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Cryptorchidism is a congenital anomaly in which, at the time of birth, a boy lacks one or both testicles in the scrotum, which is due to a delay in their descent through the inguinal canal from the retroperitoneal space. Pathology is manifested by asymmetry of the scrotum, the absence of a testicle in it during palpation, aching pains in the groin or abdomen. Diagnosis includes ultrasound of the scrotum, MRI, testicular scintigraphy, abdominal aortic angiography and testicular vein venography. The main method of treating cryptorchidism is operative, the testicle is lowered and fixed to the scrotum.
In modern andrology, undescended testicles or cryptorchidism is the most common congenital anomaly, occurring in 4% of full-term and 10-20% of premature newborn boys. During the first 6 months of life, 75% of children born with cryptorchidism have independent testicular prolapse, probably due to a gradual increase in testosterone levels. By the end of the 1st year of life, pathology persists only in 1% of boys. In the future, in the absence of medical benefits, the probability of self-lowering of the testicles into the scrotum is unlikely. Untimely surgical treatment increases the likelihood of developing male infertility and testicular cancer in the future.
The reasons for the delay in testicular prolapse and the development of pathology are not exactly known. Endocrine, mechanical and genetic factors are considered as possible prerequisites. The endocrine mechanisms of the development of the disease include the presence of hormonal imbalance in a pregnant woman (in particular, type 1, type 2 diabetes mellitus or gestational, pituitary, thyroid gland dysfunction) or testicles in the embryo. These conditions can inhibit the timely omission of testicles into the scrotum and cause the development of bilateral cryptorchidism.
Among the mechanical factors are the narrowness or obstruction of the inguinal canal, shortening of the testicular vessels or the spermatic cord, underdevelopment of the ligamentous apparatus of the testicles, intraperitoneal fusion, etc. In some cases, cryptorchidism is associated with a mutation of the GTD gene (306190, Xp21), Down syndrome, intrauterine defects in the development of the anterior abdominal wall. Premature birth and prematurity of the fetus significantly increase the likelihood of the disease. Cryptorchidism is detected in all premature boys weighing less than 910 g and in 17% with a body weight of more than 2040 g.
In some cases, cryptorchidism is acquired in nature. Thus, a wide inguinal ring or scrotal injuries can cause the migration of an initially normally located testicle into the inguinal region or abdominal cavity.
The laying and formation of testicles (testicles) in the fetus occurs in the abdominal cavity. In the last trimester of pregnancy, the testicles descend into the scrotum through the inguinal canal. It is believed that the timely independent reduction of the testicles is determined by a number of mechanisms – intra-abdominal pressure, local testosterone levels, the condition of the testicular guide ligament and its attachment to the scrotum. After the birth of the boy, further normal development of the testicles is possible only when they are in the scrotum, where the temperature is 2-3 ° C lower than in the abdominal cavity. Such a temperature difference is a necessary condition for normal spermatogenesis. Usually an undescended testicle is smaller than a lowered one in time.
There are false and true cryptorchidism. With a false type of pathology (migrating testicle), under the influence of muscle tension or cold, the testicle may shift into the inguinal canal or abdominal cavity. False cryptorchidism occurs in 25-50% of cases from all observations. It is characterized by symmetry and normal development of the scrotum; migration of the testicle to the inguinal ring or the lower third of the inguinal canal; the possibility of unhindered descent of the testicle into the scrotum during palpation or its independent lowering under the influence of heat or in a relaxed calm state of the child.
Testicular migration is a variant of the physiological norm and is explained by the small diameter of the testicle compared to the diameter of the outer inguinal ring. Therefore, when the corresponding muscles contract, the testicle is easily pulled up to the inguinal fold. False cryptorchidism does not require treatment and disappears on its own at puberty.
True cryptorchidism is spoken of when it is impossible to manually lower the testicle into the scrotum. In this case, the testicle is most often located in the inguinal ring (40%), in the inguinal canal (20%), abdominal cavity (10%). With non-omission of one of the testicles, a diagnosis of unilateral is made, with a delay in omission of both - bilateral true cryptorchidism. Bilateral anomaly is often combined with hypogonadism, hypothalamic-pituitary insufficiency (hypopituitarism), inguinal hernia.
