Undescended Testicle

What is an undescended testicle?

As a baby boy grows inside his mother, he develops testicles. Early in his development, his testicles are in his belly. Normally before he is born, his testicles move down into his scrotum, the sac that hangs below the penis. When one testicle does not move into the scrotum as it should, the baby has an undescended testicle. In rare cases, both testicles are undescended.

About 5 out of 100 baby boys are born with an undescended testicle.¹ It is most common in babies who were born before their due date or who were very small at birth. Why a baby’s testicle does not move into the scrotum is not well understood. It probably has a number of causes. This condition runs in some families (can be inherited).

In more than half of cases, the testicle descends on its own by the time the baby is 3 months old. If your baby’s testicle has not descended by the time he is 6 months of age, your doctor may suggest treatment.

What are the symptoms?

Having an undescended testicle does not cause pain or other symptoms. The scrotum may look a little smoother or less developed on one side, or the side without a testicle may look smaller and flatter.

How is an undescended testicle diagnosed?

At newborn and well-baby visits, your doctor will check your baby’s scrotum.

• If the testicle can be felt but it is not in the scrotum, the doctor will probably want to check your baby again at 3 to 6 months of age. By this time, the testicle may have moved into place on its own.
• Sometimes the doctor can't feel the testicle at all. It could still be in the baby's belly, it could be too small to feel, or it could be absent. After taking a wait-and-see approach, a doctor may recommend a type of surgery called laparoscopy to see if he or she can find the testicle. Laparoscopy requires only a small cut below the belly button, which heals quickly. During laparoscopy, the surgeon puts a tiny lighted instrument into the baby’s belly. The doctor may be able to move the testicle into the scrotum during this procedure so that the baby will most likely not need another surgery.
• If both testicles are undescended and cannot be felt in the groin, the doctor will do a blood hormone test to find out if the testicles are absent. It is rare to have two absent testicles.

Doctors sometimes use an imaging test, such as ultrasound, to help find an undescended testicle. These tests are more useful for older boys and men than for babies.

Some other conditions are closely related to undescended testicles. Your doctor will take care to make the correct diagnosis so your child can get the right treatment.

How is it treated?

Usually, doctors recommend a wait-and-see approach for newborns. If the testicle has not descended on its own within the baby's first year, your doctor may recommend surgery to move it into the scrotum, probably when the baby is 9 to 15 months old. In most cases, surgery takes about an hour. The baby will be given medicine so he sleeps through it. After surgery, the baby will be watched for a while after he wakes up, and then he can go home. Most babies recover quickly.

When babies have a testicle that can't be felt (nonpalpable), doctors may perform a different surgery that needs only a small cut (laparoscopy).

In some cases, the doctor may want to give your baby hormones before surgery to see if they cause the testicle to move down into the scrotum. Studies of hormone therapy have not found it to be very effective, and it can cause side effects. It may be a good option if the testicle is already very close to the scrotum.

Why is it important to treat an undescended testicle?

Treatment is important because having an undescended testicle increases the risk of:

• Infertility. Being in the scrotum keeps the testicles cool, which helps them make sperm. If the testicle remains inside the body, it stays too warm and its ability to make sperm drops. This can cause infertility later in life. Damage to the testicle's sperm-making ability can begin as early as 12 months of age. That is why many doctors advise treating an undescended testicle by the time a baby is 1 year old and no later than age 2.
• Cancer of the testicles. Although rare, testicular cancer is the most common form of cancer in men between the ages of 20 and 34.² And men who have undescended testicles have a much higher rate of testicular cancer than other men. This cancer can usually be cured, especially if it is found early. Treatment of an undescended testicle makes it easier for you or your doctor to find testicular cancer if it develops. If you are a young man who has an undescended testicle, talk to your doctor about what you should do. For more information about testicular exams, see the topic Testicular Examination and Testicular Self-Examination.

Having an undescended testicle does not cause pain or other symptoms. It may cause the scrotum to look:

• Smoother and less rounded than normal on one or both sides.
• Larger, fuller, and better developed on the side with a testicle. The side without a testicle usually is smaller and flatter.

Also, you will not be able to feel the rounded mass of the testicle in the scrotum on the side where it has not descended.

Usually the doctor will notice an undescended testicle during a physical exam as part of a newborn or routine well-baby checkup. The doctor will ask questions about your baby's medical history that can help diagnose an undescended testicle. If your baby's doctor suspects this is the problem, he or she will usually refer your baby to a specialist, such as a pediatric surgeon or a pediatric urologist.

Your baby's doctor will conduct a physical exam to see whether the testicle can be felt (palpable). If it is palpable but has not descended into the scrotum, your baby likely will be examined again in 3 to 6 months. Undescended testicles usually descend on their own sometime within the first year, usually within the first 3 months.

