eMedicine Specialties > Pediatrics: Surgery > Urology
Cryptorchidism: Treatment & Medication
Updated: Sep 18, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
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Treatment
Medical Care
General issues
Engle proposed hormonal manipulation as a treatment for cryptorchidism in the 1930s. The main goals of hormonal or surgical treatment are to allow for a normal anatomic position of the testicle, the preservation of fertility and hormonal production, and the diagnosis of potential testicular malignancies. Other putative benefits include correction of associated hernias and prevention of testicular torsion.
The risk of trauma and possible psychological effects of having a missing testis must be taken into account. Orchiopexy should be considered after 4 months of life, as the rate of descent diminishes considerably after this point.
For postpubertal adolescents and men younger than 32 years who underwent unilateral orchiopexy, orchiectomy should be considered. For postpubertal men older than 32 years, close observation and routine physical examination should be considered. Any man with bilateral undescended testes should undergo bilateral testicular biopsy and orchiopexy.
Hormonal therapy
Hormonal therapy should be considered in patients in whom the diagnosis of retractile testis is not certain. In patients who are not candidates for surgical interventions, hormonal therapy might be appropriate. Hormonal therapy has been used in Europe for many years as a primary therapy for cryptorchidism. hCG or LH-releasing hormones (LHRH) are mainly used. In Europe, hCG and LHRH have been used in combination, with initial success rates of 14%-65%. However, some long-term studies have shown lower success rates.
Similarly to LH, hCG acts on Leydig cells to stimulate the production of gonadal steroid hormones. However, its effects on testicular descent are not fully understood. In most patients with retractile testis, their condition responds to hCG. Studies have shown short-term success rates as high as 70%. Controlled studies have shown results less impressive than this, with rates around 14%. Multiple dosage schedules have been proposed. The authors' current protocol is 1000 IU/wk for children who weigh less than 10 kg, 1500 IU/wk for children who weigh 10-20 kg, and 2500 IU/wk for children who weigh more than 20 kg. The duration of therapy is 4 weeks.
LHRH acts indirectly in the pituitary by stimulating the release of gonadotropins LH and FSH. LHRH may be more efficient in increasing testosterone than hCG. LHRH is currently available only in Europe for use in cryptorchidism. Success rates are similar to those of hCG and are in the range of 10%-15%.
Adverse effects from both hormonal therapies include increase in scrotal rugae, pigmentation, growth of pubic hair, increased penile size, and erections. Adverse effects of LHRH are fewer than those of hCG.
Surgical Care
Several surgical approaches to the undescended testis have been described. The approach chosen is determined by the position of the testis and the surgeon's expertise.
The palpable testis can be approached from a scrotal, subinguinal, inguinal, or suprainguinal approach. The nonpalpable testis can be approached using an inguinal, suprainguinal, or laparoscopic approach.
Routine testicular biopsy during orchiopexy is not recommended and should be considered only in cases involving prune belly syndrome, ambiguous genitalia, abnormal karyotypes, or postpubertal adolescents or men. Some authors have recommended that, if the biopsy reveals carcinoma in situ, repeat exploration and unilateral orchiectomy should be performed. In bilateral cases, radiation therapy may be useful.
Surgical pearls regarding the palpable testis
- Look for the testis after incising the Scarpa fascia to avoid injuring a testis and its cord found outside of the external inguinal ring (ectopic testis in the superficial inguinal pouch).
- Divide all attachments, including the gubernaculum, the cremasteric fibers, and the lateral spermatic fascia.
- Identify the patent processus vaginalis in the anteromedial surface of the cord, separate it from the cord structures, and perform a high ligation; be careful not to trap the vas or vessels.
- Place the testis in a subdartos pouch.
Surgical pearls for the nonpalpable testis
- Preference should be to carry out diagnostic laparoscopy versus inguinal exploration.
- Blind-ending vas and vessels confirm the diagnosis of a vanishing testis and do not warrant further therapy. Consideration should be given to exploring the contralateral scrotum and placing some anchoring stitches to prevent possible testis torsion on the other side.