A condition such as testicular ectopia should be distinguished from true cryptorchidism. In the case of ectopia, the testicle, having passed the inguinal canal, does not enter the scrotum, but into the perineum, the medial surface of the thigh, the anterior abdominal wall, rarely - on the dorsal surface of the penis. With testicular ectopia, even after treatment, most patients are infertile.
The main manifestation of pathology is the absence of one or two testicles in the scrotum, which the andrologist determines palpationally. In this case, the scrotum looks underdeveloped, flattened or asymmetrical. With cryptorchidism, there may be aching and pulling pains in the groin or abdomen. When the testicle is localized in the abdominal cavity, pain, as a rule, appears only at puberty and can increase with muscle tension, straining, constipation, sexual arousal.
Cryptorchidism increases the risk of testicular cancer (seminoma), fertility disorders (a decrease in the number of spermatozoa according to the spermogram, poor quality of sperm and its fertilizing ability). With bilateral pathology, about 70% of men are infertile. In addition, cryptorchidism can cause the development of testicular torsion, more precisely, the spermatic cord formed by blood vessels, nerves and the vas deferens.
In the case of a combination of the disease with an inguinal hernia, the infringement of the testicle together with the intestinal loops in the inguinal ring is not excluded. These conditions are accompanied by sharp pains due to a violation of the blood supply to the testicle and its death within the next few hours. When an undescended testicle is located in the groin, the pubic bone may press on it, which, in turn, increases the risk of injury to the genital gland.
Cryptorchidism is detected by examination and palpation of the scrotum. In the absence of a testicle, the scrotum on the corresponding side looks underdeveloped and flattened. With abdominal retention, the testicle cannot be palpated; in other cases, the testicle is found in the inguinal canal. With the inguinal location of the testicle, it is to a certain extent mobile, displaced, with false cryptorchidism, it easily shifts into the scrotum. In the case of true cryptorchidism, it is not possible to lower it into the scrotum. The absence of a testicle is confirmed by ultrasound of the scrotum.
If it is impossible to determine the location of the testicle by palpation, they resort to performing ultrasound of the abdominal cavity and inguinal region, an overview radiography of the abdominal cavity. If the ultrasound is uninformative, contrast MRI or CT may be required, and in difficult cases, diagnostic laparoscopy may be required to confirm abdominal retention of the testicle or to establish monarchism or anarchism. If palpatory and instrumental detection of both testicles is impossible, the exclusion of male pseudohermaphroditism is required, for which genetic analyses, studies of testosterone, gonadotropins are carried out.
In case of a false pathology, no treatment is required. Correction of true cryptorchidism is carried out by pediatric endocrinologists, urologist surgeons. The treatment of cryptorchidism is started when the child reaches the age of 9 months, before this period, counting on the possibility of spontaneous omission of the testicle into the scrotum. Drug therapy is performed by intramuscular injection of human HCG or intranasal administration of gonadorelin.
As a result of conservative therapy, it is possible to achieve testicular prolapse in 30-60% of patients. Hormonal drug treatment is contraindicated at puberty, when there is an increase in the level of own testosterone and gonadotropins. If conservative therapy is unsuccessful by the age of 15-24 months, surgical intervention is indicated – orchipexy (surgical reduction of the testicle into the scrotum).
During the operation, a testicular biopsy is required to exclude malignant processes and gonadal dyskenesis. Intervention is absolutely necessary in case of torsion, testicular infringement, inguinal hernia, testicular ectopia. If hypotrophy or necrosis of the gland is detected, testicular resection or its removal is performed - orchiectomy. In the latter case, as well as with anorhism at an older age, a donor testicle transplant or implantation of an artificial testicle is required for cosmetic correction of the defect.
In the case of early (up to 2 years) testicular deposition or unilateral cryptorchidism, the risk of subsequent complications is significantly reduced. Infertility further develops in 20% of patients with unilateral cryptorchidism and in 70-80% of patients with bilateral cryptorchidism. In the absence of at least a single, normally functioning testicle, boys need treatment from an endocrinologist for normal sexual and physical maturation according to the male type. In the future, parents and then the teenager are recommended to conduct a self-examination of the testicles to detect possible tumor processes. Primary prevention has not been developed.
