![References
• Bhat,S.M.(2016).SRBS manual of sugery (5edition)
• Khatwa UA, Menon PS. Management of undescended testis. Indian J
Pediatr. 2000 Jun;67(6):449-54. [PubMed]
• Shin J, Jeon GW. Comparison of diagnostic and treatment guidelines for
undescended testis. Clin Exp Pediatr. 2020 Nov;63(11):415-421. [PMC
free article]
• Hadziselimovic F. On the descent of the epididymo-testicular unit,
cryptorchidism, and prevention of infertility. Basic Clin Androl.
2017;27:21. [PMC free article] [PubMed]](https://image.slidesharecdn.com/criptorchidism-250512143746-cece4ba5/85/CRIPTORCHIDISM-pptx-in-gynecology-and-ob-49-320.jpg)
CRIPTORCHIDISM.pptx in gynecology and ob
- 1. CRYPTORCHIDISM PREPARED BY ISSA RAMADHANI MASABILE ZUWENA ISSA
- 2. Contents • Introduction • Embryology • Classification • Etiology • Epidemiology • Pathophysiology • Physical examination • Clinical features • Investigation • Treatment • Differential Diagnosis • Complications • Prognosis
- 3. Introduction • Cryptorchidism is the most prevalent congenital condition involving male genitalia, is characterized by the absence of at least one testicle from the scrotum; • this often manifests unilaterally or bilaterally, with a higher frequency of involvement observed in the right testicle. • It results from arrest of descent of the testis in some part along its pathway to the scrotum. • Bilateral undescended testis is called cryptorchidism (means hidden testis)
- 4. Embriology • Primitive testis develops from the genital fold which is attached to the posterior abdominal wall by mesorchium. • It lies below the developing kidneys. • Wolffian duct develops into epididymis and vas deferens. • A fold of peritoneum develops at the junction of vas deferens and epididymis which can be traced down up to the developing phallus (scrotum) and is called as gubernaculum.
- 5. Cont… • Along with some hormonal factors, the muscular fibres in the gubernaculum assist in the descent of testis. • During 9th month of gestation, testis reaches deep inguinal ring. Later, just before or after delivery it descends into the scrotum. • Increased intra-abdominal pressure, differential growth of the abdominal wall are other mechanical factors. • Müllerian inhibiting substance from fetal sertoli cells; androgens and HCG are hormonal factors.
- 7. Classification • Anatomical Classification: • Intra-abdominal Cryptorchidism: The testicle is located in the abdomen. • Inguinal Cryptorchidism: The testicle is in the inguinal canal, which is the passageway in the lower abdomen. • Ectopic Cryptorchidism: The testicle is located outside of the normal path to the scrotum, in unusual locations like the perineum or femoral region.
- 8. Cont… • Timing of Descent: • Congenital Cryptorchidism: Present at birth, where the testicle has failed to descend by the time of birth. • Acquired Cryptorchidism: The testicle descends initially but becomes undescended at some point during the first year or beyond.
- 9. Cont… • Degree of Descent: • Non-palpable Cryptorchidism: The testicle is not palpable or cannot be felt during physical examination, indicating it may be located in the abdomen. • Palpable Cryptorchidism: The testicle can be felt in the inguinal canal or another location but has not fully descended into the scrotum.
- 10. Cont… Surgical Classification: • Unilateral Cryptorchidism: Only one testicle is undescended. • Bilateral Cryptorchidism: Both testicles are undescended. • Bilateral undescended testes which are clinically impalpable is called as cryptorchidism.
- 11. Etiology • Gubernacular dysfunction • Iack of gonadotrophin (HCG). • Lack of ‘Calcitonin Gene Related Peptide (CGRP)’ produced by genitofemoral nerve responsible for testicular descent • Prune-Belly syndrome—due to weak abdominal wall • Familial • Retroperitoneal adhesions • Short vas deferens/short testicular vessels
- 12. Cont… • Altered hypothalamopituitary—gonadal axis; • testosterone (androgen) deficiency, • deficiency of Müllerian inhibiting substance which is secreted by fetal Sertoli cells which is essential for testicular descent—are other factors. • Maternal exposure to diethylstilbestrol • Maternal obesity • Persistent Müllerian duct syndrome • Pesticide exposure
- 13. Cont… • Preeclampsia (especially in its more severe forms, poses an increased risk of cryptorchidism) • Premature infants born before the descent of the testicles • Small for gestational-age infants • Smaller placental weight
- 14. Epidemiology • Cryptorchidism is observed in 3% of full-term newborn infants, with this prevalence decreasing to 1% in infants aged 6 months to 1 year. • In the US, cryptorchidism ranges from approximately 3% at birth to 1% from 1 year to adulthood. • Globally, the prevalence varies, starting at around 4% to 5% at birth, decreasing to about 1% to 1.5% at age 3 months, and further decreasing to 1% to 2.5% at 9 months. • The prevalence of cryptorchidism is 30% in premature male neonates. • This elevated prevalence highlights the significance of closely monitoring testicular development and considering timely interventions when necessary.
