Monorchism

Alternative names
Cryptorchidism; Empty scrotum - undescended testes; Scrotum - empty (undescended testes); Undescended testicle; Vanished testes - undescended

Definition
The testicles develop before birth in the abdominal cavity. Normally, they descend into the scrotum before birth. Undescended testicle occurs when one or both testicles fail to move into the scrotum prior to birth.

Causes, incidence, and risk factors

Undescended testicles are fairly common in premature infants, and occur in about 3 to 4% of full-term infants. About 65% of the testicles typically descend by 9 months of age.

Once a testicle has been discovered in the scrotum, it is generally considered descended, even if it is temporarily retracted on a later examination. Sometimes a condition (referred to as retractile testes) will develop, in which the examiner can sometimes locate the testicles and sometimes not.

This occurs because of the strength of the muscular reflex (cremasteric reflex) that retracts the testicles and the small mass of the testicles before puberty. In this instance, the testicles descend at puberty. This is considered a variant of normal and surgical correction is not needed.

Testicles that do not descend by one year of age should be carefully evaluated. The literature suggest that definitive surgery should be accomplished by this age to confirm diagnosis and to lessen the likelihood of permanent testicular damage.

Testicles that do not naturally descend into the scrotum are considered abnormal throughout the patient’s life. These undescended testicles have an increased likelihood of developing cancer regardless of whether or not they are brought down into the scrotum.

Bringing the testicle into the scrotum maximizes sperm production and increases the odds of good fertility. It also allows examination for early detection of testicular cancer.

In other cases, such as vanished testis, no testicle may be found upon surgical exploration. This may be due to in utero vascular insult (testicular torsion), resulting in an infarction (death of affected tissue).

Alternatively, this may be associated with congenital anomaly, in which case blind-ending blood vessels are seen in the vas deferens (the tube which normally carries sperm).

Symptoms

There are usually no symptoms other than inability to find the testicle within the scrotum (may be described as an empty scrotum). Adult males with an undescended testicle may complain of infertility.

Signs and tests

Examination confirms that one or both of the testicles are not present in the scrotum.

The undescended testicle may or may not be felt in the abdominal wall above the scrotum.

Treatment

Usually the testicle will descend into the scrotum without any intervention during the first year of life. If this does not occur, hormonal injections (B-HCG or testosterone) may be given in an attempt to stimulate movement of the testicle into the scrotum.

Surgery (orchiopexy) is the definitive therapy. The trend in literature favors earlier surgery to prevent irreversible damage to the testis, which may cause infertility.

Expectations (prognosis)

The majority of cases resolve spontaneously, without any treatment. Medical or surgical correction of the condition is usually successful.

About 5% of patients with undescended testicles do not have testicles that can be found at the time of surgery. This is called a vanished or absent testis.

Complications

If one or both testicles do not descend, a man may be infertile later in life. Men who have an undescended testicle at birth are at higher risk of developing testicular cancer in both testes.

Calling your health care provider

Call your child’s health care provider if he appears to have an undescended testicle.

Call your provider if you are a male, 15 years or older and you are unsure how to perform testicular self-examination (TSE) to screen for testicular cancer.

Johns Hopkins patient information

Last revised: December 3, 2012
by Martin A. Harms, M.D.

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