partial preservation of fertility; less than optimal but significantly better than no treatment.
Orchidopexy after puberty — minimal or no improvement in spermatogenesis in the affected testicle. Cryptorchidism is the most common single identifiable cause of male infertility — most of this infertility is preventable by timely orchidopexy.
Cancer risk reduction — orchidopexy before puberty reduces the subsequent testicular cancer risk in the affected testicle (from approximately 10 times the general population risk in undescended testicle) by approximately 2 to 6 times. The testicle remains at some elevated risk even after orchidopexy — which is why all orchidopexy patients are taught testicular self-examination and the importance of reporting any testicular lump to a doctor.
Surgical treatment at KIMS — orchidopexy
Inguinal orchidopexy (for palpable undescended testicle)
A small inguinal incision is made, the testicle and spermatic cord are dissected free of the surrounding structures, sufficient cord length is achieved by dividing the gubernaculum and mobilising the retroperitoneal cord, and the testicle is brought into the scrotum through a subdartos pouch (a pocket beneath the scrotal skin that prevents retraction). The procedure takes 30 to 45 minutes under general anaesthesia — typically a day-case or overnight stay at KIMS.
Laparoscopic orchidopexy (for non-palpable undescended testicle)
Diagnostic laparoscopy is performed first — the intraabdominal space is examined laparoscopically to locate the testicle, assess its viability, and identify the status of the vas deferens and vessels. A one-stage laparoscopic orchidopexy (for low abdominal testes with adequate vessels) or a two-stage Fowler-Stephens orchidopexy (for high abdominal testes with short vessels) is then performed. In Fowler-Stephens: Stage 1 clips the testicular vessels laparoscopically (allowing collateral supply through the deferential artery to develop over 6 months); Stage 2 brings the testicle to the scrotum through the collateral supply 6 months later.
Every male infant should have both testicles palpated in the scrotum at birth and at the 6-week postnatal check. If both testicles are not palpable in the scrotum at 6 months of age, a specialist paediatric urology referral is required. The window for optimal orchidopexy — before 18 months — is the most time-sensitive intervention in paediatric urology.
Book a Paediatric Urology Assessment for Undescended Testicle at KIMS
Frequently Asked Questions — Undescended Testicles
Spontaneous descent occurs in approximately 70% of undescended testicles by 3 to 6 months of age — particularly for testicles that are already in or near the inguinal canal at birth. After 6 months of age, spontaneous descent is rare. If the testicle has not descended by 6 months, a specialist paediatric urology assessment at KIMS should be arranged. The current EAU guideline recommendation is orchidopexy between 6 and 18 months — waiting beyond 18 months to see if the testicle descends further significantly reduces the chances of preserving normal spermatogenesis in that testicle.
Yes — if left untreated or treated late. The higher temperature in the abdomen or inguinal canal progressively damages the spermatogenic cells within the undescended testicle from approximately 6 months of age. The earlier orchidopexy is performed, the better the preservation of spermatogenesis. Men with bilateral undescended testicles treated late (after 2 to 3 years) have significantly higher rates of azoospermia and infertility than men with normally descended testicles or those treated before 18 months. Unilateral undescended testicle treated before 18 months has minimal long-term impact on fertility — the contralateral normal testicle compensates.
Cryptorchidism increases the lifetime risk of testicular germ cell tumour — approximately 10 times the risk of the general population in the undescended testicle. Early orchidopexy (before puberty) reduces this risk by 2 to 6 times, but the testicle remains at some elevated risk even after successful orchidopexy. Men with a history of undescended testicle — treated or not — should perform monthly testicular self-examination for life and report any testicular lump to a doctor immediately. The cancer risk is also slightly elevated in the contralateral normally descended testicle — suggesting a systemic predisposition rather than solely a temperature effect.
A retractile testicle is a testicle that has descended normally into the scrotum but is pulled back into the inguinal canal by a hyperactive cremasteric reflex (the reflex that normally pulls the testicle upward in response to cold or anxiety). On examination, the testicle is not in the scrotum — but it can be gently brought into the scrotum by manipulation and stays there briefly without tension. A retractile testicle is not the same as a true undescended testicle — it does not require orchidopexy at the time of diagnosis. However, retractile testicles must be followed annually to the end of puberty — some 'ascend' (fail to remain in the scrotum permanently) as the child grows, requiring orchidopexy. An ascending retractile testicle is recognised by the fact that, over serial examinations, it can no longer be brought fully into the scrotum without tension.
KIMS Secunderabad — Dr. Neil Narendra Trivedi (MCh Urology KEM Mumbai, Member SIU, Paediatric Urology), clinical examination with distinguishing retractile vs undescended testicle, scrotal ultrasound, inguinal orchidopexy (day-case), laparoscopic orchidopexy for non-palpable testicle, two-stage Fowler-Stephens for high abdominal testes, post-orchidopexy surveillance with annual testicular self-examination education. NABH and NABL accredited. Call 040-4488-5000.