- 15. Cont… • In premature infants—30%. • In full-term infants—4%. • In later childhood—2%. • Right testis alone is involved commonly in 50% cases, left alone in 30% cases, bilateral in 20% cases.
- 16. Pathophisiology • Unlike the scrotum, the altered microenvironment within the abdominal cavity or inguinal canal can disturb the optimal conditions for normal testicular function. • The scrotum provides a cooler temperature, essential for the proper functioning of the testes and the production of sperm. • Elevated temperature in the abdominal or inguinal region can adversely impact sperm development and fertility.
- 17. Cont… • Cryptorchidism can disrupt communication between the testes and the endocrine system, potentially leading to transient hormone deficiencies. • These hormonal imbalances may contribute to the failure of testicular descent and impede the development of the spermatogenic tissue, consequently compromising fertility.
- 18. Different Positions • In the abdomen just above the internal ring, • extraperitoneally • In the inguinal canal • In the superficial inguinal pouch. Scrotum is not fully developed and testis cannot be brought down manually to the bottom of the scrotum in undescended
- 20. Physical examination • The most apparent sign in a patient with a cryptorchid testis is the absence of a palpable scrotal testicle. • An inguinal hernia and decreased scrotal rugae or ridges are often present. • If a scrotum exhibits normal rugae and contains a testicle, it may suggest a retractile testicle, typically not necessitating further treatment. • Although changes in the scrotum are frequently observed in cryptorchidism, patients may also present with additional signs and symptoms.
- 22. Clinical features • Absence of Testis in the Scrotum: The most obvious sign is the absence of one or both testes from the scrotum. One or both testes may be located in the groin, abdomen, or inguinal canal. • Asymmetry of the Scrotum: There may be an asymmetric appearance of the scrotum, with one side being smaller or underdeveloped, suggesting the absence of a testis.
- 23. Cont… • Non-Palpable Testis: When the testis cannot be felt in the groin or scrotum, it may be located in the abdomen or may be absent altogether. • Possible Pain or Discomfort: If the undescended testis is located in the inguinal canal, it may cause discomfort or mild pain.
- 24. Cont… • Delayed Pubertal Development (if untreated): If cryptorchidism is not corrected, there can be delays in pubertal development, such as lack of secondary sexual characteristics like penile enlargement, facial hair, and deepening of the voice. • Increased Risk of Infertility: The condition can lead to poor sperm production and long-term infertility, particularly if untreated.
- 25. Cont… • Increased Risk of Testicular Cancer: There is an increased risk of testicular cancer in individuals with cryptorchidism, especially if it is not treated surgically. • Risk of Inguinal Hernia: Cryptorchidism can be associated with an inguinal hernia, especially if the processus vaginalis doesn't close properly during fetal development.
- 26. Cont… • Palpable Testis in the Groin or Abdominal Area: In some cases, a testis may be palpable in the groin or near the inguinal canal, indicating it has not fully descended.
- 27. Investigation • According to American Urological Association (AUA) guidelines: • "In the hands of an experienced provider, more than 70% of cryptorchid testes are palpable by physical examination and need no imaging. In the remaining 30% of cases with nonpalpable testis, the challenge is to confirm the testis's absence or presence and identify the location of the viable nonpalpable testis.”
- 28. Cont… • Routine ultrasound usage is generally unhelpful, as it exhibits limited sensitivity and specificity in localizing nonpalpable testes, with reported values of 45% sensitivity and 78% specificity. • The utilization of computed tomography is limited due to cost and concerns about ionizing radiation exposure.
- 29. Cont… • Magnetic resonance imaging, often used with or without angiography, demonstrates greater sensitivity and specificity. However, its use is discouraged due to the associated high cost, limited availability, and the requirement for anesthesia. • Currently, no radiological test can definitively and with absolute reliability confirm the absence of a testis.
- 30. Cont… • A karyotype analysis can confirm or rule out dysgenetic primary hypogonadism. • Hormone levels, such as gonadotropins and Müllerian inhibitory substance, may confirm hormonally functional testicles suitable for preservation.
