A missing testicle is a fairly common finding when examining newborn infants, particularly when they are born prematurely. We commonly refer to this finding as cryptorchidism, although by strict definition that term specifically applies to testes that haven’t fully completed their epic journey into the scrotum by 4 months of age. Cryptorchidism, which is also diagnosed initially when one or both testes is absent, is the most common congenital abnormal finding related to the male genitourinary tract.

Most cases of cryptorchidism involve undescended but healthy testes. As mentioned above, sometimes one or both of the testicles are missing, or shriveled and useless, because of vascular compromise that occurred at some point prior to delivery. Testicles that have descended, but are prone to retracting out of the scrotum, are called retractile testes and while the phenomenon usually resolves over time they are at increased risk of evolving into a true undescended state. Rarely testes descend but do not end up in a normal anatomical position, settling in surrounding tissue such as the superficial inguinal pouch or suprapubic region.

But the vast majority of the time, when I am unable to palpate a testicle during a newborn or early infant exam, it is because it simply hasn’t yet descended, even when asked politely.

Epidemiology, risk factors, and causes of cryptorchidism

As many as five of every 100 term newborn male infants will have an undescended testicle, and it occurs in 30% of premature infants. One out of ten cases will affect both testes. Most of these children will experience spontaneous descent in early infancy, but by a year of age roughly 1% will have yet to resolve.

There are some notable potential risk factors for cryptorchidism. Generally, we tend to see it more commonly in premature and/or low birth weight babies. There have also been proposed genetic and environmental factors at play, including exposure to endocrine disruptors in pesticides and maternal medications/conditions that interfere with normal fetal hormone levels. At almost 10%, the condition appears to be significantly more common in Denmark, the land of babies that maybe perhaps don’t cry as much as some other babies, compared to the rest of the world.

As to why some testes are unusually shy, nobody really knows. We know a lot about how normal descent occurs but it isn’t clear which step or steps go wrong when it doesn’t. Each testicle starts out in the abdomen and migrates downward, reaching the inguinal canal early in the 3rd trimester. Normal descent is regulated by androgen hormone levels and a complicated interplay of neurotransmitters and numerous other chemical factors as well as mechanical changes in abdominal pressure and the opening up of a pathway into the scrotum. Essentially, developmental changes are probably key which is why abnormal descent is more common in premature infants.

Why do we care about undescended testes?

First off, the presence of a hidden testis or testes can be a clue that something more sinister is going on, in particular when there is a finding of bilateral non-palpable testes. Although usually it is the only abnormality on exam, there are associations with various other disorders and genetic syndromes, including disorders of sexual development. So a thorough evaluation of the entire infant is always in order, although that is true regardless of how many of their boys are home.

In the case of true undescended testes, as opposed to absent or retractile testes, there are many possible future complications. This can include an increased risk of developing a hernia through the inguinal canal, loss of the testicle because of vascular compromise (testicular torsion), and trauma from compression of the testicle against the pubic bone. Fertility can also be impaired, and there is even an increased risk of testicular cancer.

Pediatricians and family doctors caring for newborns will generally require the expertise of specialists, such as an endocrinologist or even a multidisciplinary team whenever there is concern for a disorder of sexual development or the possibility of a life-threatening condition. In most cases, however, only one testicle is involved and the rest of the evaluation is normal. These children can be referred to a pediatric urologist or surgeon at 4-6 months of age.

Why a surgeon?

While most cases of cryptorchidism will not require the services of a specialist or pediatric surgeon, after 6 months of age it is very unlikely to resolve without intervention. Treatment before a year of age will prevent some of the associated complications (hernia, trauma, vascular injury) and may reduce the risk of others (subfertility). Unfortunately, while the increased risk of malignancy of the testicle can be reduced with appropriate management prior to puberty, it cannot be removed entirely and there is even a small increased risk in the testicle that descended normally.

The only proven management of a true undescended testicle is surgery. During the procedure, known as orchiopexy, viability of the testicle is determined and, if warranted, it is fixed in the normal anatomical position in the scrotum. The best timing for correction is as early as possible after 4-6 months of age and ideally before the child’s first birthday. Spontaneous descent can occur, but it is rare after six months and early correction can improve testicular growth and function.

Historically, hormonal therapy has been recommended in an effort to induce descent into the scrotum. There is some evidence of a small increased chance of descent, but this was primarily seen when the testes were already close to the scrotum and may be a result of inappropriately labeling retractile testes as undescended. And with hormonal therapy, we don’t have long term data on complications such as fertility and malignancy. It is not recommended by the American Urological Association, however it is still sometimes attempted, particularly outside of the United States.

Are there alternative approaches to the science-based management of cryptorchidism?

