Acquired Cryptorchidism in Children

Definition and Diagnosis

• The American Academy of Pediatrics recommends that testes which cannot be manipulated into the scrotum and kept there without traction at 15 months require surgical referral because these testes will not spontaneously descend and face the same fertility and cancer risks as congenital undescended testes 1, 2, 3
• Acquired cryptorchidism (secondary ascent) is a previously descended testis that has ascended and cannot be manipulated back into the scrotum, which is what "getting stuck" means 1, 2, 4

Risk Factors and Complications

• Retractile testes carry a 2-45% risk of becoming truly undescended (secondary ascent) during childhood, which is mechanistically related to hyperactive cremasteric reflex, foreshortened patent processus vaginalis, or entrapping adhesions 1, 2, 3, 5
• Germ cell damage begins after 15-18 months, with progressive loss of fertility potential 1, 3, 5

Management and Treatment

• The American Academy of Pediatrics recommends that if the testis cannot be manipulated into the scrotum and kept there without traction at 15 months, refer immediately to a pediatric urologist or pediatric surgeon for orchiopexy 1, 3, 4
• Orchiopexy should ideally be performed by 18 months to preserve fertility potential 1, 3, 5

Follow-up and Surveillance

• Even with successful orchiopexy, the child will need lifelong surveillance for testicular cancer, with a relative risk 2.75-8 times higher, though prepubertal orchiopexy reduces this risk 2-6 fold compared to postpubertal surgery 1, 3

Diagnosis and Management of Retractile Testis

Key Characteristics and Diagnostic Features

• The American Urological Association notes that a retractile testis can be easily manipulated into the scrotum and remains there without traction, distinguishing it from true cryptorchidism 6, 7
• The testis is palpable in the inguinal canal, which is a key feature of retractile testis, as noted by the American Urological Association 6, 7
• Represents a hyperactive cremasteric reflex pulling the testis upward, according to the American Urological Association 6, 7

Differential Diagnosis

• True undescended testes cannot be easily manipulated into the scrotum or do not remain there, as distinguished by the American Urological Association 6, 7
• In cryptorchidism, the testis is arrested along the path of descent and requires surgical intervention, as noted by the American Urological Association 6 and other guidelines 8

Management Approach

• Annual monitoring is required because retractile testes carry a risk of becoming truly undescended during childhood, as recommended by the American Urological Association 6, 7
• Assess testicular position at least annually at well-child visits to monitor for secondary ascent, as advised by the American Urological Association 6, 7

Important Clinical Considerations

• The American Urological Association recommends against ordering imaging studies, as they rarely assist in decision-making 6, 7, 8

Management of Retractile Testes

Diagnosis and Monitoring

• The American Academy of Pediatrics recommends that a 9-month-old with retractile testes should be monitored annually to detect secondary ascent, as the risk of secondary ascent is 2-45% during childhood 9
• The critical germ cell damage that occurs with true cryptorchidism begins after 15-18 months of age, so there is no urgency for intervention in truly retractile testes at this age 9
• Annual assessment is mandatory because retractile testes carry a risk of secondary ascent, which is mechanistically related to hyperactive cremasteric reflex, foreshortened patent processus vaginalis, or entrapping adhesions 9

Treatment

• Hormonal therapy (hCG or GnRH) should not be used, as evidence shows low response rates (6-38% success) and lack of long-term efficacy 9
• If secondary ascent occurs, surgery should be performed by 18 months of age to preserve fertility potential and reduce cancer risk, although the exact timing may vary depending on individual circumstances 9

Management of Testicular Retraction in Infants

Initial Evaluation

• The American Academy of Pediatrics recommends examining the infant in a warm room with warm hands to minimize cremasteric reflex activation, and to attempt to manipulate each testis into the scrotum and observe whether it remains there without traction 10
• If both testes are completely nonpalpable, immediate specialist consultation is mandatory to rule out disorders of sex development, particularly life-threatening congenital adrenal hyperplasia, as recommended by the American Academy of Pediatrics 10, 11

Diagnostic Approach

• Imaging studies such as ultrasound should not be ordered, as they rarely assist in decision-making and have poor sensitivity (45%) and specificity (78%) for nonpalpable testes, according to the American Urological Association 10, 11

Management Based on Findings

• The American Academy of Pediatrics recommends instituting annual monitoring at well-child visits to assess for secondary ascent (acquired cryptorchidism) if retractile testes are confirmed 10
• Hormonal therapy (hCG or GnRH) should not be used, as evidence shows low response rates (6-38%) and lack of long-term efficacy, as stated by the American Urological Association 10

Common Pitfalls to Avoid

• Failing to distinguish retractile from truly undescended testes leads to unnecessary imaging and delayed appropriate management, as warned by the American Academy of Pediatrics 10
• Ordering ultrasound wastes resources and provides no actionable information in most cases, according to the American Urological Association 10, 11
• Missing bilateral nonpalpable testes as a potential disorder of sex development can result in life-threatening adrenal crisis, as emphasized by the American Academy of Pediatrics 10, 11

Management of Retractile Testes in Early Childhood

Diagnostic Imaging

• Ultrasound can demonstrate normal testicular echotexture and the ability of the testes to slide into and remain within the scrotum, confirming a retractile (not undescended) testis. The American Urological Association notes that imaging is rarely needed because it has only ≈ 45 % sensitivity and ≈ 78 % specificity for locating non‑palpable testes. 12

• Routine repeat ultrasonography is not recommended for follow‑up of retractile testes; serial clinical examinations are more reliable for detecting secondary ascent. 12

Monitoring Recommendations

• The American Urological Association mandates an annual assessment of testicular position at well‑child visits to screen for secondary (acquired) ascent. Examination should be performed in a warm environment, with the child examined in multiple positions and each testis gently manipulated into the scrotum to verify that it remains without traction. 13

• Retractile testes carry a reported 2 %–45 % risk of becoming truly undescended during childhood, a process linked to a hyperactive cremasteric reflex, a short patent processus vaginalis, or entrapping adhesions. 13

Indications for Surgical Intervention

• If, during annual monitoring, a testis can no longer be brought into the scrotum and held there without traction, immediate referral to a pediatric urology/surgical specialist for orchiopexy is indicated. Surgery should be performed by ≈ 18 months of age (or as soon as possible thereafter) to preserve fertility and reduce malignancy risk.

• Orchiopexy performed before puberty decreases the risk of subsequent testicular cancer by approximately 2‑ to 6‑fold compared with surgery after puberty. This recommendation is supported by the American Urological Association. 14

Hormonal Therapy

• The American Urological Association advises against the use of hormonal therapy (hCG or GnRH) for retractile or undescended testes, citing low short‑term success rates (≈ 6 %–38 %) and a lack of proven long‑term benefit. 13

Long‑Term Counseling for Families

• Parents should be counseled that annual monitoring must continue throughout childhood until puberty. 13

• If orchiopexy becomes necessary, the child will require lifelong surveillance for testicular cancer, with a relative risk estimated at ≈ 2.8‑8 times that of the general population. 14

• After puberty, the child should be taught monthly testicular self‑examination to facilitate early detection of malignancy. 14