Undescended Testicles: Steps to Follow Prior to Urology Referral

Column Author: Lacy Dillon, APRN | Nurse Practitioner, Urology

Column Editor: Chris Day, MD | Pediatric Infectious Diseases; Director, Transplant Infectious Disease Services; Medical Director, Travel Medicine; Assistant Professor of Pediatrics, University of Missouri-Kansas City School of Medicine; Clinical Assistant Professor of Pediatrics, University of Kansas School of Medicine

Undescended testicles (cryptorchidism) and retractile testicles are reasonably common findings in the primary care setting. The prevalence of retractile testicles in school age boys is estimated to be between 4% and 13%.¹ The true incidence of undescended testicles, after the third month of life when they are most likely to spontaneously descend, is about 1%.² Testicles that are undescended cannot be brought down into the scrotum and are often felt within the inguinal canal. Retractile testicles can be brought down into the scrotum by manipulation but retract into the inguinal canals by cremasteric contraction.¹

American Urological Association (AUA) guidelines suggest that primary care providers should palpate for quality and position of the testes at every well-child visit.³ To ensure that undescended testicles are properly identified, it is important to get a good scrotal exam. When testicles cannot be easily seen or palpated in the scrotum, it is helpful to assess for retractile versus undescended testicles. Sweep down from the anterior iliac spine along the inguinal canal with one hand to see if the testicle can be palpated within the inguinal canal and manipulated into the scrotum. If it can and the testicle does not quickly return to the inguinal canal, then this testicle is retractile and not undescended. It is often helpful to hold the testicle in the scrotum for some time to fatigue the cremasteric muscle and decrease the retractability of the testicle.¹ Retractile testicles are a variant of normal. AUA guidelines recommend yearly scrotal exams for children with retractile testicles to assess for secondary ascent.³ If the testicle cannot be manipulated into the scrotum or if it quickly returns to the inguinal canal even after an attempt to fatigue the cremasteric muscle, it is likely undescended. This condition will require further evaluation by urology.

Scrotal ultrasounds are not recommended prior to referral. Ultrasound is not helpful in routine use: sensitivity and specificity to localize nonpalpable testicles are 45% and 78% respectively. The data also show that in boys with a nonpalpable testicle and a negative ultrasound 49% will ultimately be shown to have an intraabdominal testicle. If testicles cannot be palpated or are palpated but cannot be brought down into the scrotum easily, a referral to urology is warranted and no imaging needs to be obtained prior to the referral. Patients with undescended testicles should be referred as soon as possible and within six months of discovery. Infants with undescended testicles should be referred if the testicle has not descended by 6 months of age as it is unlikely to descend after this age.³ If the infant has bilateral non-palpable testicles, an early evaluation for a possible disorder of sexual development is needed.²

In summary:

• Scrotal exams should be performed at all well-child checks to ensure testicles are descended.
• Any undescended testicles that persist after 6 months of age are unlikely to descend spontaneously and need to be referred to urology.
• Scrotal ultrasounds are not needed prior to a urology referral for undescended testicles.
• When in doubt, refer to urology or reach out to us for a consult.

References: 

1. La Scala GC, Ein SH. Retractile testes: an outcome analysis on 150 patients. J Pediatr Surg. 2004;39(7):1014-1017. PMID: 15213889. doi:10.1016/j.jpedsurg.2004.03.057
2. Leslie SW, Sajjad H, Villanueva CA. Cryptorchidism. StatPearls. Updated November 28, 2022. https://www.ncbi.nlm.nih.gov/books/NBK470270/
3. Kolon TF, Herndon CD, Baker LA, et al; American Urological Association. Evaluation and treatment of cryptorchidism: AUA guideline. J Urol. 2014;192(2):337-345. PMID: 24857650. doi:10.1016/j.juro.2014.05.005
4. Sheldon CA. The pediatric genitourinary examination: inguinal, urethral, and genital diseases. Pediatr Clin North Am. 2001;48(6):1339-1380. PMID: 11732121. doi:10.1016/s0031-3955(05)70382-5