Practical approach to evaluating testicular status in infants and children

Diagnosis.

The male genital examination can be challenging to teach and difficult to master. Multiple studies have documented limited practitioner comfort with this examination.⁴ Thus, it could be expected that this unfamiliarity, coupled with the added difficulty of the natural anxiety a child often experiences during such an examination, complicates the determination of testicular position.

Testicular position is best determined in the supine and frog-legged position (Figure 1). Abduction of the thighs contributes to dampening the natural cremasteric reflex, as well as avoiding the resultant testicular elevation from inadvertent contact with the inner thigh during scrotal examination. Patient distraction and relaxation are helpful, and provider and patient comfort will assist with this. The examination room should be warm, and the child’s pants and underwear should be removed completely.

• Download figure
• Open in new tab

Figure 1.

Demonstration of proper positioning to facilitate testicular examination: The patient is frog-legged and there is gentle upward traction applied to the suprapubic area.

Careful observation should begin before the examination. First, the examiner’s nondominant hand is used to retract the skin of the suprapubic area upward. In many cases the testis will become visible in the scrotum with this maneuver alone. If not, the examiner can then use the nondominant hand to gently apply pressure sweeping in a cranial to caudal direction to help encourage descent of the testis, while the dominant hand waits to receive or trap the testicle in its lowest possible location. Occasionally, a testis can be felt to “pop” under the fingertips of the nondominant hand when just superior to the inguinal ligament, indicating a testis near the internal ring (ie, a palpable undescended testis). Repeated examination can be helpful.

Examination documentation should include testicular palpability, position, mobility, size, and any associated findings such as hernia or hydrocele. Indications for referral for consultation are outlined in Box 1.

Management of testes, classified by position

Normal scrotal position: Normally positioned scrotal testes require nothing more than annual examination in childhood as part of a routine well-child visit; however, it is important that these examinations continue throughout childhood, as there is evidence that 1% to 3% of testes might become ascended after normal newborn examination findings or after previous spontaneous descent.²

Retractile testis: Testes classified as retractile require regular repeat examinations. Testes that are quite retractile can be difficult to differentiate from UDT. Testes that rarely show spontaneous descent into the scrotum or that do not remain in position after manipulation must be watched more closely.^5,6 Retractile testes should be monitored until puberty, as rarely testes can ascend or become trapped in the inguinal canal, leading to acquired (also known as ascending) cryptorchidism. The causes of this might include inadequate spermatic vessel growth, tethering by the processus vaginalis, or inadequate postnatal testosterone surge to stabilize the testis.⁷

Testes that are truly retractile are believed to be a variant of normal testis position and do not require surgical treatment or specialist evaluation. If there is doubt, however, a more experienced specialist can confirm the appropriateness of continued observation versus the need for surgical intervention. The testes can be expected to remain consistently in a dependent scrotal position by puberty.

Undescended testis (palpable and nonpalpable) : Undescended testes (palpable and nonpalpable) require prompt subspecialist referral at the corrected gestational age of 6 months, or upon detection if later. Spontaneous descent is unlikely after 6 months of age, so referral should not be further delayed. The Choosing Wisely Canada campaign supports this timeline, as this allows for surgical correction within the range of 6 to 12 months of age, which might optimize spermatogenic functions.⁸

Ultrasound imaging before referral is not recommended, as determination of UDT is a physical examination finding, and imaging has been irrefutably shown to be a poor indicator of true testicular position.⁹ Owing to the high number of referrals for UDT that include a completed inguinoscrotal ultrasound, the Choosing Wisely Canada campaign has advised as one of its educational mandates that primary care providers not order ultrasound for UDT before referral.⁸

Ultrasound imaging data were included in the review of our UDT referral data from 2008 to 2012. Of the 894 eligible patients that were identified, 32% had accompanying inguinoscrotal ultrasound. In 61% of cases the ultrasound results did not correlate with the urologist’s findings. Thus, review of our referrals showed that ultrasound was unhelpful, or even misleading, in most cases.

After urologic examination, the undescended testis is determined to be nonpalpable or palpable, and this will guide surgical intervention, as an inguinal approach is used for palpable UDT and laparoscopic exploration is required for nonpalpable UDT.