Undescended testicles (cryptorchidism)

An undescended testicle is one that is not in the scrotum because it stopped part way along the journey it should have completed before birth: in the inguinal canal, or higher up inside the abdomen. It is one of the commonest things boys are born with, and it happens considerably more often in babies born early. The word "cryptorchidism", which is what doctors call it, sounds alarming, but behind it lies a straightforward and very solvable problem. The main thing for parents to know is this: in some boys it sorts itself out during the first months, and if it does not, there is a simple planned operation — done not "at some point later" but at a particular age, and there are reasons for that.

How it is spotted

Most often a doctor finds it during the newborn examination in the first days of life, and it is then checked again at the routine appointments of the first year. Parents can perfectly well notice it too: one side of the scrotum looks empty and smaller, and no round, mobile lump can be felt inside it.

If you want to check yourself, do it somewhere warm and unhurried — in a warm bath or straight afterwards, when your baby is relaxed. Your hands need to be warm, because cold and touch make the muscle draw the testicle upwards, and on a chilly changing mat you may fail to find something that is actually in place. Feel gently over both sides of the scrotum.

Do not try to make the diagnosis yourself, and certainly do not try to move anything into place. The point of checking at home is different: to notice that one side is missing and tell a doctor. It is then for the doctor to work out exactly where the testicle is, whether it can be felt in the groin, and whether one side or both are affected — all of which determines what happens next and how quickly.

Why it happens

The testicles form inside the baby's abdomen and move down into the scrotum towards the end of pregnancy. The reason for that journey is simple: the scrotum is a couple of degrees cooler than the inside of the body, and that is precisely the temperature sperm will need later on in order to mature normally. Sometimes the journey is left unfinished and a testicle stops along the way.

In any individual case the exact cause usually cannot be named. What is known are the circumstances in which it happens more often: being born early (the testicles simply did not have time to descend), a low birth weight, and the same thing having happened to the father or a brother. Occasionally it forms part of a wider picture linked to hormonal or genetic differences; a doctor pays particular attention to that if neither testicle has descended or if there are other unusual findings.

It is worth saying separately what is not on that list: nothing the mother did during pregnancy, nothing about how the birth went and nothing about how the baby has been cared for leads to this. It is a feature of development, not anyone's oversight.

Retractile testicle: a common cause of needless worry

Before worrying, one situation has to be ruled out that needs no treatment at all. Young boys have a well-developed reflex in which a muscle pulls the testicle up into the groin in response to cold, to fright or to being touched. Such a testicle is called retractile, meaning that it draws itself up.

The difference is simple: a retractile testicle can be gently brought down into the scrotum and stays there at least for a while before going back up on its own. An undescended one either does not come down into the scrotum at all or shoots straight back. A retractile testicle is a normal variant, needs no treatment, and by school age the reflex weakens and it stops hiding.

It is this reflex that frightens parents for nothing: in the evening bath both testicles are there, and next morning on a cool changing mat one has gone. Telling the two situations apart is the doctor's job, done by examination in a warm room and without hurry. Even so, a retractile testicle is worth showing at the routine checks: very occasionally it stops descending as time goes on, and then the approach changes.

Will it come down by itself, and why waiting too long is a bad idea

In a good proportion of boys the testicle descends on its own during the first months of life and no treatment is needed at all. That is why there is usually no rush straight after birth: the baby is simply kept under review at the routine appointments.

But if it has not happened during those first months, waiting longer gains almost nothing while time slips away. After about six months spontaneous descent is uncommon, and surgery is then planned. The standard approach is to carry it out during the first or second year of life, most often before eighteen months; the exact age is set by the paediatric surgeon or urologist.

Why that way, rather than "let us wait until he is older"? There are two reasons and both are practical. The first: testicular tissue left outside the scrotum, at the higher temperature inside the body, gradually changes, and the longer that continues the more the future ability to father children suffers; an operation done in good time prevents those changes. The second: a testicle sitting in the scrotum can be looked at and felt, which means anything going wrong with it can be picked up early. While it stays hidden in the groin or abdomen, no such monitoring is possible.

So if a doctor says "we will review until such and such an age and then operate", that is not putting things off — it is a timetable. Write down the date of the next appointment and keep it.

