ABSENCE OF TESTIS FROM SCROTUM
Dr. Vivek M. Rege
Pediatric Surgeon & Pediatric Urologist
B J Wadia Hospital For Children, Hurkisondas Hospital, Wockhardt Hospital, Mumbai
This condition occurs only in boys for obvious reasons. Parents may notice that one or both testes may be missing from their normal location in the scrotum. This defect is usually present from birth, though may be noticed as late as 3 ? 4 years. The incidence of this defect in full term boys is about 3 %, but, in prematures is as high a 30%. The reason is based on natural embryology in a boy. The testes are formed within the abdomen just below the developing kidneys. As the fetus grows, the testes descend down towards the groin or inguinal region around the 7th month. Around the 9th month, or, just before birth, they come out of the inguinal canal and descend down into the scrotum. Hence the very high incidence of nondescent of testes in prematures born at 8 ? 9th month.
In some boys, for many reasons both hormonal and/or mechanical, the testes on one or both sides may not descend normally into the scrotum. This results in absence of testis on one or both sides. The absent testis can be anywhere along the normal course of descent.
In those boys in whom a testis is not seen or felt on one or both sides, there are four basic possibilities and the goal is to find out which of these and treat it accordingly:
1. Retractile testis
2. Ectopic testis
3. Undescended testis
4. Absent testis.
Retractile testis: In these boys, the testis has come well down into the scrotum to begin with. There is a muscle called Cremaster that surrounds the cord namely the vas deferens & blood vessels of the testis. In boys with retractile testis, this muscle is over active and oversensitive, a slight touch can cause it to contract and pull the testis upwards into the inguinal canal and disappear from the scrotum. Thus, when the parent is bathing the child, no testis may be seen or felt in the scrotum and the testis may remain up later too. A doctor examining the boy will be able to gradually and manually massage the testis down into the scrotum and hold it there. This proves that the testis has descended normally and no further treatment is required. As the boy grows up, and achieves puberty, the hormonal action on the testis will increase the weight, dimensions. Simultaneously, the cremaster becomes non sensitive and the ombined effect will allow the testis to come and stay within the scrotum.
No testis in scrotum
Testis can be brought down
Ectopic Testis : In this condition, the testis is normal in all aspects and also descends normally till it reaches the inguinal canal from where, instead of going down into the scrotum, it goes into all abnormal directions ? like behind the scrotum, in front of the root of the penis, the upper thigh etc. as seen in the picture. Since this is an atypical position ?this is called ectopic testis. This definitely requires a surgical operation to get the testis into the scrotum and fix it there.
Undescended Testis: In this condition, there is a halt in the normal process and the descent of the testis stops ? these are cases of undescended testis. The point at which it stops may vary: in some, the testis comes into the inguinal canal, exits but stops short of entering the scrotum this is Emergent testis. In others, the testis enters the canal and then halts ? called inguinal testis. In a few boys, the testis comes down up to the inguinal canal but stops before entering the canal in the abdomen ? these are called abdominal testis. Rarer still are those testes that halt even higher up in the abdomen. The treatment will vary according to which position the testis is in. In the emergent and the inguinal testes, the examining doctor is able to feel the testis and hence they are called palpable undescended testes. In boys whose testes are in the abdomen and a few with those in the inguinal canal which cannot be felt by the doctor ? are called nonpalpable unescended testes. All undescended testes require surgery to bring them don and fix them in the scrotum. The type of surgery may be open or Laparoscopic assisted surgery.
Testis not in scrotum but in inguinal region
Absent testis: This is a very rare condition and only 20% of all undescended testes are absent and nothing needs to be done after confirming the diagnosis. This is a diagnosis made after ruling out the other 3 possibilities.
Reasons for correction?
There are a number of reasons why a testis in an abnormal position must be brought down to the scrotum. The best results are achieved if the surgery is finished by the age of 1 ?1 ½ years . The reasons for operation are :
When the testis is in an abnormal position its temperature remains higher than in the scrotum by 1 degree Farenheit. Just a small difference alters the function of the organ ? making of sperms. The process of making sperms in the testis is complicated and involves many stages. It has been proved that the function begin to deteriorate rapidly after 1and half years if the testis is not in its normal position. By 5 years of age, the tubule producing sperms are reduced by half and the greater the age of the child when testes is brought down, the worse is the function that will be life long. This is directly related to the fertility in terms of number and quality of sperms. The chances of such a male to father a child later in life are very much reduced. In fact, even though there may be an undescended testis on only one side, yet, it affects the unction of both sides. It has been shown that even in those boys whose defect has been corrected by the right age still have a 25% chance of infertility.
In boys with undescended testes, the testis is usually found to be in the inguinal region. In this abnormal position, the boy is more likely to injure the testis while playing, fighting, falling. Due to direct impact to the testis, it may rupture, cause a blood clot or smash the testis and destroy it. The incidence of trauma to the testis in these boys is far more than that in boys with a well descended testes.
An undescended testis is not fully down and fixed in position, and hence can move from above downwards, as well as side to side. Since the testis is preceeded by its vesels and the vas there can be a twist of the testis on its vessels ? called torsion and this can be dangerous. During torsion, the twist can cut off the blood supply to the testis and cause an infarction and death of the testis. The testis in such a case will have to be removed permanently. This will affect not only the function of the same side but is also found to adversely affect the opposite side testis function.
