Undescended testis is the third most common surgical problem in children after hernia and hydrocele in the inguinal region.
Testes develop in the abdomen during intrauterine life. It enters the inguinal canal in the 7th month of embryonic life. Then, the processus vaginalis, which is in the form of a protrusion in the canal, goes down by dragging it and is located at the level of the outer mouth of the bag (inside the scrotum) or the inguinal canal at birth.
The exact cause of undescended testis is not known. However, factors such as mechanical obstacles on the descent path, defect in the structure of the testis, and insufficient gonadotropic hormone level in the blood in intrauterine life have been suggested. In the hormonal deficiency theory, it is very difficult to explain unilateral undescended testicles.
In undescended testis, it is 30.3% in premature children, 3.4% in newborn babies, 0.66% in babies who have completed one year old, and 0.28% in adults.
About 15% of the undescended testis is bilateral. Its incidence is slightly higher on the right side compared to the left side.
What are the problems that occur with testicular non-descending:
1. Histopathological changes in the testis
2. Inguinal hernia (inguinal hernia)
3. Sexual and childbearing status
4. Testicular torsion (spermatic cord) torsion )
5. Trauma
6. Psychological changes
7. Cancer transformation potential
1. Histopathological changes in testis;
Histopathological (structural) studies on undescended testes reveal that degenerative changes begin in the undescended testes from the age of one, and these changes begin with advancing age, and these changes become more severe with advancing age.
2. Inguinal hernia (inguinal hernia);
The inguinal canal (Processus vaginalis) of children with undescended testicles remains open at a rate of 90-95%, causing inguinal hernia.
3. Sexual and childbearing status;
Children with undescended testicles do not have any impairment in sexual function. There is no reproductive problem in unilateral undescended testicles. In addition, reproductive function, which is below 10% in bilateral undescended testicles, is close to normal in patients who are surgically reduced before the age of one or two years. It causes structural disorder in unilateral undescended testicles.
4.Testicular torsion (Spermatic cord torsion);
It is formed by the rotation of the spermatic cord and testis around their own axis. Torsion primarily prevents the return of venous blood flow. With the cessation of arterial blood flow, it causes necrosis (tissue death) in the testis. Although testicular torsion is more common in young adults, it is most common in childhood under the age of 3 years. Although undescended testis is shown as retractile testis and trauma, torsion can also be seen during sleep. Torsion may also develop in descended testicles. The testis becomes extremely sensitive and heavy. There is a color change in the scrotum. In addition, the diagnosis should be made with strangulated hernia orchitis (testicular inflammation) and hydrocele. Torsion is also translumination negative. The diagnosis should be made quickly and the torsion should be corrected with surgical intervention, otherwise tissue death occurs in the testis. The destruction of one side testicle affects the other testicle negatively.
5. Trauma;
Testes in the inguinal canal are more open to trauma than those in the scrotum.
6. Psychological changes;
Children begin to deal with their external genitalia from the age of one. The penis becomes an asset to them above all else. Whether the testicles are in the scrotum or not does not have a significant physical or psychological effect until the age of 4-5. However, because of this situation of their children, the parents are alarmed and the discussions about what their future masculinity will be in the presence of them creates a feeling of depression and inadequacy in the child. After the age of five, the child who realizes that one or both testicles is not in the scrotum may go into a great fear and depression.
7. Cancer transformation potential;
The chance of cancer in undescended testicles is higher than in descended testicles. Although it was previously thought that the cancer rate did not change when it was reduced by surgery (orchiopexy), but the follow-up of the testis became easier. However, it has been shown in the literature that the rate of cancer in testicles lowered before the age of 10 is exceptionally low. This shows that early surgery reduces the conversion to cancer.
In general, testicular cancers are less common than other tumors. For this reason, it would not be right to do orchipexy by telling the family about cancer and scaring them. There are those who recommend removing the intra-abdominal testicles that cannot be lowered into the scrotum due to the risk of cancer.
Treatment principles in undescended testicles;
In the past, it was recommended to follow up patients (6 – 7 years old) until pre-school in undescended testicles. Studies conducted in the last 10-15 years have revealed that if the testis has not descended by the end of the age of one, it is impossible to descend on its own after that. In addition, according to some studies, it has been shown that degenerative changes begin in the undescended testicles after the age of one. For this reason, he revealed that undescended testis surgery should be performed at the age of one, but before the age of two.
The role of hormone therapy in undescended testicles;
It is based on the thought of some endocrinologists that pituitary anterior-lobe hormones may have an effect on testicles in intrauterine life in undescended testicles. In the last two decades, hormone therapy has been abandoned in almost all pediatric and pediatric surgery centers. As we do not have enough information today about the effect of hormones on testicular descent with intrauterine life, it cannot be accepted that hormone therapy removes the fibrous tunica vaginalis that we encountered in the inguinal canal during surgery and lowers the testis.
Hormone therapy applied before puberty also has undesirable side effects. It is seen that the hormone given in unilateral undescended testes causes untimely and excessive growths on the descended testes. In addition, negative effects of hormones on spermatogenesis have been shown. In addition, the carcinogenic effects of hormones are still a matter of debate.
THAT’S WHY HORMONE THERAPY HAS NO PLACE IN THE UNDOWN TESTIS.
Histopathological studies have revealed the necessity of surgical lowering of the testis (orchiopexy) before the age of one, when degenerative changes begin in the undescended testicles, but definitely before the age of two. Surgery should be performed as soon as possible with the treatment of clinically obvious inguinal hernia.
In cases where the testis is absent or atrophic, testicular prostheses can be used to prevent psychological and aesthetic disorders.
ECTOPIC TESTIS
It is used for testicles that follow the normal descent path into the upper inguinal canal but are located in the perineal or femoral region instead of the scrotum. Such testicles must be surgically lowered into the scrotum.
RETRACTIL TESTIS (Shy or shy TESTIS):
In this case, although the testis actually descended into the scrotum, it was pulled into the outer opening of the inguinal canal as a result of various situmuli. From time to time, they descend into the scrotum, and from time to time, they rise up into the inguinal canal instead of the scrotum. There is no real undescended testis here. However, if the testis does not descend into the scrotum during a certain period of the day, spermatogenesis (sperm production) may be impaired in such testicles. Therefore, in such cases that are considered to be retractile (testes that spend most of the day in the inguinal canal or the outer mouth of the inguinal canal), it will be beneficial for the patient to evaluate it in the undescended testis group.