The operation: what it involves

The operation is called orchidopexy. The surgeon finds the testicle, frees it from whatever is stopping it descending, brings it into the scrotum and secures it there. It is a planned, well-established procedure done under general anaesthetic, and most children go home the same day or the next.

If the testicle can be felt in the groin, a small incision is usually enough. If it cannot be felt at all, a laparoscopy is done first — an inspection through a tiny cut — to find the testicle inside the abdomen and decide how to proceed; sometimes the treatment is split into two stages. It is worth knowing about another possibility too: occasionally it turns out that there is no testicle on that side, or that it never developed, and the surgeon will explain straight away what that means for the child.

Recovery is usually easy. There may be some discomfort for a few days, managed with the usual children's painkillers at the dose for the child's age; for a couple of weeks, rough games, sit-on toys and anything that presses on the groin are avoided. Contact a doctor sooner than planned if the child develops a temperature, if the wound reddens or discharges, if the scrotum swells markedly or if the child is unusually distressed. A follow-up check is then needed, at which the doctor confirms that the testicle has stayed where it was fixed and is growing normally.

Adult life: fertility, tumour risk and the habit of checking

All of this is better known calmly and in advance than stumbled upon and found frightening.

As for having children, most men who were operated on in good time for a single undescended testicle go on to do so in the ordinary way. Where both testicles were affected, the likelihood of difficulty conceiving is higher — but that is a likelihood and not a verdict, and in adulthood it is checked with a simple semen test.

The second point: an undescended testicle carries a raised risk of testicular tumour later in life. Proportion matters here. Testicular tumour is a rare disease, and even a raised risk remains a small one; on top of that, it is among the cancers that respond best to treatment, particularly when found early. Surgery in childhood does not remove the risk altogether, but it puts the testicle back where it can be examined — and examination is the main tool of early detection.

From that comes a practical point worth passing on to a son as he grows up: the habit of checking his own scrotum once a month. It is done in a warm shower, rolling each testicle gently between the fingers and getting to know its usual size and firmness. Reasons to see a doctor are a painless lump or nodule, a change in size or firmness, a feeling of heaviness, or a dull ache low in the abdomen and in the scrotum. This is worth saying without alarm: it is as ordinary a habit as brushing your teeth, and it takes a minute.

When to call an ambulance

Everything above describes situations that can be planned, where there is time to think and to book an appointment. There is one where there is not.

If a testicle that was in place suddenly disappears from the scrotum and severe pain and swelling appear in the groin or scrotum, this is an emergency. Call an ambulance (in Spain, Italy, Portugal, Poland and Ukraine the single number 112 is in use) or take the child straight to the emergency department. That is how testicular torsion and entrapment present; both cut off the blood supply, and the margin is measured in hours — the sooner the child reaches a surgeon, the better the chance of saving the testicle.

What else to look for in that situation: the skin of the scrotum turning red or dusky, the child crying and refusing to be touched, sometimes vomiting, and in a baby unexplained intense distress and refusal to feed. Teenagers are sometimes too embarrassed to mention pain there and put up with it — it is worth talking to your son about this beforehand and making clear that this is not something to keep quiet about. Do not give the child anything to eat or drink until a doctor has examined him, because an urgent operation may be needed. And do not wait for it to pass: pain easing off does not always mean the danger has gone, and a doctor should see him either way.

Online consultation

This is exactly the sort of subject where parents need fewer investigations and more calm explanation. An online consultation is a good place to work out what is actually being talked about when the word "cryptorchidism" turns up in a report, to grasp the difference between an undescended and a retractile testicle, and to find out what "we will keep an eye on it" means and up to what age it applies in your case.

Remotely it is also convenient to prepare for the surgical appointment: which questions to ask, what to clarify about the anaesthetic and the timing, how to explain what is going to happen to the child himself, what is normal in the first days after the operation and what is already a reason to ring the doctor. The doctor can also show you how to check the scrotum at home and what to watch for as your son grows up. Do bear in mind, though, that telling an undescended testicle from a retractile one can only be done by hand, at an examination — and that severe pain with swelling in the scrotum calls for an ambulance rather than a consultation.

This material is for information only and does not replace medical advice.