Cryptorchidism is the congenital absence of a testicle in the scrotum, which includes incomplete testicular descent, testicular ectopic and testicular agenesis. Cryptorchidism refers to a condition in which the testicle does not descend to the bottom of the scrotum after birth and remains somewhere on the way down, including in the abdomen. Insufficient testicular descent is often referred to clinically as cryptorchidism. Cryptorchidism is when the testicle leaves the normal descent pathway and reaches the perineum, femur, suprapubic area, or even inside the opposite scrotum.
Cryptorchidism is when a male infant is born with unilateral or bilateral testes that do not descend into the scrotum but remain anywhere in their normal descent. This means that there is no testicle in the scrotum or only one side has a testicle.
Normally, as the fetus grows and develops, the testes begin to descend from the retroperitoneal lumbar region and descend into the scrotum in the late fetal stage, and if they are obstructed in the descent process, cryptorchidism is formed. Research results show that the chance of cryptorchidism is 1-7%, among which there are more patients with unilateral cryptorchidism than bilateral cryptorchidism, especially the right cryptorchidism is more common. 25% of cryptorchidism is located in the abdominal cavity, 70% stays in the groin, and about 5% stays above the scrotum or other parts.
Symptoms of cryptorchidism can cause adverse consequences if the testicles remain in an abnormal position for a long time.
Cryptorchidism
1. Testicular atrophy: The testicles do not descend into the scrotum, and there are still only mild tissue changes within 2 years after birth, which will cause testicular underdevelopment or atrophy after 2 to 5 years old. Cryptorchidism on both sides can make 90% of patients infertile.
2.Malignant transformation: The risk of malignant transformation in patients with cryptorchidism is 20 to 48 times greater than that of normal intra-scrotal testis; while the risk of malignant transformation of intra-abdominal testis is 5 times greater than that of inguinal testis. The congenital defect of the testis, the abnormal position of the testis and the high temperature of the surrounding area are the reasons for the malignant transformation of the cryptorchid testis.
3. Easy to be traumatized: The testicles are located in the scrotum and have greater mobility, so there is less chance of trauma. The testicles located in the groin, when the abdominal muscle contracts, the inguinal canal also contracts, in which the testicles are squeezed. The testicles in the abdominal cavity are also often squeezed by the change of abdominal pressure.
Testicular torsion: The testicle of cryptorchidism may have abnormal attachment of testicular lead, testicular muscle or testicular sheath, which makes it easy for testicular torsion to occur.
5.Other: About 65% of patients with cryptorchidism have hernia.
6.Empty scrotum may cause inferiority complex, mental distress, and withdrawn temperament.
Etiology
How is cryptorchidism formed? Cryptorchidism is caused by abnormal testicular descent. There are many factors that cause abnormal testicular descent, the common ones are
1.Abnormality or absence of the testicular lead belt that introduces the testicle into the scrotum, so that the testicle cannot descend to the scrotum from its original position.
2, congenital testicular hypoplasia makes the testes insensitive to gonadotropins and loses the power of descent.
3. Luteinizing hormone-releasing hormone produced by the hypothalamus causes the lack of LH and follicle-stimulating hormone FSH secreted by the pituitary gland, which also affects the power role of testicular descent. It has been proved that most of the cases caused by endocrine factors are bilateral cryptorchidism, while most of the cases caused by other factors are unilateral cryptorchidism, and sometimes cryptorchidism can be combined with inguinal hernia.
Classification
The classification of cryptorchidism is based on the cause, the location and the nature of the cryptorchidism.
King classifies cryptorchidism according to the causes of its occurrence as follows.
(1) End organ dysplasia, where the testis is smaller than normal and has a small number of germ cells, often with abnormal ductal structures.
(2) Ectopic testis, in which the testis descends through the inguinal canal but into a location other than the scrotum.
(3) Abnormal gonadotropin stimulation, including endocrine abnormalities syndrome can produce cryptorchidism.
(4) Mechanical factors (e.g., atresia of the inguinal canal).
(5) Abnormal intra-abdominal pressure (e.g. Prune Belly syndrome), where the testis does not descend.
The following classification is generally considered to be more clinically practical.
(1) Retractable testis.
(2) True cryptorchidism.
(1) High intra-abdominal cryptorchidism.
(2) Inguinal cryptorchidism.
(3) High scrotal cryptorchidism.
(4) Sliding cryptorchidism.
(3) Ectopic testis.
(4) Testicular anomaly (unilateral and bilateral anomalies).
