Undescended testicles

Testicle Elevation: Description

At an undescended testicle (Maldescensus testis), at least one testicle is not in its natural position in the scrotum (scrotum), but in the inguinal canal or lower abdominal cavity.

Most of the time it is a congenital phenomenon (primary undescended testicles). In children, the misfortune already occurs immediately after birth. Only in rare cases, a testicle is initially in the correct position and only later assumes a wrong position (secondary testicle elevation).

How does an undescended testicle develop?

In the unborn, the testes develop in the abdominal cavity at the level of the upper lumbar vertebrae. In the course of pregnancy they migrate first to the edge of the pelvis and from there from the seventh month of pregnancy on the inguinal canal in the scrotum.

The testicles are not isolated in the scrotum, but are attached to the spermatic cord (Funiculus spermaticus). It is a bundle of vessels, nerve fibers and the vas deferens, which pulls from the testes through the inguinal canal into the abdomen.

The “migration” of the testicle towards the scrotum in the embryonic period is called Descensus testis. In a normal pregnancy, both testes should reach the scrotum until birth.

Various factors can hamper complete testicular descent. One speaks then of a Maldescensus testis. Depending on the height of his walk, the descent stops, the affected testes remain either in the abdominal cavity or in the inguinal canal. So it is higher than normal, hence the term “undescended testicles”.

In a secondary undescended testicle, the testicle returns to the inguinal canal or even the abdomen, after he was initially in the scrotum. This happens, for example, through stunted growth or scarring after certain operations.

Which forms of undescended testicles exist?

Depending on the location of the affected testicle, a distinction is made between three different variants of undescended testes:

• Abdominal testicles (abdominal testicular retention): In this form, the migration of the testis has already stopped in the abdomen.
• Inguinal testicles (reticulum testis inguinalis): The testes are located in the area of ​​the inguinal canal and can not be displaced into the scrotum. This is the most common form of undescended testicles.
• Sliding testes (retention testis prescrotalis): The testes are located in the lowest part of the inguinal canal, just above the scrotum. Although it is possible to move the sliding bottom gently into the scrotum, it then slides back to its original position because the spermatic cord is too short.
• Pendelhoden (also: “Wanderhoden”): Although the testicle lies in the scrotum, but is drawn by reflex-like tension of a muscle running in the spermatic cord, the cremaster muscle, in the inguinal canal. For example, cold, stress or sexual arousal triggers the Kremaster reflex.

Unlike the aforementioned forms of undescended testicles, a pendulum testis is not pathological and does not cause any complications. He therefore does not need to be treated.

In connection with an undescended testicle is sometimes referred to by a so-called cryptorchidism. These two terms do not mean the same thing. Also, the cryptorchidism is not a variant of the undescended testicles.

“Cryptorchidism” is just a generic term for not being able to feel a testicle. This is true for an abdominal testicle, but also if a testicle is not created (testicular agenesis). In the same way it can also lie in other places, outside the abdomen and inguinal canal (testicle ectopia) and therefore can not be felt.

How common is the undescended testicle?

Testicular upleg is the most common congenital malformation of the genitals. In about one to three percent of the boys born in maturity, at least one testicle does not descend to the scrotum. Among premature babies, the proportion is even higher at 30 percent. In about 1.5 percent of boys, a secondary testicular elevation develops only after birth.

Testicle elevation: symptoms

At first, most of the time, there are no immediate symptoms due to undescended testicles. However, if timely treatment is not provided, serious complications may sometimes occur later.

Symptoms of undescended testicles: baby and child

Babies and children with undescended testicles usually have no direct symptoms, such as pain or hormonal imbalances. The affected testicles are not correct, but are normally trained.

In adolescence, however, it can become a psychological burden with increasing sexual awareness, if one or both testicles are not in the scrotum. But as a rule, a scrotal supernatant is treated before the first birthday, so it usually comes not at all.

Complications of undescended testicles: Adult male

Even if a therapy was given early, a past undescended testicles may lead to complications in the course. These are usually noticeable only in adulthood.

testicular rotation

In some cases, the false position of the testes favors a testicular torsion, ie rotation of the testicle on the spermatic cord. This laces the vessels that feed the testicles. If the torsion is not treated very quickly, the testicle dies.

hernia

In addition, in inguinal and gliding hives sometimes weak points in the inguinal canal, through which guts from the abdominal cavity can break. It then protrudes a so-called hernia bag with intestinal components in the inguinal canal. Such a hernia (inguinal hernia) is usually noticeable as a painless swelling in the groin. However, it should be treated soon to prevent the intestinal blood flow is disturbed.

infertility

An undescended testicle can affect fertility. If only one testicle is affected, this hardly matters, but men testify with a bilateral Maldescensus testis much less often children.

testicular cancer

The development of testicular tumors is favored by an undescended testicle. In the man with an operated testis maldescensus, the risk of testicular cancer is three to eight times higher than that of men with normal testicles. Without therapy, the risk is even more than 30 times higher.

