786
DIAGNOSIS
AND
TREATMENT:
THE
.UNDESCENDED
TESTICLE
Alfred M. Bongiovanni, M.D.
Physician-in-Chief, Children’s Hospital of Phikideiphia, Professor and Chairman,
Department of Pediatrics, University of Pennsylvania
INTRODUCTORY NOTE : A discussion of some common problem of pediatrics
regularly appears as the la.st article preceding the “Experience and Reason”
section. Usually contributed by a member of the Editorial Board, each of
these short papers is intended to present his current practice in regard to
diagnosis or therapy or both. The Editor will welcome suggestions for
de-sirable topics.
T
HE QUESTION of the management oferyptonchidism remains vexing and
controvensial. Perhaps the major argument
centers on the ideal age for treatment and
the outcome to be anticipated. So much
has been written from the single
view-point of an individual clinical experience
that the varying conclusions attest mainly
to the disagreement among authorities.
In-deed, it is not at present possible to arrive
at a single plan of action which will
pro-vide ideal nesults in the majority of cases.
With any plan the outcome will depend
also to some extent upon surgical skill
and practice.
It has long been regarded as injurious to
the human testis to remain above the
scro-tum. Yet, in certain species the testes do
not descend until well after birth and in
some seasonal breeders the morphologic
and functional states of the gonads vary
from intra-abdominal to scrotal position
without deleterious effects. In man the
testes generally descend between the
eighth to ninth fetal month. However, it
is recognized that a variable number of
newborn male infants-estimated between
1 and
10%,
and higher in prematures-haveundeseended testes which, in more than
half the cases, subsequently migrate to
their normal position, usually within the
first year of life. There is no reason to
suspect damage to these organs when de-scent occurs in early life, and realization of this justifies dismissal of any consideration
of treatment during early infancy. Thus,
in certain infants with eryptonchidism, the
testes will descend spontaneously. It has
also been stated that spontaneous descent
will occur in a smaller number of instances
after the first year of life and even up to
the time of puberty. Precise
documenta-tion on this latter point is difficult to as-semble, although the literature is not with-out various approximations.
The aspect more relevant to the practice of pediatrics, and indeed most troublesome
in the assessment of reputedly successful
treatment, is the differentiation of
crypt-orchidism from the retractile testis. The
young boy whose testes may occupy the
scrotum much of the time, upon
submis-sion to examination may withdraw his
testes into the inguinal canal or into the
abdomen, the result of an active
crc-mastenie reflex. It is important to approach
the child gently, examine him frequently in
the erect and supine position, to palpate
slowly and with great care along the
en-tine inguinal canal. A cough may cause
extnusion of the testes into a lower position
whence they may he manipulated part way
into the scrotum. It is often extremely
diffi-cult to locate retractile testes in the obese
sensitive boy. Repeated examination is
ad-visabic and occasionally immersion in a
warm tub of water may lead to testicular
emergence. The difficulties in recognizing the retractile testis cannot be exaggerated.
Once the testes are palpated and
ARTICLES 787
ble to manipulation into the scrotum, it
should be clear that no treatment is
mdi-cated.
Failure of descent of the testes may be
due to several causes. Primary testicular
dysgenesis may represent the principal
reason; although this is sometimes
recog-nizable by morphologic abnormalities in
earliest life it is possible that in some
instances of dysgenesis the perceptible
ab-normalities of structure will not be
appar-ent until later. Some believe that a
pni-mary testicular disorder causes maldcsccnt
in a large number of cases, a matter
diffi-cult to assess without better objective
criteria for the discernment of such
de-nangement. Primary gonadal aplasia on
hypoplasia, the consequence of obvious
maldevclopmcnt, may be discovered upon
surgical exploration. The testes may be
ectopic, having deviated from their
nor-mal pathway during descent. Adhesion or
shortness of the spermatic vessels may
arrest them during their passage. There
may be a premature tightening of the
cx-ternal ingumnal ring before the testes reach
their goal. The success of any treatment is
obviously related to the cause and this is
not always plain.
In man the high testis is subject to a
number of disadvantages. Observations in
man and in the rodent indicate that the
maturation of the germinal elements is
hindered and fibrosis of the tubules is apt
to occur. Nevertheless, changes of varying
degree in the cryptonchid testis are not
necessarily irreversible, according to some experimental observations, and realization
of this affects the interpretation of some
minor morphologic changes observed in
clinical studies. Interstitial elements are
less subject to damage. Although there is
evidence for some impairment of
andro-genie secretion, the high testis generally
distressed if visible gonads are lacking in
the scrotum. The anxiety over possible
malignancy of the undescended testis has
been exaggerated, for though a higher rate
of malignancy is noted in the undeseended
than in the scrotal testis, the incidence is
nonetheless very small.
