A 3-Year-Old Boy with a Unilateral Non-Palpable Testis and a Contralateral Retractile Testis
A 3-year-old boy is referred because the right testis cannot be felt in the scrotum. On examination, the left testis is retractile and can be brought into the scrotum, while the right testis is not palpable in the groin or scrotum. The parents report that the right testis was never seen in the scrotum. Ultrasound reports a right testis in the inguinal canal, but examination under anaesthesia is planned. There is no other comorbidity.
1. How do you evaluate the non-palpable testis, and what is the role of imaging?
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Evaluation: The key distinction is between an impalpable testis (intra-abdominal, inguinal canal, absent, or ectopic) and a retractile testis (which is normal and needs no surgery). Examination in a warm room, with the child relaxed, supine and then cross-legged, is the mainstay; a retractile testis can be milked into the scrotum and stays there.
Imaging: Ultrasound is not routinely indicated for a non-palpable testis because it cannot reliably distinguish an intra-abdominal testis from an absent one and does not change management. The reported inguinal testis on ultrasound is not definitive; if the testis is truly impalpable, the next step is diagnostic laparoscopy, which is the gold standard. It identifies an intra-abdominal testis, allows assessment of the vas and vessels entering the internal ring, and identifies an absent testis (blind-ending vessels) or a vanishing testis.
Examination under anaesthesia is valuable because a retractile testis may descend under anaesthesia, avoiding unnecessary surgery.
Plan: Examination under anaesthesia, and if the testis remains impalpable, laparoscopy. If laparoscopy shows an intra-abdominal testis, proceed to one- or two-stage Fowler-Stephens orchidopexy depending on the distance from the internal ring and the length of the vessels.
2. What are the management options for an intra-abdominal testis, and how do you counsel the family about fertility and malignancy?
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Options:
- One-stage Fowler-Stephens orchidopexy (ligation of the testicular vessels with mobilisation of the testis on the vasal collateral supply) for a testis close to the internal ring with adequate vessel length.
- Two-stage Fowler-Stephens for a higher testis, allowing collateral circulation to develop between stages; this has a higher success rate for high intra-abdominal testes.
- Orchidopexy without vessel ligation if the vessels are long enough to reach the scrotum.
- Orchiectomy if the testis is atrophic, dysgenetic or cannot be brought down; this is considered if the testis is non-viable.
Counselling:
- Fertility: An undescended testis has impaired spermatogenesis, and unilateral orchidopexy improves but does not guarantee fertility; the contralateral testis is usually normal, and most men with a unilateral undescended testis are fertile. The family should understand that earlier surgery (before 1 year, ideally 6-12 months) is associated with better outcomes, and that this child is already 3 years old.
- Malignancy: The risk of testicular germ cell tumour is increased in undescended testes, and orchidopexy facilitates examination and early detection but does not eliminate the risk. The family should be taught testicular self-examination from adolescence.
- Cosmesis and body image, and the need for follow-up into adolescence.
- Contralateral retractile testis: this is normal and does not require surgery, but should be reviewed to ensure it is not a true undescended testis.
- Anaesthetic and surgical risks, including testicular atrophy from vessel ligation.