Testicular Atrophy as a Late Complication of Orchiopexy
A 12-year-old boy presented with a chief concern of a small left testicle. His past medical history was significant for a left-sided undescended testicle and orchiopexy at age 4.
On physical examination, the boy had Tanner stage 3 genitalia. The right testicle measured 15 mL and the left measured 4 mL. The rest of the examination findings were normal.
Cryptorchidism is the most common genital problem encountered in pediatrics. The prevalence reaches 3% in full-term newborns and 30% in premature infants.1 Because undescended testes rarely descend spontaneously after 6 months of life, correction before 1 year of age is recommended to improve surveillance for testicular cancer (TC); to decrease the risk of TC, torsion and inguinal hernia; and to preserve fertility.1,2
Medical and surgical cryptorchidism treatments have varying success rates. Hormonal agents such as human chorionic gonadotropin and gonadotropin-releasing hormone promote testicular descent in 20% of patients but may result in apoptosis, inflammation, and a reduced number of germ cells in the developing testes.3 Surgical intervention has success rates of up to 90% and is the preferred treatment.4,5 However, early complications can include inadequate positioning of the testis in 10% of patients, division of the vas deferens in 1% to 2% of patients, and epididymo-orchitis in rare cases. Late complications can include testicular atrophy, TC, and infertility. Atrophy occurs in up to 8% of patients after orchiopexy but can occur in as many as 25% of patients with an intra-abdominal testis.6
TC occurs in 1 in 100,000 men among the general population, but the prevalence increases to 1 in 1,000 in men with cryptorchidism.7 While insufficient evidence exists to state that orchiopexy reduces the lifetime incidence of TC, the procedure does reduce the lead time to its detection.8 Because TC is fast growing, testicular self-examination (TSE) of an intrascrotal testicle may detect a tumor earlier than a periodic well-child examination or ultrasonography.
Cryptorchidism can affect fertility, but it does not affect paternity. One study showed that men who had orchiopexy in the first year of life had higher sperm counts (52.3 million vs 23.5 million sperm/mL) and sperm mobility (36.2% vs 23.1%) compared with men who had the procedure in the second year of life.9 However, males with one undescended testis have the same paternity rate as males with bilateral descended testes.10
Testicular atrophy can occur after orchiopexy for cryptorchidism, but it may not become evident until puberty. Therefore, regular TSE is important for all males but especially for those who have undergone orchiopexy. Because TC can occur as early as 1 year after surgery, health care providers should educate parents on TSE technique until patients are old enough to perform TSE themselves.11 Additionally, a discussion about participation in contact sports is important; the wearing of a protective cup is recommended to decrease the chance of injury and subsequent loss of fertility.12
References
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10. Tekgül S, Dogan HS, Erdem E, et al. Cryptorchidism. In: Tekgül S, Dogan HS, Erdem E, et al. Guidelines on Paediatric Urology. Arnhem, Netherlands: European Society for Paediatric Urology, European Association of Urology; 2015:9-11. http://uroweb.org/wp-content/uploads/23-Paediatric-Urology_LR_full.pdf. Accessed October 15, 2015.
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