(Author’s note: With the development of medicine, the understanding and treatment views of cryptorchidism are changing both at home and abroad. Here the relevant knowledge is updated in order to help parents.)
Cryptorchidism, or incomplete testicular descent, is a very common congenital disorder of the reproductive system in children. Children with cryptorchidism are usually painless and seemingly harmless, but it affects the quality of life in the future. Therefore, we remind parents that when you find or suspect that your child has a problem in this area, you should see a pediatric urologist, who will determine the condition and develop a treatment plan. Here, answers are given to the questions that often bother parents of pediatric patients.
I. What are the signs of cryptorchidism?
The testicles cannot be felt on one or both sides of the scrotum and are empty. Often you can see that the scrotum is poorly developed, flattened, or asymmetrical on the left and right side. However, it is not the case that no testicle can be felt in the scrotum is cryptorchidism, other diseases with similar manifestations include ectopic testicle, sliding testicle, epithelial testicle, and testicular agenesis. This requires careful examination and diagnosis by an experienced urologist.
Second, how does cryptorchidism occur?
During the embryonic period, the testicles are first located at the level of the lower kidney in the lumbar region. Starting from the seventh month of pregnancy, it gradually moves down along the retroperitoneum, through the groin and finally reaches the scrotum. If this descent process occurs abnormally, the testicle stays at a certain position on the way, which is pathological. Therefore, cryptorchidism is also called incomplete testicular descent or undescended testicle.
What causes the testicles to fail to descend normally?
Modern medical research has found that cryptorchidism is related to the following factors.
①Endocrine abnormalities during the embryonic period, including maternal hormone abnormalities, or the use of certain hormone drugs, or certain pollutants in the environment (called environmental hormones).
②Mechanical factors: such as abnormalities of the testicular lead, local adhesions in the groin, etc.
(iii) Abnormal development of the testes themselves.
④Some patients have genetic factors. However, for a specific child, it is difficult for doctors to find out the specific cause, and they cannot cure it by eliminating a certain cause.
What are the dangers of cryptorchidism to children?
This is a question that parents are very worried about. The harm of cryptorchidism to the body is mainly in the following aspects.
1. Affecting fertility: This is the most important and parents’ greatest concern. Some studies show that the incidence of future sterility in unilateral cryptorchidism is 10% to 20%, while in bilateral cases it is 40% to 80%. Because cryptorchidism has varying degrees of testicular dysplasia, its sperm-producing cells are abnormal and its hormone receptors are abnormal, and many of them are accompanied by abnormal development of the epididymis and vas deferens (which are the conditions for sperm maturation and transportation). A variety of factors lead to adverse consequences in terms of fertility.
2. Combined inguinal hernia or syringomyelia: This is caused by the incomplete closure of the accompanying sphincter, which may or may not manifest itself (e.g., a mass in the inguinal region, sometimes appearing and sometimes disappearing, especially during crying and strenuous activity). In particular, inguinal hernias, once embedded, may cause intestinal necrosis, which is life-threatening, and may also lead to ischemic necrosis of the testicles. Therefore, when a child develops inguinal mass with painful crying; or unexplained crying, or even with vomiting and other manifestations, he should go to the hospital in time.
3.Testicular torsion: Due to abnormal fixation of cryptorchid, torsion can occur leading to testicular necrosis.
4.Psychological impact: After children have self-awareness, they will pay attention to their own body structure. When they find that they are different from their peers and have one less “egg” or no “egg”, they may have inferiority complex and need parents to guide them.
5.Cancer: It occurs mostly in adulthood, and its chance of occurrence is more than 20 times that of normal testicles. Those located in the abdominal cavity have a higher chance of cancer. Therefore, after the treatment of cryptorchidism, it is still necessary to follow up the medical examination for life, so that abnormalities can be found and treated in time.
How does the doctor diagnose cryptorchidism?
It mainly depends on the physical examination of the doctor. When the testicles cannot be felt in the groin and scrotum area, it may be that the cryptorchid is in the abdomen, or it may be that the testicles are absent. The diagnosis is difficult and the process is more complicated at this point. Ultrasound, CT, MRI, isotope scan and other tests can be done to assist in finding the testicles. However, some of these auxiliary examination methods are difficult to implement and not very accurate, and the diagnosis will eventually be made clear by surgical exploration.
VI. How is cryptorchidism treated? Is surgery necessary?
Surgery is the most important and effective treatment and has been used for more than 150 years. There are various surgical methods, such as conventional one-time testicular descending fixation, staged testicular fixation, laparoscopic-assisted staged or staged testicular fixation, orchiectomy and autologous testicular transplantation. Medication, also known as hormone therapy, works by promoting the development of spermatogenic cells and causing the spermatic cord to become flaccid and the testes to become more mobile, producing a limited descent effect. These changes in medication are often not felt by parents, who may see changes such as the growth of the child’s penis and the coloring of the scrotal skin of the penis. The commonly used hormone in China is chorionic gonadotropin (chorionic gonadotropin), with a dosage of about 10,000 units for a course of treatment, usually no more than 15,000 units. After hormone treatment, only a very small number of cryptorchidism descends into the scrotum and is exempted from surgery. Therefore, parents are reminded that hormone therapy is not a substitute for surgery. It is worth mentioning that each child’s specific situation is different, so the specialist should design a personalized plan according to the specific situation, such as using hormone before surgery, or surgery before hormone, or using hormone after the first stage surgery and then the second stage surgery, etc.
