Guideline Recommendations for Management of Undescended Testis in Newborns

Initial Clinical Assessment

• A thorough physical examination (palpable vs. non‑palpable; unilateral vs. bilateral) is the only essential evaluation; imaging or laboratory tests are not indicated. European Association of Urology / European Society for Paediatric Urology (EAU/ESPU) 2025 guideline 1
• Obtain a focused medical history that includes gestational age, because the prevalence of undescended testis (UDT) ranges from 1.0–4.6 % in full‑term infants to 1.1–45 % in preterm infants. EAU/ESPU 2025 guideline 2
• Classification of the testis as palpable versus non‑palpable determines the entire surgical approach. EAU/ESPU 2025 guideline 1
• Document whether the involvement is unilateral or bilateral. EAU/ESPU 2025 guideline 1

Imaging Studies – What to Avoid

• Ultrasound, CT, and MRI provide no additional benefit in the newborn period and should not be performed before referral. EAU/ESPU 2025 guideline and American Urological Association (AUA) 2014 guideline [1][3]
• Imaging “rarely assists in decision‑making” and does not change clinical management. AUA 2014 guideline 3
• Use of imaging delays definitive surgical treatment and has poor sensitivity and specificity for locating non‑palpable testes. AUA 2014 guideline 3
• Approximately 70 % of cryptorchid testes are palpable on examination by an experienced provider, making routine imaging unnecessary. AUA 2014 guideline 3

Red‑Flag Findings Requiring Immediate Specialist Consultation (DSD Evaluation)

• Bilateral non‑palpable testes in a phenotypic male newborn mandate urgent specialist referral to exclude disorders of sex development, especially congenital adrenal hyperplasia (CAH). AUA 2014 guideline 3
• CAH can present as a phenotypic male with bilateral cryptorchidism; missed diagnosis may lead to life‑threatening electrolyte disturbances (hyponatremia, hyperkalemia, shock). AUA 2014 guideline 3
• Circumcision should be deferred until a DSD work‑up is completed. AUA 2014 guideline 3
• Evaluation should include measurement of anti‑Müllerian hormone and other hormone assays to assess for anorchia. AUA 2014 guideline 3
• The presence of hypospadias, micropenis, or other phallic anomalies together with UDT also triggers immediate DSD evaluation. AUA 2014 guideline 3

Timing of Referral and Surgical Intervention

• Newborns with UDT that have not descended spontaneously by 6 months corrected age should be referred to a pediatric urologist or pediatric surgeon. AUA 2014 guideline 3
• Testes remaining undescended after 6 months corrected age are extremely unlikely to descend spontaneously. EAU/ESPU 2025 guideline and AUA 2014 guideline [1][3]
• Progressive germ‑cell loss and Leydig‑cell diminution begin after 6 months, with histologic damage evident by 12–18 months. EAU/ESPU 2025 guideline 2
• Orchidopexy should be initiated at 6 months of age and completed by 12 months, with 18 months as the absolute latest. EAU/ESPU 2025 guideline 1
• Early surgery mitigates the increased risks of impaired fertility and testicular cancer associated with UDT. EAU/ESPU 2025 guideline 2

Hormonal Therapy

• Hormonal treatment is not recommended as primary therapy for inducing testicular descent. EAU/ESPU 2025 guideline 1
• The 2025 EAU/ESPU guideline states that hormone therapy appears to have no benefit regarding descent. EAU/ESPU 2025 guideline 1
• Although some studies suggest hormonal therapy might improve fertility indices as an adjunct to orchidopexy, it should not be used as a standalone treatment. EAU/ESPU 2025 guideline 1

Acquired Cryptorchidism

• When a testis that was previously in the scrotum later ascends (acquired cryptorchidism), the same adverse histologic changes occur as in congenital UDT, requiring timely surgical referral. AUA 2014 guideline 3
• Acquired cryptorchidism has a prevalence of 1–7 %, with a peak incidence around 8 years of age. AUA 2014 guideline 3

Management of Undescended Testis in Newborns

Initial Assessment

• The newborn should be observed until 6 months corrected age; if the testis has not descended, a referral to pediatric urology for orchidopexy should be made, with surgery completed by 12 months (absolute latest 18 months)【4】.
• A thorough physical examination that classifies the testis as palpable vs. non‑palpable determines the entire subsequent surgical strategy【4】.
• Undescended testis occurs in ≈1.0–4.6 % of full‑term infants and ≈1.1–45 % of pre‑term infants; timing recommendations are based on corrected gestational age, not chronological age【4】.

Timing of Referral and Surgery

• If the testis remains undescended at 6 months corrected age, the infant should be referred to pediatric urology or pediatric surgery, and definitive treatment should be initiated at that time because spontaneous descent after this age is exceedingly rare【4】.
• Orchidopexy must be completed by 12 months of age, with 18 months being the absolute latest deadline【4】【5】.
• Histologic studies demonstrate progressive loss of germ cells and Leydig cells between 12 and 18 months in undescended testes, underscoring the need for early intervention【4】【5】.
• Performing orchidopexy before 12 months reduces the heightened risks of impaired fertility and testicular cancer associated with undescended testes【4】.