Retractable testis means that the testicular levator muscle is too active and the testis can be retracted to a position above the scrotum, but the testis can be placed in the scrotum by hand at night rest and during examination, and the position and size of the testis are normal after puberty in such patients, and the fertility is the same as normal. Ectopic testis means that the testis is located outside the scrotum above the pubic bone, the femur of the thigh, the perineum, the probable root of the penis and transverse ectopic position, which should be corrected by surgery. Ectopic testes are usually caused by torsion of the spermatic cord in the uterus during pregnancy.
Hazards
1.Impact on fertility
Cryptorchidism is because the temperature inside the scrotum is 1.5-2℃ lower than the body temperature of 37℃, and this “low temperature” condition is necessary for the testicles to produce sperm. Cryptorchidism does not have this “low temperature” condition, and the sperm production function is affected, so how can we have children? Of course, if both testicles do not descend into the scrotum, testicular development is blocked, and sex hormones are not secreted enough, sexual function can be affected in the future.
Why does cryptorchidism affect fertility? The testes are the place where human sperm is generated, and the testes are sensitive to temperature. If the testicles cannot reach the scrotum for various reasons and stay in other parts, the temperature and biochemical environment of these parts are not conducive to the growth and development of the testicles, which will make the testicles underdeveloped or not developed at all, and will not be able to play the function of sperm production and cause infertility.
2.Vulnerable to malignant change
Due to the change of growth environment and developmental disorder of cryptorchidism, the testicular cells will become malignant and form malignant tumor, and the possibility of cancer is 35 times higher than that of normal testicles.
3.Prone to injury
Since the testicles are hidden above and superficially located, they are easily damaged by slight impact or trauma, resulting in pain.
4.Psychological disorder
The absence of testicles in the scrotum of cryptorchidism and the change in the shape of external genitalia can make patients have low self-esteem and be reluctant to go to public bathrooms, resulting in psychological abnormalities.
Parents should pay enough attention to boys with cryptorchidism. When the child is still young, they should check whether the testicles in the scrotum are normal, and if there is cryptorchidism, they should be treated early. After examination, if it is proved to be a manifestation of so-called “cryptorchidism”, surgical treatment or non-surgical treatment with medication is available.
Some people have observed through electron microscope and found that 87.7% of people with cryptorchidism operated before the age of 2 have normal fertility in adulthood, while only 57.1% of people operated at the age of 3 to 4 have normal fertility. The older the age, the lower the fertility after surgery. Therefore, the best time for surgery should be around 2 years old, otherwise it will affect the function of testes and cause irreversible damage, which will affect the fertility after marriage.
Examination
Patients with cryptorchidism often come to the clinic because the scrotum is empty and there is no testicle inside. There are also patients who come to the clinic with the complaint of “hernia”, or come for examination because of bilateral cryptorchidism and infertility after marriage. The diagnosis is usually not difficult. However, the differentiation between cryptorchidism, where the testicles cannot be felt, and absence of testicles should be taken seriously, because the latter does not require surgery.
If the patient has XY chromosome, elevated serum follicle stimulating hormone (FSH), decreased serum testosterone (T), and the level of testosterone does not respond to chorionic gonadotropin (HCG) stimulation, the patient has bilateral testicular agenesis (i.e., no testes) and does not require surgical exploration.
For unilateral testicular agenesis, which is difficult to diagnose preoperatively, hormone tests are normal. Gonadal venography, laparoscopy, ultrasound, and CT scan may be helpful for diagnosis, and surgical exploration is still needed if necessary.
Treatment
Parents of cryptorchidism should go to the hospital as soon as they notice that your child has no testicles in the scrotum or only one side of the testicles. For children within one year old, it is possible to make the testicles descend into the scrotum through the application of some drugs. If they still cannot descend into the scrotum at the age of two, surgery should be considered. Therefore, cryptorchidism descent fixation should be performed before the age of two. Many patients with cryptorchidism come to the clinic because of infertility, and it can be said that almost all of them are incurable in terms of fertility. When they know that their infertility cannot be treated, they often show infinite regret and self-blame, and sometimes they complain that their parents have ruined their lives. In fact, if the parents had found out that their child had cryptorchidism early and treated it in time, there would not have been such a result. But where can we buy the medicine for regret? I would like to advise parents of children with cryptorchidism to take their son to a specialist at an early stage in order to prevent him from becoming a child with infertility in the future.