- Vessels entering the internal inguinal ring require further inguinal or scrotal exploration to identify the undescended testis or testicular nubbin.
- In patients with findings of a vanishing testis or a testicular nubbin, fixation of the contralateral testis fixation should be considered but is controversial.
- A small intra-abdominal testis or an abnormal testis requires orchiectomy.
Maneuvers to increase length of an undescended testis
- The Prentiss maneuver involves rerouting the cord under the epigastric vessels or the division of epigastric vessels.
- The internal inguinal ring can be opened to perform more complete retroperitoneal mobilization.
- The Fowler-Stephens principle involves dividing the testicular vessels to allow the blood supply to the vas deferens to keep the undescended testis viable. The testicular vessels should be divided away from the testis.
- Testicular autotransplantation can be performed by transecting the testicular vessels and by performing a microvascular anastomosis to the inferior epigastric vessels
Success rates
- Orchiopexy for palpable testis (scrotal, inguinal and suprainguinal) - 80%-90%
- Orchiopexy for nonpalpable testis
- Inguinal approach - 60%-88%
- Suprainguinal approach - Up to 95%
- One-stage Fowler-Stephens procedure - 67%-96%
- Two-stage Fowler-Stephens procedure - 77%-95%
- Microvascular transplantation - 83%-96%
- Laparoscopic orchiopexy - 80%-95%
- Laparoscopic Fowler-Stephens procedure - Up to 96%
Consultations
Patients with bilateral anorchia or an intersex condition may benefit from a consultation with a pediatric endocrinologist.
Diet
No changes in diet are required after treatment.
Activity
After surgery, patients should be advised to limit their activities for a week and refrain from straddling.
Medication
Hormonal therapy
This treatment should be considered when the diagnosis of retractile testis is uncertain. This is also used for cases of nonpalpable testis in which Fowler-Stephens orchiopexy is considered or in patients who are poor candidates for surgical intervention. Hormonal therapy has been used in Europe for many years as a primary therapy for cryptorchidism.
Human chorionic gonadotropin (hCG, Choron, Pregnyl)
Acts on Leydig cells similar to pituitary LH by stimulating production of gonadal steroid hormones, including testosterone. Effect on testicular descent not fully understood. Success rates 14-70%.
Adult
Not established
Pediatric
500-1000 U 3 times/wk; adjust by protocol
Various protocols exist, eg:
<10 kg: 1000 IU IM qwk for 4 wk
10-20 kg: 1500 IU IM qwk for 4 wk
>20 kg: 2500 IU IM qwk for 4 wk
None reported
Documented hypersensitivity; prostatic carcinoma, precocious puberty
Pregnancy
X - Contraindicated; benefit does not outweigh risk
Precautions
Caution in asthma, seizure disorders, cardiac or renal disease, and migraine; may cause increase in scrotal rugae, pigmentation, pubic hair growth, increase penile size and erection; other adverse effects include headache, irritability, restlessness, depression, or gynecomastia
More on Cryptorchidism |
| Overview: Cryptorchidism |
| Differential Diagnoses & Workup: Cryptorchidism |
 Treatment & Medication: Cryptorchidism |
| Follow-up: Cryptorchidism |
| Multimedia: Cryptorchidism |
| References |
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References
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Further Reading
Keywords
cryptorchidism, undescended testis, undescended testes, undescended testicles, ectopic testis, ectopic testes, ectopic testicles, retractile testis, retracted testis, retracted testes, retracted testicles, absent testis, absent testes, absent testicles, atrophic testis, atrophic testes, atrophic testicles, hidden testis, hidden testes, hidden testicles, obscure testis, obscure testes, obscure testicles, Fowler Stephens orchidopexy, Fowler-Stephens orchidopexy, testicular maldescent, SRY gene, Hoxa-10 gene, Hoxa-11 gene, intra-abdominal testis, intraabdominal testis, inguinal testis
