Cryptorchidism, the failure of the testicle to descend into the scrotum
Cryptorchidism is the failure of the testicle to descend into the scrotum, and it is the most common anomaly of the male urogenital system in childhood
This type of problem can often be associated with other anomalies located in the area, such as inguinal hernias
The medical condition develops in the embryonic stage: when the fetus is forming – normally – the testicles descend into the scrotum from the abdominal cavity, passing through the inguinal canal.
However, it can happen that one or both stop at any point along the way, altering the normal anatomical structure, with subsequent consequences on fertility: in cryptorchid disease, the probability of reduction of sperm and hormones in adulthood significantly increases.
But let’s see more specifically what cryptorchidism is, how it is diagnosed and treated.
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What is cryptorchidism?
The term cryptorchidism derives from the Greek “cryptos” which means hidden and “orcus” which means testicle: therefore it could literally be translated as “hidden testicle”.
The very explicit word refers to that condition in which one or both testicles have not descended into the scrotal sac and therefore are not visible and, in some patients, not even palpable because their descent has stopped too prematurely during development.
In most cases cryptorchidism is unilateral, i.e. affects only one testicle, but it can happen that it is bilateral, affecting both testicles.
It is generally a congenital disease, although very rarely it is possible to find acquired forms, caused by other factors.
As mentioned before, in the formation of the fetus the testicles start from the abdominal cavity and descend, passing through the inguinal canal, into the scrotum, which is their definitive location. It may happen that this physiological path is interrupted and therefore the testicle stops, locating in a different point from the testicle.
What impact does cryptorchidism have?
The pathology is quite widespread and affects 3-5% of children born at term and 10-30% (a considerably higher percentage) of children born preterm.
In about 75% of cases, this condition resolves spontaneously within one year of age, after which only a small proportion of children are still affected.
After one year of age, failure to descend one or both testicles is considered pathological and surgery will probably be needed to resolve it.
Pathologic cryptorchidism is often associated with other malformative congenital anomalies, such as Prader-Willi syndrome and Noonan syndrome.
Cryptorchidism classification
Cryptorchidism can be classified according to the position occupied by the testicle.
Therefore, depending on whether it is located in a more or less “high” anatomical place, we distinguish:
- True cryptorchidism or undescended testicle. The testicle is in a very high position, in the abdominal cavity. For this reason, not only is it not visible but palpation will also be impossible. If the undescended testicle does not position itself correctly by the age of one year, it is likely that an operation will be needed.
- Ectopic cryptorchidism. This is probably a more serious case, because the testicle is positioned outside the physiological path of descent. This type of cryptorchidism in almost all cases will require surgery.
- Cryptorchidism with retractile testis. It can sometimes happen that the testicle comes back inside the scrotal sac at some point. Fortunately, in this case surgery or special therapies are not necessary because the testicle manages to return to its seat with some maneuvers.
- Cryptorchidism with incomplete testicular descent. The testicle is located on the physiological path of descent, very close to its definitive location: during embryonic formation, however, it stops at the level of the inguinal canal or external inguinal orifice. It is the least severe form of the disease and is more likely to resolve spontaneously.
Let’s not forget that there is also acquired cryptorchidism, in which the testicle descends at birth but goes back up following an external event, such as a hernia: in this case it can no longer be repositioned in its seat.
It is then possible that one (monorchidia) or both (anorchidia) testicles have not really formed and therefore are absent in any part of the body: here too, any intervention will be impossible.
The causes
Among the causes of cryptorchidism there seems to be a hormonal alteration, caused by some environmental substances, called endocrine disruptors.
However, it is possible that there are also mechanical or genetic causes.
However, there are also risk factors that increase the possibility of cryptorchidism, such as preterm birth, low birth weight and special conditions of the mother during pregnancy, such as diabetes or smoking.
There are no particular symptoms attributable to cryptorchid disease, patients do not complain of pain or discomfort
The problem arises, however, if the condition is not treated in the right way, leading to important long-term consequences.
Let’s start by describing the most annoying: cryptorchidism causes the formation of an anomalous mass that can lead to difficulty walking.
Any degeneration can also lead to other complications, such as testicular torsion, hypogonadism and impotence.
A serious effect of untreated cryptorchidism can also be infertility, so it is good to treat the pathology in the best possible way, even if it is asymptomatic, respecting the right timing to avoid complications.
If neglected for a long time, cryptorchidism also facilitates the formation of localized neoplasms: the cause seems to be the temperature of the testicle, which is one degree higher than it would be in the scrotal sac.
The diagnosis
Identifying any cryptorchidism in a newborn is not at all complicated and an objective examination by a doctor (usually a pediatrician) is often enough for a correct diagnosis.
Laboratory tests become necessary when cryptorchidism is associated with an abnormal development of the urethra: in this case the possibility of anorchia will also be considered.
They may be prescribed:
- Inguinal and scrotal ultrasound
- MRI of the abdomen
- Control of hormones such as LH and FSH
- Karyogram, or the representation of the chromosomal kit of an individual
- Evaluation of testosterone
In the event of the onset of cryptorchidism in adulthood, it is advisable to consult with your general practitioner, who will be able to direct you to the most appropriate specialist to deal with the issue in order to rule out much more serious triggering causes.
The treatment
As we have seen, the vast majority of children born with cryptorchidism recover spontaneously in the first year of life.
If, unfortunately, this does not happen, it is advisable to intervene promptly to avoid the complications we have mentioned.
The objective, obviously, is to bring the testicle back into place no later than the completion of the second year of life, with a treatment that is as least invasive as possible.
In the child who suffers from cryptorchid disease and who has passed the year of life, we will initially intervene with a medical-pharmacological therapy which involves the administration of hormones – specifically gonadotropins.
This remedy must be timely as it can be administered within 18 months of life and, even if administered in the right time, this cure has a rather low probability of success, working only in 15-30% of cases.
If the problem persists, surgery to bring the testicle back into place, called orchidopexy or orchidopexy, will be evaluated.
Whatever the resolution of the problem was, it is important that those who have suffered from cryptorchidism have periodic checks by a specialist andrologist, who will evaluate the condition from time to time and whether further tests are necessary.
Effects on fertility
As we have seen, despite the absence of symptoms, it is essential to intervene promptly in cases of cryptorchidism because it could lead to infertility.
Infertility could also occur if the medical condition is treated too late: therefore, if a child continues to have cryptorchidism even after the first year of age, consult with your pediatrician immediately.
In fact, if neglected, cryptorchid disease could cause the failure of the seminal tissue to develop, therefore a progressive atrophy of the testicle which leads to a poor or absent sperm production, which leads to an irreversible infertility condition.
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