Why do complications arise in undescended testicles?

On the one hand, undescended testicles are associated with increased risks of infertility and testicular cancer from the beginning. In those affected, the wrongly positioned and even the correctly positioned testes are in general more at risk of developing complications later in the course (primary damage).

In addition, a permanently elevated ambient temperature additionally damages the testes (secondary damage). While in the scrotum namely a temperature of about 33 degrees Celsius, it is in the inguinal canal or abdominal cavity two to four degrees warmer.

The higher the temperature and the longer the testis is exposed to it, the more the risk of long-term consequences increases. Correspondingly, in connection with the abdominal testes, complications are more frequent than with inguinal canes or gliding hives, because it is warmer in the abdominal cavity than in the inguinal canal.

Testicular Elevation: Causes and Risk Factors

An undescended testicle usually has several causes, many of which are based on genetic factors. Certain errors in the genetic material of the unborn child disturb the correct testicular descent during pregnancy. In this case, a Maldescensus testis can occur isolated or in the context of genetic syndromes, ie together with other malformations and other symptoms of disturbed development.

Direct triggers of an undescended testicle are, for example, anatomical malformations that mechanically impede the descent of the testicle (prune-belly syndrome, gastroschisis, omphalocele). Or an insufficient release of important messengers during pregnancy. For a correct testicular descent, the hormones HCG (human chorionic gonadotropin), GnRH (gonadotropin releasing hormone) and the male sex hormone testosterone are particularly important.

An undescended testicle can also be caused by external influences. The causes without genetic background include, for example:

• Smoking during pregnancy
• Alcohol consumption during pregnancy
• Diabetes mellitus of the mother
• Environmental factors such as certain pesticides
• Pregnancy by the artificial introduction of sperm directly into the uterine cavity (intrauterine insemination)

Testicle elevation: examinations and diagnosis

There are several diagnostic methods that help the doctor to detect undescended testicles and to classify them accurately.

Physical examination

Because the undescended testicles are a relatively common congenital malformation, the scrutum and groin scrutiny is a routine neonatal procedure.

The doctor begins the examination by palpating the scrotum and groins. For babies, the examiner pulls the child’s legs to the abdomen, whereby the mother can assist. By palpation would already be noticed if a scrotum is missing in the scrotum or there is a groin.

In order to determine the type of undescended testicles, the doctor tries the testicles with one hand repeatedly from the bar down stroke and gently pull the other hand into the scrotum. If he succeeds and the testicles go back to the inguinal canal after releasing it, it is a sliding bottom. If one can not move the testicle out of the inguinal canal, it is a groin testicle.

The physical examination should be done by the doctor in a warm and relaxed environment. Because cold and stress can trigger the so-called Kremaster reflex and thus disrupt the investigation.

The Kremaster muscle is a thin strand of muscle that surrounds testicles and spermatic cords and pulls into the inguinal canal. When he contracts, he pulls the testicles up towards the groin. A pendulum testicle can thus slide into the inguinal canal through the Kremaster reflex and thus appear like a groin or sliding floor.

Imaging investigation

If a testicle is not palpable in the scrotum or in the groin, ultrasound (sonography) or magnetic resonance imaging (MRI) may help. Although these procedures are not 100 percent reliable, most of the hidden testicles can be traced. The MRI can facilitate the orientation of a testicle, especially in very thick patients.

blood tests

In the event that both testes are neither palpable, nor can be found using the imaging methods, there are special blood tests. The blood is analyzed for certain messenger substances, which are mainly produced by the testes.

Especially the testosterone content is instructive if the doctor can not feel testicles. For if they are still present – for example, in the abdominal cavity – then there is more testosterone in the blood, as if they were not created. In order for the test to be more meaningful, the patient is injected with HCG, a special hormone that boosts testosterone release from the testes three to four days before taking the blood (HCG stimulation test).

Alternatively, one can determine the blood concentration of inhibin-B. This substance also arises in certain testicle cells and therefore serves as a marker for existing testes.

If the blood tests show normal or elevated levels of testosterone or inhibin B, then it can be assumed that the patient has testes. The next step is followed by the laparoscopy to find the hidden testicles. If the blood tests are negative, it is unlikely that the patient has testicles.

Laparoscopy

Laparoscopy is an operative procedure for examining the abdominal area. Through a small incision into the abdominal wall, the laparoscope – a long, thin tube with camera – is inserted into the abdominal cavity of the patient. The laparoscope is equipped with a light source and displays everything enlarged. A rinsing and suction device ensures that the examiner has a clear view.

With the help of laparoscopy, the doctor can scan the entire abdomen for the hidden testicles, without the need for major surgery. The method leaves only very small scars and is also called “keyhole surgery”.

The laparoscopy is not only an examination method, but can also be used to correct the undescended testicles. However, the surgeon must introduce additional instruments into the abdominal cavity via further cuts.

