Cryptorchidism affects ~3% of term and 30% of preterm males. Most descend by 6 months. Persistent cryptorchidism after 6 mo → urology referral with orchiopexy ideally before 12–18 months to preserve fertility and reduce malignancy risk.
🚩 Red-flag clues (must not miss)
- •Bilateral non-palpable testes + ambiguous genitalia → exclude CAH (life-threatening salt-wasting)
- •Acutely painful, non-palpable testis with abdominal pain in infant = torsion of undescended testis
- •Ascending testis (was descended, now retracted) — surgical referral
Exam
- Warm room/hands; supine + cross-legged sitting
- Palpable in canal (most common) vs non-palpable
- Distinguish from retractile (can be brought into scrotum and stays)
Labs
- Bilateral non-palpable: karyotype, 17-OH progesterone, electrolytes, LH/FSH, testosterone, AMH
Imaging
- Imaging NOT routinely indicated (US misses intra-abdominal); laparoscopy is diagnostic + therapeutic
Differential & next step
| Diagnosis | Clue | Next step |
|---|---|---|
| True undescended (canalicular or abdominal) | — | Urology referral by 6 mo; orchiopexy 6–18 mo |
| Retractile testis | Can be milked into scrotum, stays briefly | Annual exam; usually normal |
| Ectopic testis | Outside normal pathway (perineum, femoral) | Urology, orchiopexy |
| Anorchia / vanishing testis | Non-palpable, low AMH/inhibin | Laparoscopy |
| Disorders of sex development (DSD) | Bilateral non-palpable + ambiguous genitalia | URGENT endo + genetics + 17-OHP |
Management / next steps
- Re-examine at 6 mo; if not descended → urology referral
- Orchiopexy by 12–18 mo to maximize fertility & reduce ↑ risk of testicular cancer (relative risk persists)
- Hormonal therapy not first-line