If the undescended testicle cannot be felt (nonpalpable) during a physical exam, further testing will be needed to determine whether the condition is:

• An ectopic testicle. The testicle is in an abnormal position in the groin area.
• A retractile testicle. In this case, the testicle has fully descended but is sometimes pulled up out of the scrotum by the muscle that is attached to it.
• An absent or malformed testicle. This can be caused by a problem with the development of the testicle during pregnancy.
• Hypospadias. This is a common birth defect where the urethra does not extend to the tip of the penis. Instead, the opening of the urethra is located somewhere along the underside of the penis. In many cases of hypospadias, the testicles do not descend.

The process to identify the type of undescended testicle or rule out other similar conditions may include:

• Hormone testing, using a blood sample, to determine whether the testicles are absent (anorchia). But the test results sometimes do not clearly indicate whether the testicles are missing.
• Exploratory surgery, to verify the presence of one or both testicles and to evaluate their condition. The doctor may use laparoscopy to look inside the abdomen if a testicle is not felt during a physical exam. During laparoscopy, the surgeon puts a tiny lighted instrument into the baby’s belly through a small cut below the belly button.
• Medical imaging tests, such as ultrasound, MRI, or CT scan, to help locate an undescended testicle. But these tests are not effective enough to replace physical exams, hormone testing, and laparoscopy. Also, small children have to be sedated for some imaging tests, which makes these tests less likely to be used. Imaging tests are used more often for older boys, teens, and adult men than for infants and young boys.

What to think about

The risk for testicular cancer is more than 20 times greater in males who have ever had an undescended testicle than in other males.³ Because of this risk, men who have ever had an undescended testicle should have regular medical checkups (at least once every 2 years) throughout life. These checkups should include a testicular exam. If you have ever had an undescended testicle, talk to your doctor about how often you need to be checked. Also, learn how to do self-exams.

If your newborn has an undescended testicle, your doctor will probably want to wait and see whether the testicle will descend into the scrotum on its own. Your doctor will examine your baby at each well-baby checkup to see whether the testicle has moved toward or into the scrotum.

If the testicle has not descended within the first 6 months, it is not likely to do so on its own. Your doctor will probably recommend surgery to move it into the scrotum, most likely when the baby is 9 to 15 months old.¹ In some cases, surgery can be done using laparoscopy, which requires only a small cut below the belly button. In others, open surgery is needed.

Surgery to move an undescended testicle into the scrotum is called orchiopexy or orchidopexy. It is considered a safe and effective procedure that has few risks.

• Depending on the location of the testicle, one or two small incisions are made in the scrotum, the groin, or the belly to allow the surgeon to reach the testicle and move it to the scrotum.
• Usually only one surgery is needed. But if testicles are located in the belly, your baby may need two separate operations, several months apart.
• If an inguinal hernia is also present, it will be repaired at the same time.
• Your baby will be given general anesthesia so that he sleeps through the procedure. After surgery, he will be watched for a while after he wakes up, and then he can go home. Most babies recover quickly.

Another possible treatment is hormone therapy. Hormone therapy may stimulate the testicle to complete its descent into the scrotum. If it works, surgery is not necessary.

• Hormone therapy alone is effective in less than 20% of cases.⁴ It may be a good option if the testicle is already very close to the scrotum.
• Sometimes, a testicle may only partially descend with hormone treatment. This may still be helpful because it may make the surgery easier to do.

The treatment your doctor recommends will depend on a number of factors:

• For babies, most doctors recommend treatment as early as 6 months of age but no later than 2 years of age. Early treatment between age 6 months and 1 year may help prevent infertility later in life.
• For a teen or adult who has an undescended testicle, surgery is generally recommended after puberty and up to about age 32. It makes it easier to check the testicle for cancer. After age 32, the risks of surgery are greater than the risk of cancer.⁵ If you have an undescended testicle, talk with your doctor about what is best for you.
• If an undescended testicle is incomplete or malformed in males up to about age 32, most doctors recommend that it be removed rather than placed in the scrotum.

