Assessment and Management of Undescended Testes
Flowchart
Introduction
Orchidopexy for undescended testis (UDT) is one of the most common paediatric surgerical operations. Each year there are around 6,000 elective orchidopexies performed in England for undescended testes. At term, undescended testis occurs in 3-5% of male infants but, in the majority, the testis reaches its normal scrotal position by 3 months of age.
Whilst most UDT is present at birth, there is a significant cohort of boys in whom the testis was originally located in the scrotum but UDT is diagnosed later in childhood - sometimes termed the 'ascending testis'.
Patients and their families benefit from assessment and surgery performed locally, with selected referral to a tertiary paediatric surgical centre, governed by clinical need.
Orchidopexy for undescended testis (UDT) is one of the most common paediatric surgerical operations. Each year there are around 6,000 elective orchidopexies performed in England for undescended testes. At term, undescended testis occurs in 3-5% of male infants but, in the majority, the testis reaches its normal scrotal position by 3 months of age.
Whilst most UDT is present at birth, there is a significant cohort of boys in whom the testis was originally located in the scrotum but UDT is diagnosed later in childhood - sometimes termed the 'ascending testis'.
Patients and their families benefit from assessment and surgery performed locally, with selected referral to a tertiary paediatric surgical centre, governed by clinical need.
Scope
This guideline applies to all paediatric patients in the region but not to neonates on neonatal units.
This is not intended as a guide for management of patients requiring an emergency scrotal exploration for suspected testicular torsion.
This guideline applies to all paediatric patients in the region but not to neonates on neonatal units.
This is not intended as a guide for management of patients requiring an emergency scrotal exploration for suspected testicular torsion.
Purpose
The purpose of this guideline is to describe a standardised approach to the diagnosis, assessment and management of Undescended Testis.
The purpose of this guideline is to describe a standardised approach to the diagnosis, assessment and management of Undescended Testis.
Definitions
Undescended Testis - a testis that cannot be brought into the scrotum, or will not stay there.
Orchidopexy - surgery to bring the testis into the scrotum.
Secondary Care Surgical Provider - a Consultant General Surgeon or Urologist with appropriate experience and skills to evaluate and manage a patient at their local hospital.
Undescended Testis - a testis that cannot be brought into the scrotum, or will not stay there.
Orchidopexy - surgery to bring the testis into the scrotum.
Secondary Care Surgical Provider - a Consultant General Surgeon or Urologist with appropriate experience and skills to evaluate and manage a patient at their local hospital.
Primary Care / Neonatology Assessment
At term, undescended testis occurs in 3-5% of male infants but, in the majority, the testis reaches its normal scrotal position by 3 months of age.
Primary Care assessment of retractile and ascending testes
A significant number of boys have a retractile testis of which a proportion will become an undescended testis. There is also a significant cohort of boys in whom the testis was originally located in the scrotum but is then identified as 'ascending' later in childhood.
At term, undescended testis occurs in 3-5% of male infants but, in the majority, the testis reaches its normal scrotal position by 3 months of age.
- All male infants should be assessed for testicular mal-descent at both the neonatal baby check and the 6-8 week postnatal examination.
- If the testis remains undescended/impalpable they should all be referred by 4 months of age on an outpatient basis to an appropriate Secondary Care Surgical Provider with appropriate experience and skills to manage the patient at their local hospital.
- Patients with associated hipospadias should be referred to the Paediatric Urology team at Southampton General Hospital for specialist assessment.
- Imaging, including ultrasound, is not indicated prior to referral, and should not be done.
- Patients should not be referred routinely to a paediatrician.
Primary Care assessment of retractile and ascending testes
A significant number of boys have a retractile testis of which a proportion will become an undescended testis. There is also a significant cohort of boys in whom the testis was originally located in the scrotum but is then identified as 'ascending' later in childhood.
- A testis that is retractile/ascending should be referred for assessment by a Secondary Care Surgery Provider with appropriate experience and skills to manage the patient at their local hospital.
Secondary Care Assessment
- GP referrals should be seen and assessed in the outpatient clinic by 8 months of age.
- Ultrasound is not indicated prior to surgery or referral to the Paediatric Surgery Team.
- If orchidopexy is indicated, this should ideally be performed between 12 and 18 months of age.
- Orchidopexy should be performed as a day-case procedure.
- Impalpable testes (unilateral or bilateral) should be referred to the Paediatric Surgery team at Southampton General Hospital for further assessment.
- Bilateral palpable undescended testes should be referred to the Paediatric Surgery team at Southampton General Hospital .
- A unilateral undescended testis in a patient who is post-pubertal, is at higher risk of malignancy, unlikely to be functional, and the surgery is technically more difficult to perform. Consideration should therefore be given to orchidectomy in such patients.
Tertiary Care Assessment - impalpable testis
- Referrals should be seen and assessed in the outpatient clinic by age 8 months.
- Ultrasound is not indicated prior to surgery.
- If orchidectomy is indicated, this should ideally be performed between 12 and 18 months of age.
- Unilateral or bilateral impalpable testes require EUA and laparoscopy to look for the presence of an intra-abdominal testis.
- Orchidopexy and laparoscopy should be performed as day-case procedures unless specific patient factors, such as co-morbidity, prevent this.
Post-operative Follow Up
- Patients should be assessed once in the outpatient clinic at 6 months post-operation to assess for testicular position and atrophy.
General Guidance - All Providers
- Children must be cared for in an appropriate child-friendly environment.
- Patient information should be given to parents or carers prior to surgery.
- Patients undergoing surgery should have a pain management plan on discharge.
- Care should be provided within a managed network of appropriately trained secondary and tertiary care providers.
- All staff members that come into contact with children and young people must be trained in safe guarding to an appropriate level.
- Units delivering care should participate in collection and monitoring of parent/carer feedback.
- Units delivering care should participate in regional audits.
Implementation
- `This guideline will be made available regionally on the PIER website. Local leads for paediatric surgery will disseminate this guideline and raise awareness locally.
Process for Monitoring Effectiveness
- The Wessex Paediatric Surgical Network will review problems associated with a failure to comply with this guideline through its regional governance process.
References
- Paediatric Orchidopexy Commissioning Guide - Royal College of Surgeons / British Association of Paediatric Surgeons. 2015. Available at: http://www.rcseng.ac.uk/library-and-publications/college-publications/docs/paediatric-orchidopexy/ (last accessed Jan 2020)
- European Society of Urology Guideline - Paediatric Urology. 2015. Available at: https://uroweb.org/guideline/paediatric-urology/ (last accessed Jan 2020)
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Document Version:
1.0 Lead Author: Ms Lara Kitteringham, Consultant Paediatric Surgeon Additional Author: Mr Jake Foster, SpR General Surgery, Wessex Region |
Approving Network:
Wessex Paediatric Surgery Network Date of Approval: 01/2020 Review Date: 01/2023 |
PIER Contact |
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