Perhaps the two principal reasons for
correction of enyptorehidism are to
im-prove appearance and to insure fertility.
In unilateral eryptorchidism with a
nor-mal eontnalateral gland, the favorable
prognosis for fertility may properly he
stressed, and the arguments concerning
the best time and the best form of
treat-ment are not critical, vet cosmetic and the
psychological considerations remain
sig-nificant to most boys approaching puberty.
On the other hand, in bilateral
crypt-orchidism there is justifiable concern over
possible damage to the gonads and
im-pained fertility. It would be useful if the
time at which damage from abnormal
position of the testes is likely to occur
might be fixed so that treatment could he
employed well before injury could take
place. Unfortunately, there has long been
turbulence over this particular matter-at
what age does the undescended testis
undergo irreversible deterioration of its
germinal elements? Morphologic and
his-tochemical studies have been reported
with numerous estimates ranging from
early infancy to the age of puberty as the
time when the earliest changes are
reeog-nized. The morphologic interpretations
themselves are, unfortunately, less precise
and reliable than those attending other
techniques in clinical medicine today.
Furthermore the “earliest” changes may be
perceptible long before any irreparable
impairment has set in. Or, as has been
claimed l)V some, the changes visible
by
788 THE UNDESCENDED TESTICLE dysgenesis, although the exact proportion
is not known.
Reliable clinical experience indicates
eventual fertility in a significant propor-tion of boys with bilateral cryptorchidism
not surgically connected until just before
puberty, so that a delay of several years
after birth seems permissible. Yet other
reports are less encouraging and reporters
disagree regarding surgical technique. It
is, regrettably, impossible to assess the
populations treated by several informants.
It would be helpful to know the
propor-tion of those with primary testicular
dys-genesis and those with arrest attributable
to other factors in each group. However,
it is difficult to recognize this distinction
by current techniques except when
pni-many morphologic abnormalities are
obvi-ous early in life. More complete studies
with technical and other controls are
needed to settle the dispute. At present it
would seem that surgical correction is the
treatment of choice in bilateral eryptorchid-ism. The time for correction of unilateral
cryptorchidism is not critical but should
probably be before puberty.
Hormonal therapy is no longer favored
in most quarters. Even after the
wide-spread earlier interest in this technique accurate and full accounts of its results are
wanting. There has been some fear that
exogenous gonadotnopins administered for
this purpose may themselves damage the
testes. Such damage as has been reported
may, however, be the result of too large
doses or may represent the evolution of
abnormalities which, sooner on later, were
hound to appear in primarily dysgenetic
testes. Finally, it has seemed possible that
testes which would descend with hormones
would not be firmly arrested but simply
retractile and would gravitate
spontane-ously under the influence of endogenous
gonadotropins. Hormonal therapy would
be unlikely to bring down fixed
intra-abdominal testes. While, therefore, most
authorities would select surgery as the
treatment of choice, it is recommended to
those strongly disposed toward trial of
medical treatment that small doses of
chonionic gonadotropin be used for a brief
period: 500-1,000 units twice weekly for
6 weeks. It is agreed by most that
testos-terone has no place in the primary
treat-ment of cryptorchidism.
In view of the uncertainties over the
crucial time for the disencumbrance of the
gonads from their unfavorable
environ-ment in bilateral enyptochidism, it is
diffi-cult not to conclude “the sooner the
better.” Until the question of the critical
age is decided, the practical clinical
ap-proach would favor surgery as early as
possible. Yet any routine of surgical
con-reetion during infancy brings one up
against several important considerations,
some of which have been commented upon
earlier. The fragility and small size of the
gonads and their blood supply in the baby
render them vulnerable to all but relatively
few highly expert and thoroughly seasoned
operators, experienced in the surgery of
young infants. Hence deferral of surgery
until 7 or 8 years of age, as supported by
some clinical and histologic studies, is not
at basic variance with any well-founded
and conclusive evidence at this time.
Dc-ferral much beyond this time would be
unwise. The outcome as concerns
fer-tility will depend upon the basic cause and