- 31. Treatment • Medical Treatment:The American Pediatric Association guidelines recommend the use of hormones in patients with undescended testis associated with Prader-Willi syndrome. • The rationale stems from the belief that a therapeutic trial of hCG is indicated as a treatment for undescended testes before surgical intervention
- 32. Cont… • The primary hormone utilized for hormone therapy is hCG. • A course of hCG injections is administered, and then the status of the undescended testicle is reassessed. • The reported success rate for this treatment method ranges from 5% to 50%. • In addition, hormone treatment serves the dual purpose of confirming Leydig cell responsiveness and stimulating further growth of a small penis due to the elevation in testosterone levels.
- 33. Surgery(orchidopexy) • Techniques of Orchiopexy; • For palpable undescended testes, performing an inguinal or scrotal orchiopexy is recommended.The procedure typically involves the following factors: • Depending on the case, an incision is made in the high scrotum, median scrotal raphe, high edge of the scrotum, or groin. • Inguinal incisions can be as small as 1 cm, whereas scrotal incisions can be larger as they tend to heal concealed, especially when placed along the median raphe.
- 34. Cont.. • The surgeon can choose to approach either the testis or the cord first. • In scrotal cases, the testis is typically located first. • In an inguinal approach, the testis can be approached first, or the external oblique fascia is opened proximal to the external ring, and the cord can be accessed first.
- 35. Cont… • How the testis is positioned and secured in the scrotum can vary among surgeons. • Most surgeons prefer to create a sub-dartos pouch. • Some surgeons do not suture the testis in place, while others use absorbable or nonabsorbable sutures. • Alternatively, some may choose to close the passage into the groin.
- 38. • For nonpalpable testes under anesthesia, exploratory laparoscopy is the recommended approach. • During exploratory laparoscopy, if a testis is discovered, the surgeons perform any of the following available options for their patients. • Laparoscopic orchiopexy with preservation of the vessels: This procedure involves dissecting the testis from a triangular pedicle containing the gonadal vessels and the vas deferens.
- 41. Cont… • Laparoscopic 1-stage Fowler-Stephens orchiopexy: In this process, the gonadal vessels are divided, and the testis is dissected off a pedicle of the vas deferens, bringing it down in one stage. • Laparoscopic 2-stage Fowler-Stephens orchiopexy: This technique uses clips to divide the gonadal vessels. • However, dissection of the testis is deferred for 6 months, allowing for optimal development of collaterals before proceeding with the testicular relocation.
- 44. Cont… • Laparoscopic 2-stage traction-orchidopexy (Shehata technique): In this procedure, the intra-abdominal testis is fixed to a point 1 inch (2 cm) medially and superiorly to the contralateral anterior superior iliac spine to provide traction. • The testis remains in its undescended position for 3 months. • Afterward, a laparoscopy-assisted ipsilateral subdartos orchidopexy is performed. • This technique is an alternative to the 2-stage Fowler-Stephens (FS) orchidopexy.
- 45. Differential Diagnosis • A typical diagnostic challenge involves differentiating a retractile testicle from a testicle that does not spontaneously descend into the scrotum. • Retractile testes are more prevalent than undescended testes and do not necessitate surgical correction. • The cremaster muscle contracts in normal instances, causing the testicles to retract into the upper scrotum and inguinal canal. • This reflex is more active in infants.
- 46. Cont… • Various maneuvers are used to aid in identification, such as having the patient in a cross-legged position, using soaped fingers during examination, and assessing the patient while in a warm bath.
- 47. Complications • Sterility • Trauma and pain. • An associated indirect inguinal hernia (70%). • Torsion testis. • Epididymo-orchitis (as the pain will be high up it mimics acute appendicitis). • Testicular atrophy. • Malignant transformation in undescended testis is 20 times more common than normally descended testis
- 48. Prognosis • With proper diagnosis and treatment, the prog nosis for cryptorchidism is excellent. • However, there is a slight increase in the risks of testicular cancer and infertility compared to the general population.
- 49. References • Bhat,S.M.(2016).SRBS manual of sugery (5edition) • Khatwa UA, Menon PS. Management of undescended testis. Indian J Pediatr. 2000 Jun;67(6):449-54. [PubMed] • Shin J, Jeon GW. Comparison of diagnostic and treatment guidelines for undescended testis. Clin Exp Pediatr. 2020 Nov;63(11):415-421. [PMC free article] • Hadziselimovic F. On the descent of the epididymo-testicular unit, cryptorchidism, and prevention of infertility. Basic Clin Androl. 2017;27:21. [PMC free article] [PubMed]
- 50. S