I am usually inspired to write these posts after I encounter a particular diagnosis while rounding on my patients. Invariably as I sit at the computer to refresh my knowledge of a diagnosis or to access the most current treatment recommendations, I become curious how the world of so-called alternative medicine might addresses these specific medical problems. My searches rarely come up empty. The topic of undescended testes was no exception.

I thought that I would have a little fun with this post, however. I will briefly present four alternative medical management options for congenital cryptorchidism, but one of them will be completely fictional. And by fictional I mean made up by me rather than someone else. The others will be based on actual information available online for worried caregivers to stumble on and potentially take as a serious option to pursue. See if you can tell the difference!

  1. Abnormal descent of one or both testicles can occur due to misalignment of the pelvic complex. Applied kinesiology is helpful in making this diagnosis in a young child. Having the parent hold the child allows for a melding of the energy fields and the ability to uncover abnormalities in a child through standard muscle testing of the caregiver. One such case was presented in 2003 at a meeting of the International College of Applied Kinesiology-USA. An infant was found to have a bilateral sacroiliac sprain/strain, causing subluxations in cervical and thoracic spinal segments in a pattern commonly associated with this type of pelvic lesion. Gentle correction was performed after entrainment of the caregiver and child’s breathing patterns was allowed to develop because the straighter spinal curve during inspiration allows for easier adjustment of the subluxation. After repeat adjustment one week later, there was resolution of the right undescended testicle which remained in the scrotum 4 years later.
  2. Homeopathy can be a great help for children of all ages with undescended testicles, stimulating the body to remedy the condition and helping to avoid surgery. Concerned parents can give Thyroidinum 30c. Sometimes just one dose is all it takes. If this doesn’t work, the following algorithm may prove useful: If the left testicle is undescended, but not the right, Clematis 6c should be given twice daily. If neither has descended and the boy is puny for his age, give Aurum 30c twice daily. If there is no improvement after 2 months, consult your family homeopath for a full constitutional review and start daily neck exercises to stimulate the thyroid gland.
  3. Failure of the testicle to descend occurs because of an interruption in the natural developmental process, so the Eight Extraordinary Channels can be used for treatment. The Ren and Du channels are the most relevant because they originate from the groin and govern sexual development. The Liver and Gall Bladder Channels can also be used to move qi to the groin. Instead of needles, microcurrent stimulation and qigong applied by touching the chosen points can assist in moving qi to the desired areas.
  4. There is a cosmic connection between mother and child that exists on both physical and quantum planes. Each plane has conduits to the other and each acts upon both their own influences as well as reciprocal entities. While our ability to communicate with an infant with undescended testicles is limited by physical reality, it is not bound by any such constraints at the quantum level of consciousness. Forging a physical connection, such as occurs when a mother places her naked infant against her bare chest or abdomen, allows for communication through surrogate guided imagery techniques that tap into the cosmic consciousness. The mother can be assisted in forming a mental construct to represent her child’s testicle and visualizing its descent through the inguinal canal and into its scrotal home. This process can be repeated in the case of bilateral undescended testicles but a different mental construct should be conjured so as to not confuse the original testicle.

Conclusion: A tough nut to crack?

Congenital undescended testes are common in newborns. We may not have a complete understanding of why they occur, but there is a science-based approach to their management that is safe and prevents or reduces the known complications. There are no legitimate alternative options to true undescended testes, although there may be some anecdotal reports of success because of a misunderstanding of the natural course of the condition. Or, more likely, because of an initial misdiagnosis.

See if you guessed which of the four alternative approaches was made up on the spot by me by clicking on the following links:

1. Chiropractic care for the undescended testicle

2. Homeopathic care for the undescended testicle. It’s a simple cure! Of note homeopathic Aurum metallicum, which is metallic gold diluted out of existence, is also good for depression, qualmishness, and violent erections.

3. Acupuncture for the undescended testicle.

4. Surrogate visualization for the undescended testicle.

Posted by Clay Jones

Clay Jones, M.D. is a pediatrician and a regular contributor to the Science-Based Medicine blog. He primarily cares for healthy newborns and hospitalized children, and devotes his full time to educating pediatric residents and medical students. Dr. Jones first became aware of and interested in the incursion of pseudoscience into his chosen profession while completing his pediatric residency at Vanderbilt Children’s Hospital a decade ago. He has since focused his efforts on teaching the application of critical thinking and scientific skepticism to the practice of pediatric medicine. Dr. Jones has no conflicts of interest to disclose and no ties to the pharmaceutical industry. He can be found on Twitter as @SBMPediatrics and is the co-host of The Prism Podcast with fellow SBM contributor Grant Ritchey. The comments expressed by Dr. Jones are his own and do not represent the views or opinions of Newton-Wellesley Hospital or its administration.