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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 of

eryptonchidism 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-have

undeseended 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

(2)

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

(3)

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

(4)

1965;36;786

Pediatrics

Alfred M. Bongiovanni

DIAGNOSIS AND TREATMENT: THE UNDESCENDED TESTICLE

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(5)

1965;36;786

Pediatrics

Alfred M. Bongiovanni

DIAGNOSIS AND TREATMENT: THE UNDESCENDED TESTICLE

http://pediatrics.aappublications.org/content/36/5/786

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American Academy of Pediatrics. All rights reserved. Print ISSN: 1073-0397.

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