Outcome Analysis for Retractile Testes

Abstract

Source: La Scala GC, Ein S. Retractile testes: an outcome analysis on 150 patients. J Pediatr Surg. 2004;39:1014–1017.This report from the University of Geneva, Switzerland, and Toronto’s Hospital for Sick Children details the outcome of a series of 150 consecutive patients with retractile testes referred by primary care physicians to a single surgeon between April 1982 and April 1999. Data was collected prospectively regarding testicle position, size (normal, smaller than the opposite testis, or atrophic), presence of accompanying hernia-hydrocele, and family history of retractile testis. In addition, the surgeon noted the degree of spermatic cord tension or the amount of tug necessary to bring the testis into the mid-scrotum: normal or no tension, mild or minimal tension, moderate tension which may cause some discomfort, or true undescended testis. Orchidopexy was performed if a retractile testis ascended and became cryptorchid (34 patients) or if testicular size decreased during the follow-up period (3 patients). Follow-up duration averaged 3.8 ± 3.0 years. At the end of follow-up, the author recorded testicle size and one of the following outcomes: 1) descended to normal position; 2) testis brought to dependent position without retraction; 3) mild residual cord tension; 4) moderate residual cord tension; or 5) patient required orchidopexy for retractile testis that evolved to true undescended type.Median age at presentation was 4.7 years. No information on ethnicity was reported. Neither family history of retractile testis (positive in 8 [5.3%]), age at presentation, nor duration of follow-up was associated with a need for orchidopexy. Inguinal hernias occurred in 14.2% of right and 17.4% of left retractile testes. Orchidopexy was required more frequently in patients who had an inguinal hernia than in those who did not (68.8% vs 9.2%, P<.001). The authors conclude that the majority of patients presenting with retractile testis have spontaneous evolution to a dependent position after age 14 with no surgical intervention. However, they note that no conclusions could be drawn regarding final adult testicle size or function.Between 4.5 and 13 per 1000 school-age males have retractile testes, and many are referred to a pediatric surgeon mislabeled as having an undescended testicle.1–3 A retractile testis is usually defined as a testis that has completed the descent process but remains in the dependent scrotal position because of a hyperactive cremasteric reflex. The testis can be brought into the scrotum, but when traction is released, the testis will slide back into its accustomed position (usually adjacent to the external ring or just in the inguinal canal). In making the distinction between an undescended testis and a retractile one, there are several useful historical features. Parents can be asked whether the testis appears when the child has been in a warm bath for several minutes, and whether it quickly recedes after the child is removed from the bath. Other questions center around whether either parent noted symmetry of the testes or scrotal symmetry when changing diapers early in infancy. An older child may actually complain of vague groin pain associated with the hyperactive cremasteric muscle and its constant contraction.The testicular exam is crucial. Many pediatric surgeons feel that the physician should be able to gently coax the testis into the scrotum with little difficulty and no discomfort. It should remain in the scrotum for a brief period of time as long as the room and the surgeon’s hands are not cold. If the child is frightened about the exam, a later visit is in order before labeling his testis as undescended or retractile. However, if the testis in question springs back into the inguinal canal and can be pulled into the scrotum only with significant discomfort, that testis will likely require orchidopexy. A markedly asymmetric scrotum with a relatively flat hemi-scrotum on the side of the suspect testis indicates a patient in whom the testis rarely, if ever, visits that scrotal space—a sign of an undescended testis. Finally, the pediatric surgeon should be mindful of the retractile testis seen in conjunction with a surgical referral for a hernia on the same side. The retractile testis must be addressed at the time of the hernia repair and is usually secured in some fashion; otherwise, an iatrogenic undescended testis may result.The bottom line seems to us to be that a patient with retractile testis requires follow-up until the testis is definitively secured in the scrotum. The authors’ series demonstrates that almost one-fourth of their patients with retractile testes required surgery because the testes became cryptorchid or decreased in size. The authors note that treatment with human chorionic gonadotropin (HCG) is ineffective in treatment of cryptorchid testes,4,5 and do not encourage its use in retractile testes.