Testicle elevation: treatment

The treatment of an undescended testicle has the goal to shift the wrong testicle (s) early into the scrotum. On the one hand, one tries to reduce the risk of later complications. On the other hand, he is then palpable and in the future a physical examination accessible.

To prevent the testes from being exposed to an elevated temperature for too long, therapy should be given as early as possible and completed at the latest at the end of the twelfth month of life. During the first six months, however, one waits, since in this time the too high-lying testicles may even descend by themselves.

There are basically two different treatment approaches. Conservative therapy attempts to achieve testicular descent using certain hormones. However, the operative displacement of the testicle has a greater chance of success.

Testicle elevation: hormone therapy

In some cases, testicular descent succeeds in giving the patient special hormones. They use messenger substances that are also responsible for natural testicular descent during pregnancy: GnRH and HCG. The attending physician can administer the hormones individually or in combination. GnRH is available as a nasal spray, HCG only as a syringe.

The closer a testicle is to the scrotum, the more likely hormone therapy will succeed. Overall, the success rate is moderate. Only in every fifth patient does one reach a testicle descent, whereby the two hormones hardly differ in their effectiveness.

In addition, this form of therapy is associated with some side effects. The treated babies sometimes grow pubic hair, and the penis can grow unusually in size and occasionally occur in the genital area.

Testicle elevation: OP

The chances of success of an operative treatment of undescended testicles are significantly greater than with hormone therapy. However, the surgical displacement of a false testicle is demanding. The surgeon should therefore have sufficient experience with this procedure. Depending on the location of the testicle, two different surgical procedures are used: open and laparoscopic surgery.

Laparoscopic testicle elevation surgery

An abdominal testicle can not only be detected with the laparoscope, but also operated on. If it is relatively close to the inguinal canal, it can be exposed immediately and laid over the inguinal canal into the scrotum (laparoscopic orchidopexy). If it is more than three centimeters from the inguinal canal, surgery is usually performed in two steps.

First, testicles and spermatic cord are only released from the surrounding tissue. Only six months later, the shift to the scrotum (“two-time operation after Fowler-Stephens”) takes place.

If it turns out during the examination that a testicle is missing, for example, if the spermatic cord ends blindly, you break off the laparoscopy.

Open scrotal open surgery (inguinal orchidopexy)

If an upstanding testicle is palpable or recognizable in the groin during the ultrasound examination, an open operation via the groin (inguinal) is usually followed. The doctor makes a small incision in the area of ​​the abdominal crease and exposes the inguinal or sliding hive and the associated spermatic cord.

Using the inguinal canal, he probes with his finger in the scrotum and places a small bag there, into which he then shifts the testicles. It is important to expose the testicles and spermatic cord in such a way that in their new position there is no pull on them. So that the testicle does not return to the old position after it has been relocated, the surgeon sews it additionally with a thin thread on the inside of the scrotum (orchidopexy).

autotransplantation

Autotransplantation, like inguinal orchidopexy, is an open surgical procedure. However, this method is not used in inguinal testes, but in certain forms of the abdominal testicles. It may be that the vessels that supply the abdominal testicles are too short to lay in the scrotum.

Then you separate the testicles first from its vessels and then connects it with vessels from the abdominal wall, which are closer to the scrotum. Thus, the testes on the one hand continues to be supplied with blood, on the other hand you can now shift it into the scrotum.

Complications of undescended testis

Every operation involves general risks. These include, for example, rebleeding, wound infections or injuries to adjacent structures, such as nerves. Special complications after orchidopexy include:

• Shrunken testes (testicular atrophy). In rare cases injury to the supplying vessels causes the testis to atrophy. After an autograft, this happens in 20 to 30 percent of patients.
• Separation of the vas deferens with subsequent restriction of fertility
• recurrent testicle elevation (recurrence). To operate a testicle elevation a second time, is associated with further complications, because after the first operation usually scarring arise.

The complications mentioned are – apart from the testicular atrophy after autotransplantation -selten. They face a high success rate of surgical procedures: 70 to 90 percent of the operations of an undescended testicles are successful.

Testicular uptake: Disease course and prognosis

In most cases, one must operate on boys with an undescended testicle, because the high testicles rarely disappear after birth without therapy. Only seven percent of those affected do so within their first year of life, after which it becomes increasingly unlikely.

Timely treatment reduces the risk of possible complications of undescended testicles. Consequences such as infertility and tumors are much less likely to occur than when the testes are transferred to the scrotum for years or not at all.

Nevertheless, those affected must always pay attention to changes in the testicles. Even if one corrects the undescended testicles within the first year of life, there is a lifelong risk of developing testicular cancer.

Most testicular tumors occur between the ages of 20 and 40 years. Typical signs are painless size and consistency changes in the testicles. Boys who have one Undescended testicles should learn early on to pay attention to such signs and thus to go to a doctor. The earlier you recognize testicular cancer, the better the chances of recovery.