Hormonal Therapy

• Hormonal therapy is not recommended as primary treatment for inducing testicular descent【4】【5】.
• Available evidence shows no benefit of hormonal agents for achieving descent【4】【5】.
• While some studies suggest hormonal therapy may modestly improve fertility indices when used as an adjunct to orchidopexy, it should not be used as a standalone therapy【5】.

Surgical Approach

Palpable Testes

• The standard approach is an inguinal or scrotal orchidopexy【4】【5】.
• Re‑examination under general anesthesia is essential because a previously non‑palpable testis may become identifiable, which can alter the planned surgical technique【4】【5】.

Non‑palpable Testes

• Diagnostic laparoscopy is the optimal method for locating intra‑abdominal or non‑palpable testes【4】【5】.

• After localization, orchidopexy can be performed laparoscopically or via an inguinal approach【4】【5】.
• For intra‑abdominal testes that require staged repair, the Fowler‑Stephens or Shehata techniques are most commonly employed【4】【5】.

Long‑Term Risks Without Treatment

• Undescended testis is linked to compromised fertility due to germ‑cell loss, impaired germ‑cell maturation, Leydig‑cell diminution, and testicular fibrosis【4】【5】.

Timing and Management of Inguinal Undescended Testis

Referral and Diagnostic Evaluation

• In infants whose testis remains undescended after 6 months corrected age, spontaneous descent is extremely unlikely, and immediate referral to pediatric urology is recommended. 6
• Approximately 70 % of cryptorchid testes are palpable on physical examination by an experienced clinician, making routine imaging unnecessary. 6
• Ultrasound, CT, and MRI provide no clinical benefit before or after referral for an inguinal testis; they have poor sensitivity and specificity, delay definitive treatment, and do not influence surgical planning. 6
• Bilateral non‑palpable testes should trigger urgent evaluation for disorders of sex development, particularly congenital adrenal hyperplasia. 6

Surgical Timing

• Orchiopexy is the definitive treatment for an undescended testis located in the inguinal canal and should be performed between 6 – 12 months of age, with 18 months as the absolute latest deadline to preserve fertility potential and reduce cancer risk. 6
• The recommended algorithm:

Risks of Delayed Intervention

• Testicular cancer risk is elevated in undescended testes; early orchiopexy reduces—but does not eliminate—this risk. 6
• Testicular torsion occurs more frequently in undescended testes, underscoring the need for timely surgical correction. 6
• Inguinal hernias are commonly associated with undescended testes and are typically addressed during orchiopexy. 6

Special Clinical Scenarios

• Retractile testes may progress to acquired cryptorchidism; they require the same timely surgical intervention as congenital undescended testes. 6

Post‑Operative Follow‑Up and Counseling

• Long‑term follow‑up is essential to monitor testicular size, position, and to screen for malignancy after orchiopexy. 6
• Patients and families should receive counseling regarding residual fertility and cancer risks even after successful surgery. 6

Guideline Summary for Management of Undescended Testes

Congenital Undescended Testis

• Spontaneous descent occurs primarily within the first 6 months of corrected age; after this window further descent is extremely unlikely. 7
• Testes that remain undescended beyond 6 months corrected age will not descend spontaneously and require referral for surgical correction. 7
• If a congenital undescended testis descends into a stable scrotal position before 6 months, observation without surgery is appropriate, with continued monitoring at routine well‑child visits to confirm stability. 7
• For testes still undescended at 6 months corrected age, immediate referral to pediatric urology for orchiopexy is recommended, ideally performed between 6–12 months and no later than 18 months. 7
• Observation beyond 6 months corrected age is not advised because spontaneous descent will not occur and progressive testicular damage begins. 7

Acquired Cryptorchidism

• Acquired cryptorchidism is defined as a testis documented in the scrotum at birth that later ascends and cannot be manually positioned in a stable scrotal location. 7
• The condition affects approximately 1–7 % of children, with a peak incidence around 8 years of age. 7
• Histologic changes (germ‑cell loss, Leydig‑cell diminution) are identical to those seen in congenital undescended testes, indicating the need for timely surgical correction. 7
• When diagnosed before puberty, referral to pediatric urology for evaluation and likely orchiopexy is recommended. 7

Clinical Pitfalls

• Retractile testes can be manually manipulated into a stable scrotal position without tension and do not require surgery unless they become truly acquired cryptorchidism. 7
• A testis documented in the scrotum at birth should not be assumed to remain there; acquired cryptorchidism can develop and warrants the same surgical intervention as congenital cases. 7

Special Considerations

• Bilateral non‑palpable testes in a phenotypic male newborn mandate immediate specialist consultation to exclude disorders of sex development, particularly congenital adrenal hyperplasia. 7
• Circumcision should be deferred until a complete disorder‑of‑sex‑development workup is completed. 7