Associated with an undescended testis, there is a high incidence of a hernia almost 60 ? 70% cases. Therefore to bring the testis down and to achieve an adequate length, the hernial sac needs to be separated from the cord structures and ligated.
In later life, the chances of developing a cancer of the testis is 20 times higher in a boy with undescended testis, than one with both descended testes. Also higher the initial position of the testis, the more the chances of the malignancy. The importance of this observation is that in cases with treated boys with the testis in the scrotum, in later life one side testis starts growing larger than its counterpart, an immediate suspicion is aroused, and a biopsy of that testis needs to be done and if proved positive for cancer, that testis can be removed and other treatment given to control the spread. However, if the testis is in the abdomen, and left untreated, the testis will grow and become cancer and the spread will occur without anyone realizing till it may be too late to treat such a man.
The last but not the least reason for bringing and fixing the testis in normal position is cosmesis ? a boy with no or a single testis is the target of jokes, fun and teasing. This will make him extremely conscious of the anomaly and have a psychological effect and thus the importance of correction. In cases of absent testis on one side, later ? a prosthesis can be inserted after measuring the size of the opposite testis.
As I have said earlier, the ideal age for correction for getting the best results is between 1 to 11/2 years of age. The surgery done is called Orchiopexy ? that is fixation of the testis in the scrotum and prevent it from going back up where it was. The operation and the approach depends on the site of the testis and the age of the boy. Examination will throw up 2 possibilities ? either I am able to feel the testis (called Palpable testis) or I am not able to feel the testis position (called non palpable testis).
If the testis is felt, no further investigations are required for the testis, and the child can undergo the surgery after routine investigations. This surgery is usually done on a day care basis ? the child comes in the morning, gets operated and leaves by the evening or night. The surgery lasts for about 1 ? 11/2 hours. There are 2 incisions in this ? one in the inguinal region for the isolation and mobilization of the testis, and the second on the scrotum where the testis is finally brought and sutured to prevent ascent.
Testis found in the inguinal canal
The testis with blood vessels separated from hernia sac
Testis brought down and fixed in scrotum
The problems occur in those boys where I am unable to feel a testis. This could mean that the testis is in the inguinal canal but cannot be felt, the testis could be in the abdomen and hence it cannot be felt, it could have undergone torsion during life and has become small and atrophic hence is not felt, or lastly, the testis could be absent. Differentiating one from the other requires the use of investigations. The first is a simple easily available and non invasive ? Ultrasonography. This will show the site of the testis clearly if it is in the inguinal region, its dimensions if normal, the previously described operation can be successfully carried out. The testis may be visualized in the inguinal region but may be seen to be small atrophic ? possible previous torsion ? in such cases during the operation it is advisable to remove the tstis rather than keeping a useless testis in the scrotum and let it affet the function of the opposite normal testis.
It may be that the testis is in the abdomen or just inside the canal, but due to technical reasons may net be visualized by Sonography. Hence ? non visualized testis should not be taken as absent testis because time and again I have explored the inguinal region and found a testis of a good size in 8 out of 10 such boys. With rapid advances in technology today I would first do a diagnostic Laparoscopy. This is introduction of a Pediatric Laparoscope thru a small 5mm hole made just at the umbilicus and the scope is put inside the abdominal cavity and the side of the missing testis is visualized ? three things may be seen ?
The blood vessels and the vas deferens can be seen going into the inguinal canal this means that the testis is present and is in the inguinal canal and can be tackle like previously described and brought down easily. There may be a possibility that the testi is in the inguinal canal but is small and atrophic and hence was not seen on sonography and if so then that testis needs to be removed.
The testis may be seen just at the internal ring or higher up. The vessels and the vas are identified and either a one stage mobilization of the testis or a 2 stage procedure is done to bring the testis down into the scrotum.
In rare cases no vas, vessels or the testis is visualized within the abdomen this is confirmatory of an absent testis. No further procedure is required.
The possible complications of this surgery are damage to the vas or the vesssels during handling which can cause rupture or permanent damage to the blood supply or the passage of the sperms into the urethra. This will only be known much later in life after the boy has got married and is unable to conceive a child. Another complication is mechanical ? the testis that is brought down to the scrotum is not adequately fixed and can slip back upwards.
In any of the above mentioned surgical procedures, the child does not have to stay in the hospital for more than a day and goes home the same evening or the next morning. In the post operative period, there will be a swelling both in the inguinal and the scrotal region. This is expected due to the surgery and should not be a cause of worry to the parents of the child. The swelling will gradually decrease within the next few days and the hardening of the incision in the inguinal region will also soften over 3 months. Later, the incision will just be seen but not felt. Usually antibiotic and anti inflammatory drugs are given in the immediate post operative period. The dressing is opened on the 7th post operative day and left open. Since the sutures used are absorbable, no suture removal is required. Child can start having a bath after the dressing is removed and is allowed full normal activities including sports after 6 weeks of the surgery.
Laparoscopic view of vas and vessels
Laparoscopic view of testis in abdomen
Last Updated: 27th January 2009