Cryptorchidism or testicular descent insufficiency is a very common congenital disorder of the reproductive system in children.
I. What are the manifestations of cryptorchidism?
The testicles are not felt on one or both sides of the scrotum and are empty, and it is often seen that the scrotum is poorly developed, flattened, or asymmetrical on the left and right side. However, it does not mean that the testicles cannot be felt in the scrotum is cryptorchidism. Other diseases with similar manifestations include ectopic testicles, sliding testicles, upward shrinkage of testicles and testicular agenesis.
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, via 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.
③Developmental abnormalities 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 sphincter that accompanies it, which may or may not manifest itself (such as the appearance of a mass in the inguinal area, which sometimes appears and sometimes disappears, especially when crying and strenuous activity). In particular, inguinal hernias, once embedded, can cause intestinal necrosis, which can be life-threatening, and may also lead to ischemic necrosis of the testicles. So when a child develops inguinal mass with painful crying; or unexplained crying, even with vomiting and other manifestations should go to the hospital in time.
3.Testicular torsion: Due to the abnormal fixation of cryptorchid, torsion can occur and lead 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 the testicles may be absent. The diagnosis at this point is difficult and the process is more complicated. 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 eventually, the diagnosis will be clear by surgical exploration.
VI. How to treat cryptorchidism? 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 descent and fixation, testicular fixation in two stages, laparoscopic-assisted testicular fixation in one or two stages, orchiectomy and autologous testicular transplantation, etc. 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), and the dosage of a course of treatment is about 10,000 units, 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, and the older the age, the more serious the damage. Also, the older you are, the greater the distance you need to travel down, making it more difficult to descend into the ideal position in the scrotum.
Is it normal after cryptorchidism surgery?
Cryptorchid 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 cryptorchid surgery treatment, 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, some children with cryptorchidism cannot descend to the ideal position in the scrotum; and due to the influence of endocrine factors, hormone receptor abnormalities and other factors, they cannot develop normally, or even smaller than before surgery, or atrophied. The testicles are shown to be positioned higher than the opposite side and smaller in size than the opposite side, or even cannot be touched. 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 has atrophied, surgery is also needed to remove it.