Ascending testes: here today, gone tomorrow

The current children’s health surveillance protocol for male infants, in the National Health Service (NHS) in the UK, involves the examination of the genitalia and the testes within 24 hours of birth. This is followed by a physical examination by a primary care medical professional at six-eight weeks after birth. If the testes are found to be palpable in scrotum no further routine checks are done.

However, a number of boys are found to have undescended testes at much later ages of 11-13 years.^1,2 Although the phenomenon of ascending testes, leading to secondary cryptorchidism, has been known for some time,^3,4 the children’s health surveillance guidelines in the UK have not been amended to detect this cohort of boys. This results in a number of orchidopexies in older boys.

The normal testes rests in the scrotum and is attached to the end of the spermatic cord, which extends through the groin into the inguinal canal. The testicles develop in the abdominal cavity during foetal life and by 28 weeks gestation they reach the respective inguinal canals. By 40 weeks each testes has usually reached the scrotum.

In premature babies, the birth prevalence of undescended testes is up to 30%. In full term male infants, prevalence of one or both testes not being fully descended in the scrotum is approximately 4%. However, by three months of age only about 1% of testes will be undescended.⁵

The testicle rests within the scrotum attached to the cremaster muscle, a thin, pouch-like, muscle. The testicle can move up and down within the scrotum with the contraction and relaxation of the cremaster muscle. The main function of the cremaster muscle is to control the temperature of the testicle, so that when the environment is cold, it draws the testicle towards the warmth of the body. It relaxes and drops the testicle in the scrotum when the environment is warm. The cremaster can be stimulated as part of a reflex (cremasteric reflex), by rubbing or stroking the genitofemoral nerve on the inner thigh. The reflex can also be triggered by extreme emotion.

A hyperactive cremasteric reflex gives rise to the phenomenon of retractile testes, and as many as 35% of children’s testes are thought to be retractile. This means that they are being pulled up above the scrotum, so as to transiently lie between the inguinal canal and the scrotum. A retractile testes can be manipulated easily into the scrotum and can remain there without traction, until the cremasteric reflex is re-induced.³

Retractile testes and ascending testes

Historically, it has been thought that retractile testes are a variant of the normal with no implications for infertility or secondary maldescent or cryptorchidism. However, in the first longitudinal study of retractile testes in the United States, when investigators examined 204 retractile testes in 122 boys, it was found that 30% of testes had descended (mean age 6.6 years), 38% remained retractile and 32% became ascending testes.

The above study demonstrates that retractile testes are not always a variant of normal and potentially have significant risk of undergoing ascent and lodging outside the scrotum.³ The ascending testes are also known as ascended testes, ascensus testes, secondary cryptorchidism, secondary undescended testes and acquired undescended testes.

Further historical evidence for ascending testes comes from the observation of bimodal distribution for age of orchidopexy, with the first peak at two years and the second peak at 11 years. At the Royal Children’s Hospital, Melbourne, 341 patients underwent orchidopexy during 1985. Of those orchidopexies only 25% were performed before the age of two years and 75% after the age of two years. This finding was despite their surgical policy to perform orchidopexy at two years.¹

In a study in Dutch schoolboys, children aged six years (2,042 boys), nine years (1,038 boys) and 13 years (353 boys), the prevalence of undescended testes was 1.2%, 2.2% and 1.1% respectively. This was despite screening programmes for detecting undescended testes in early years.²

In 2007, Stec et al concluded in their study of 172 boys with 274 retractile testes that ‘retractile testes can ascend and therefore require follow up until resolution’.6 In 2008 Guven et al concluded that education of the primary care providers and parents on the benefits of early orchidopexy is important, but in addition, ascending testes are much more common than previously thought. Patients with retractile testes should be followed regularly.⁷

The ascending testes or acquired undescended testes in boys with a previously documented scrotal testes, might explain why older boys undergo orchidopexy more often than one would expect with the present health care surveillance for babies and children. A hyperactive cremasteric reflex, an inelastic spermatic cord, or a fibrous persistence of the processus vaginalis might also contribute to the ascending testes.^3,8

Discussion

The evidence presented in this article raises the need to increase awareness among parents, health visitors and primary and secondary care physicians for the phenomenon of ascending testes and, in particular, the risk of retractile testes becoming ascending testes.^3,4

Systematic or opportunistic examinations may be of benefit for boys aged two years, six years, nine years and 13 years, to avoid the delayed diagnosis of ascending testes, as evidenced by the very significant number of orchidopexies in the 11-13 year age group.

This means that the universal health surveillance for boys should be revisited and possibly adapted to this phenomenon of retractile testes, which is clearly documented and occurring.

As Agarwal states in his article: “This study is important because it demonstrates that the retractile testis is not a variant of normal; it has significant risk of undergoing ascent and residing outside the scrotum. Hence the need for long-term follow up in boys with retractile testes, given the 32% of these retractile testes become ascending testes.’³

Given the current financial constraints within the NHS, it will be difficult for health professionals to implement the increased follow-up. This can happen only if the Child Health surveillance of the Department of Health and NICE consider the evidence and re-state a national standard for child health surveillance and for primary care.

Dr Rajiv Ghurye NHS Isle of Wight CCG Author: Dr Bettina Harms Paediatrician, NHS Isle of Wight CCG

References

Fenton EJM, Woodward AA, Hudson IL, Marschner I. Pediatric Surg Int 1990; 5: 6-9
Hack WWM et al. Arch of Dis Child 2007; 92:17-20
Agarwal PK, Diaz M, Elder JS. J Urol 2006; 175: 1496-1499
Sijtermans K, Hack WWM et al. Int J Androl 2008 Feb; 31(1):1-11.
Scorer CG. Arch Dis Child 1964; 39:60
Stec AA, Thomas JC, DeMarco RT, Pope JC 4th, Brock JW 3rd, Adams MC. J Urol 2007 Oct; 178 (4 Pt 2): 1722 -4; discussion 1724-5. Epub 2007 Aug 17
Guven A, Kogan BA. J Pediat Surg 2008 Sep; 43 (9): 1700-4
Shapiro E. Rev Urol 2006 Fall; 8(4): 231-23200-4