7. What is the best age for cryptorchidism surgery?
Surgery should not be performed later than 2 years old. Nowadays, we tend to operate at a younger age, and overseas advocate surgery before 1 year old, and no later than 1.5 years old. Because studies have found that the spermatogenic cells will be further damaged as the age increases; moreover, the older the age, the more severe the damage. Also, the older the age, the greater the distance to travel down, making it more difficult to descend into the ideal position in the scrotum.
Is it normal after cryptorchidism surgery?
Cryptorchidism surgery can only change the position of the testicles to make them descend into the scrotum or closer to the scrotum. However, it cannot change the abnormal development of the testicle, nor can it make the fertility of this testicle become normal. It only creates a suitable physiological environment for the development of the testicle.
9. If cryptorchidism is still abnormal after surgery, then why do we need surgery?
Although the surgery cannot make the cryptorchid testis become normal testis, there are still benefits for the pediatrician after the surgical treatment of cryptorchidism, mainly in the following aspects.
The normal temperature of the scrotum is about 2℃ lower than the body temperature, which is the environment needed for testicular development. Cryptorchidism surgery is like sowing seeds into the right soil.
It avoids cryptorchid reversal of necrosis and complete loss of function.
If a tumor occurs later, it is easier to detect and treat early in the scrotum than in the abdomen.
The scrotum is cushioned and can avoid testicular trauma.
Reduce the negative psychological impact.
X. What is the long-term result of cryptorchidism?
Cryptorchidism changes its position through surgery and reaches or is closer to the scrotum. A part of the cryptorchid gets developed and is about the same size as the good testicle on the opposite side. However, in some children, the testicles cannot descend to the ideal position in the scrotum; and due to various factors such as endocrine factors and hormone receptor abnormalities, they cannot develop normally and are even smaller than before the surgery, or have atrophied. This is manifested by the testicles being positioned higher than the opposite side and smaller in size than the opposite side, or even not touchable. Surgery cannot guarantee future fertility or prevent cancer. The older the treatment age is, the farther the cryptorchid is from the scrotum, and the poorer the testicle development is, the worse the long term effect is. Once the testicle is atrophied, surgery is needed to remove it.
Does cryptorchidism affect the normal development of children’s body? Does it affect future marriage?
Since the endocrine function of cryptorchidism is less damaged and the secretion of male hormones can be normal, it usually does not affect the physical development and the development of secondary sexual characteristics. Generally, it does not affect the sexual function.
Can the cryptorchid descend on its own when the child grows up?
Only a few children with cryptorchidism have some degree of downward movement within half to one year of age. However, surgical treatment is usually needed. The notion of blindly expecting the testis to descend on its own is not based on science.
Can cryptorchidism be cured with Chinese medicine?
At present, the recognized effective treatment means are hormone and surgery. There is no reliable method to make it fall by hand pulling.
Is it okay to wait until the child is 5-6 years old to have the surgery if the child is too young to withstand anesthesia?
On the one hand, if we wait for the surgery when the child is 5-6 years old, we will miss the best treatment age; on the other hand, it is safer to receive the surgery around the age of 1 year old for anesthesia and surgery.
Which department should I see for cryptorchidism?
Cryptorchidism (incomplete testicular descent) belongs to the scope of diagnosis and treatment of pediatric urology.
16.What is the problem of testicular agenesis and testicular atrophy?
For some reasons, testicular agenesis is formed when the testicle does not grow in utero. If the testicle grows but becomes necrotic due to torsion or other diseases in utero or after birth, it will lead to testicular atrophy. This requires a specialist to differentiate it from cryptorchidism. Surgical exploration is usually required to figure this out. Ultrasound, magnetic resonance imaging (MRI) and other tests can only provide reference information.
Is minimally invasive surgery or traditional surgery better for the treatment of cryptorchidism?
In fact, there is no difference between minimally invasive surgery (laparoscopic surgery) and traditional open surgery for the treatment of cryptorchidism. Rather, it should be determined by the doctor depending on the specific situation of the child. Simply put, if the testicle is too far from the scrotum, more freeing of the intra-abdominal spermatic vessels is needed, then the laparoscopic approach is better; conversely, open surgery is better. The surgeon will also choose a relatively small cosmetic incision during open surgery. If the testicle is close to the scrotum, if laparoscopic surgery is necessary, it may increase the risk of damaging the blood vessels and vas deferens, which is not worth the loss.
XVIII. How to understand minimally invasive surgery?
The concept of minimally invasive surgery arose from the application of laparoscopic surgery (endoscopic surgery). In fact, the current international consensus on minimally invasive surgery implies minimal trauma to the incision and the entire surgical procedure as well as relatively short anesthesia and operative time. Laparoscopic surgery can be minimally invasive surgery, but it cannot be considered minimally invasive simply because of the small incision. It depends on the damage and time of the intra-abdominal operation. Traditional open surgery is also minimally invasive if small incisions in the direction of the skin grain are carefully chosen, and fine manipulation as well as cosmetic suturing are also in the category of minimally invasive surgery.