What to think about

• A child who has only one testicle (because one is either absent or has been removed) should take special care to preserve it and protect it from injury. If surgery is required to move the single testicle to the scrotum, the testicle may be stitched in place. This can help reduce the risk of damage if testicular torsion develops later in life.
• Males who are born with an undescended testicle have about a 20 to 40 times greater risk than other males for developing testicular cancer.⁵ Treatment of an undescended testicle makes it easier for you or your doctor to find testicular cancer if it develops. Some experts say that early treatment for undescended testicle may lower testicular cancer risk.^{6, 7} But there has not been enough research to prove that this is true. For more information on this type of cancer, see the topic Testicular Cancer.
• Because of the risk of cancer, men who have ever had an undescended testicle should have regular medical checkups (at least once every 2 years) throughout life. These checkups should include a testicular exam. If you have ever had an undescended testicle, talk to your doctor about how often you need to be checked. Also, learn how to do self-exams.
• An empty or partly empty scrotum can have a psychological and emotional effect on a male. Surgical treatment may improve his self-esteem. If the testicle is absent or malformed, a testicular prosthesis can help the scrotum appear and feel normal.

After surgery

After your child has had surgery for an undescended testicle:

• Check the surgical site for signs of infection, such as redness, swelling, pain, or drainage.
• Protect his genital area from injury. Your child should avoid riding toys such as tricycles or bicycles for about 2 weeks. Older boys should avoid games, sports, and rough play in which there is a risk of an injury to the genitals.
• Keep all appointments for follow-up exams so that the doctor can check your child for signs of complications. In rare cases, the testicle will move out of the scrotum again (reascend) after surgery and require further treatment.

Ongoing concerns

Males who have or have had an undescended testicle, even when successfully treated, have an increased risk for infertility.⁴ If you have an undescended testicle and are concerned about your fertility, talk to your doctor about your options.

Males who have or have had an undescended testicle also have an increased risk for testicular cancer.⁴ It is important for these males to have regular medical checkups (at least once every 2 years) throughout life. These checkups should include a testicular exam. If you have ever had an undescended testicle, talk to your doctor about how often you need to be checked.

Extra care should also be taken to protect the testicle from injury, such as by always wearing an athletic cup while playing contact supports.

Consult with a doctor if you have had surgery for an undescended testicle and are now considering a vasectomy. Sometimes the surgery for an undescended testicle completely removes a testicle and reimplants it in the scrotum. The surgeon may use the blood vessels that supply the vas deferens to also supply the testicle in its new location. During a vasectomy, the vas deferens is cut, and this could affect blood flow to a reimplanted testicle.

What to think about

If your teenage son has only one testicle, you may want to talk with him about the possibility of getting a testicular prosthesis. The prosthesis helps the scrotum appear and feel normal and may help your son feel better about his body. Whether a prosthesis is necessary for preteen boys is controversial. You and your child will need to decide together how important it is for the boy to have a normal-looking scrotum. If a prosthesis is implanted before puberty, it will need to be replaced later with a larger prosthesis that matches the adult size of the normal testicle.

Online Resource

Organizations

• Fertility Problems
• Hypospadias
• Inguinal Hernia
• Male Genital Problems and Injuries
• Testicular Cancer
• Testicular Examination and Testicular Self-Examination (TSE)

Citations

1. Behrman RE, et al. (2004). Disorders and anomalies of the scrotal contents. In Nelson Textbook of Pediatrics, 17th ed., pp. 1817–1818. Philadelphia: Saunders.

2. Huyghe E, et al. (2003). Increasing incidence of testicular cancer worldwide: A review. Journal of Urology, 170(1): 5–11.

3. Zeitler PS, et al. (2007). Cryptorchidism section of Endocrine disorders. In WW Hay Jr et al., eds., Current Pediatric Diagnosis and Treatment, 18th ed., p. 967. New York: Lange Medical Books/McGraw-Hill.

4. Schneck FX, Bellinger MF (2007). Abnormalities of the testes and scrotum and their surgical management. In AJ Wein, ed., Campbell-Walsh Urology, 9th ed., vol. 4, pp. 3761–3798. Philadelphia: Saunders Elsevier.

5. Wilson ED, et al. (2001). Cryptorchidism. In JMH Teichman, BD Weiss, eds., 20 Common Problems in Urology, pp. 29–38. New York: McGraw-Hill.

6. Bosl GJ, et al. (2005). Cancer of the testis. In J Pine, ed., Cancer: Principles and Practice of Oncology, 7th ed., pp. 1269–1293. Philadelphia: Lippincott Williams and Wilkins.

7. Pettersson A, et al. (2007). Age at surgery for undescended testis and risk of testicular cancer. New England Journal of Medicine, 356(18): 1835–1841.

Other Works Consulted

• Radmayr C, et al. (2003). Long-term outcome of laparoscopically managed nonpalpable testes. Journal of Urology, 170(6, Part 1): 2409–2411.

• Siegel NJ (2003). Cryptorchidism section of Kidney and urinary tract. In CD Rudolph et al., eds., Rudolph's Pediatrics, 21st ed., pp. 1740–1742. New York: McGraw-Hill.