Cryptorchidism Guidelines

Updated: Dec 03, 2018
  • Author: Joel M Sumfest, MD; Chief Editor: Edward David Kim, MD, FACS  more...
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Guidelines

Guidelines Summary

American Urological Association (AUA) guidelines on cryptorchidism contain the following recommendations on diagnosis by primary care providers:

  • Obtain gestational history at initial evaluation of boys with suspected cryptorchidism. (Standard; Evidence Strength: Grade B)
  •  Palpate testes for quality and position at each recommended well-child visit. (Standard; Evidence Strength: Grade B)
  • Refer infants with a history of cryptorchidism (detected at birth) who do not have spontaneous testicular descent by 6 months (corrected for gestational age) to an appropriate surgical specialist for timely evaluation. (Standard; Evidence Strength: Grade B)
  • Refer boys with possible newly diagnosed (acquired) cryptorchidism after 6 months (corrected for gestational age) to an appropriate surgical specialist. (Standard; Evidence Strength: Grade B)
  • Immediately consult an appropriate specialist for all phenotypic male newborns with bilateral, nonpalpable testes for evaluation of a possible disorder of sex development (DSD). (Standard; Evidence Strength: Grade A)
  • Do not perform ultrasound (US) or other imaging modalities in the evaluation of boys with cryptorchidism prior to referral, as these studies rarely assist in decision making. (Standard; Evidence Strength: Grade B)
  • Assess the possibility of a disorder of sex development (DSD) in cases of increasing severity of hypospadias with cryptorchidism. (Recommendation; Evidence Strength: Grade C)
  •  In boys with bilateral, nonpalpable testes who do not have congenital adrenal hyperplasia (CAH), measure Müllerian Inhibiting Substance (MIS or Anti-Müllerian Hormone [AMH]) level), and consider additional hormone testing, to evaluate for anorchia. (Option; Evidence Strength: Grade C)
  • In boys with retractile testes, assess the position of the testes at least annually to monitor for secondary ascent. (Standard; Evidence Strength: Grade B)

The AUA guidelines recommend against the use of hormonal therapy to induce testicular descent, due to low response rates and lack of evidence for long-term efficacy. (Standard; Evidence Strength: Grade B). AUA recommendations for treatment by surgical specialists are as follows:

  • If spontaneous testicular descent has not occurred by 6 months (corrected for gestational age), perform surgery within the next year. (Standard; Evidence Strength: Grade B)
  •  In prepubertal boys with palpable, cryptorchid testes, perform scrotal or inguinal orchidopexy. (Standard; Evidence Strength: Grade B)
  • In prepubertal boys with nonpalpable testes, perform examination under anesthesia to reassess for palpability of testes. If nonpalpable, surgical exploration—and, if indicated, abdominal orchidopexy—should be performed. (Standard; Evidence Strength: Grade B)
  • At the time of exploration for a nonpalpable testis in boys, identify the status of the testicular vessels to help determine the next course of action. (Clinical Principle)
  • In boys with a normal contralateral testis, consider performing orchiectomy (removal of the undescended testis) if a boy has a normal contralateral testis and either very short testicular vessels and vas deferens, dysmorphic or very hypoplastic testis, or postpubertal age. (Clinical Principle)

The AUA advises that providers should counsel boys with a history of cryptorchidism and/or monorchidism, and their parents, regarding potential long-term risks and provide education on infertility and cancer risk. (Clinical Principle)

European guidelines

Guidelines on cryptorchidism from the European Association of Urology and the European Society for Paediatric Urology include the following recommendations [58] :

  • Do not offer medical or surgical treatment to boys with retractile testes but follow up closely until puberty (Level of Evidence [LE] 2a, Grade A)
  • Offer surgical orchidolysis and orchidopexy before the age of 12 months, and by 18 months at the latest (LE 2b, Grade B)
  • Evaluate male neonates with bilateral non-palpable testes for possible DSDs (LE 1b, Grade A)
  • In boys with non-palpable testes and no evidence of DSDs, offer laparoscopic intervention because of its excellent sensitivity and specificity in identifying an intra-abdominal testis, as well as the possibility for subsequent treatment in the same session (LE 1a, Grade A)
  • Do not routinely offer hormonal therapy, either in an adjuvant or neo-adjuvant setting, for testicular descent; patients have to be evaluated on an individual basis (LE 2a, Grade C)
  • In cases of bilateral undescended testes, offer endocrine treatment to possibly improve further fertility potential (E 4, Grade C)
  • For an undescended testis in a post-pubertal boy or older who has a normal contralateral testis, discuss removal with the patient/parents because of the theoretical risk of a later malignancy (LE 3, Grade B)