Treatment method
Cryptorchidism patients may have their testicles descend into the scrotum on their own within 1 year of age, so endocrine therapy can be used during this period. For 10-month-old children, Crgptocur, a luteinizing hormone-releasing hormone (LHRH) preparation, can be used at 0,2 ng 3 times a day. If the testis still does not drop, chorionic gonadotropin (HCG) can be administered twice a week by intramuscular injection for four to five weeks. For adolescent patients with cryptorchidism, testicular descent fixation should be performed as soon as it is detected. If the testicle is found to be atrophied or cannot descend into the scrotum, orchiectomy can be performed if necessary. Is surgery also necessary for unilateral cryptorchidism? Unilateral cryptorchidism patients have one testicle located in the scrotum. In the past, it was thought that the spermatogenic function of this testicle settled in the scrotum was normal and thus would not affect fertility. On the other hand, the undescended testicles may also become malignant under the high temperature environment, so it is easy to see that unilateral cryptorchidism patients should be treated in time.
Issues to be noted in the treatment of cryptorchidism
Cryptorchidism: The descent of testes and epididymis is very important for the normal development of testes and sperm production. xY genes are important genes for male sexual characteristics and testes formation. Endocrine, genetic and physical-mechanical factors can affect the normal descent of the testes.
About 3% of male newborns have “cryptorchidism”, and up to 30% of premature babies. However, most of the affected children will have their testicles descend into the scrotum within a few months or a year after birth under the effect of endocrine factors, and the incidence of cryptorchidism decreases to 0.8% by the age of 1 year. If drug treatment is not effective, surgical treatment can be performed within 2 years of age under the guidance of a doctor.
The following aspects should be noted in the diagnosis and treatment of cryptorchidism.
(1) All male newborns must be examined for the presence of cryptorchidism.
(2) The most accurate examination is in the sitting position with the legs flexed.
(3) If a child with cryptorchidism shows signs of mental retardation, he should also be examined for related genetic and endocrine abnormalities.
(4) Treatment with human chorionic gonadotropin can be used after 1 year of age.
(5) If endocrine therapy is ineffective, reliable surgical treatment at 2 weeks of age is indicated to free and deliver the spermatic cord, repair the memory hernia sac, and fix the testis in the scrotum.
(6) After surgical treatment, follow-up should be done once a year until puberty.
Prevention
Parents of boys with cryptorchidism should check their children’s scrotum carefully. Generally, peanut-sized testicles can be molded on both sides of the scrotum and have a physical feeling when touching. If the scrotum is empty and the testicles cannot be felt, or if there is only one, the child should go to the hospital immediately. At present, it is believed that surgical treatment of cryptorchidism can be performed after the age of 2, and no later than the age of 10, otherwise it may affect the function of sperm.
Once a child is found to be cryptorchid, he or she must be treated immediately at a specialist in a regular hospital. The methods of treatment include medication and surgery, but whatever the treatment method is, it must be carried out within the child’s two years of age, because the testicular tissue of the child will undergo pathological changes beyond the age of two.
Complications
Cryptorchidism and infertility. Cryptorchidism has no normal spermatogenic function due to histopathological changes. the higher the position of cryptorchidism and the longer it is above the scrotum, the greater the damage to the testicular varicocele. by Mengel’s observation with a general microscope and electron microscope, patients with cryptorchidism have pathological changes of the varicocele and interstitial cells and significant spermatogenic damage in the testis before the age of 2. Hecker’s examination of normal adults and unilateral Hecker examined the sperm concentration of normal adults and unilateral cryptorchidism patients after testicular fixation, and the former was significantly higher than the latter, indicating that unilateral cryptorchidism patients had bilateral cryptorchidism damage. In untreated patients with bilateral cryptorchidism, infertility can reach 100%, and if early treatment is given, fertility can reach 40%. While unilateral cryptorchidism can reach 60% fertility after early treatment. Treatment of patients before the age of 2 years helps to improve the development of spermatogonia and increase the number of spermatogonia and subsequent spermatogenesis. Patients with unilateral and bilateral cryptorchidism have lower than normal spermatogenic capacity in adulthood despite early treatment.
Cryptorchidism and testicular torsion, because there is often abnormal development between the testicle and the tether in cryptorchidism patients, testicular torsion is prone to occur. Rigter reported that 64% of adult cryptorchid testicular torsion occurs due to malignant changes in the testis, resulting in changes in testicular weight and testicular gravitational axis. The treatment principle is testicular fixation or orchiectomy if needed.
Physiological cryptorchidism: no treatment is required.