Appendix 1.
Summary of recommendations
| Physical exam is the cornerstone of cryptorchidism evaluation, and should be conducted by an experienced healthcare provider in a warm, relaxed environment |
| Documentation in patients with cryptorchidism should include history of prematurity, scrotal asymmetry, if the gonad(s) is palpable or not, and associated genitourinary abnormalities (such as hypospadias) |
| Phenotypic males with bilateral non-palpable gonads should raise the index of suspicion of congenital adrenal hyperplasia with a 46XX karyotype (along with other disorders of sexual development), and appropriate workup should be conducted prior to discharge to rule out a salt-wasting condition |
| If cryptorchidism is documented on newborn exam, regular monitoring is warranted to assess for spontaneous descent, and appropriate referral for specialized evaluation should be secured at or before six months of corrected age |
| Imaging studies, such as ultrasound, computed tomography scan or magnetic resonance imaging, are unnecessary, expensive, potentially misleading, and not warranted. They can be selectively ordered after specialist evaluation, including patients with suspected disorder of sexual development, and prior to surgical intervention at the discretion of the specialist |
| Unless the child has important comorbidities or high anesthetic risk, there is no role for conservative (i.e., expectant) management in children diagnosed with cryptorchidism past six months corrected age |
| Children with retractile testicle(s) should be regularly examined and the location of the gonad in the absence of an active cremasteric reflex clearly documented. If noted to ascend into an ectopic/undescended location, specialist referral is warranted |
| Acute abdominal/inguinal pain in a child with cryptorchidism should be considered a possible torsion and trigger appropriate urgent surgical assessment. A genital exam indicating the presence and location of the testicles should be documented in all boys with abdominal/inguinal pain |
| Hormonal therapy has an unknown impact on subsequent gonadal function and has no advantage over timely surgical correction |
| There is no role for medical (hormonal) or surgical intervention(s) for children with retractile testicle(s) |
| Palpable undescended testicles can be addressed through a prescrotal or inguinal approach, based on location of the gonad and the ability to manipulate into the scrotum, as well as surgeon preference and expertise |
| If the testicle is not palpable on preoperative physical evaluation, an exam under-anesthesia should be conducted at the beginning of surgical exploration, as in 10–15% of patients the gonad may become palpable and surgical approach can be appropriately tailored |
| The goal of orchidopexy is to locate the gonad in its normal anatomical position, which should be documented on a postoperative followup assessment |
| Surgical procedures should address associated abnormalities, such as a patent processus vaginalis or hernia |
| The role of contralateral prophylactic orchidopexy in unilateral cryptorchidism or monorchidism (to prevent future testicular torsion) is controversial. The rationale for conducting this procedure or not should be disclosed to the family and appropriate warnings given to all families regarding the need for emergent evaluation in case of acute testicular pain |
| The diagnosis of an absent, vanishing, or atrophic testicle is based on surgical exploration. Surgical findings (including the presence of blind ending vas deferens and vessels, absence of testicle or nubbin), and/or pathological evaluation (hemosiderin, testicular tissue, vas deferens, and vessels) should be clearly documented in order to avoid future concerns and need for re-assessment |
| All patients should receive appropriate teaching regarding regular testicular self-exam following orchidopexy and need to alert healthcare providers if palpable abnormalities are noted or if a sudden increase in testicular size is perceived. |
| Patients should be referred for endocrine assessment in cases of delayed puberty and offered evaluation by an infertility specialist if concerned about future fertility potential. This recommendation in particularly important for boys at high risk for hormonal or fertility problems, such as those with bilateral intra-abdominal testicles, cryptorchidism in a solitary gonad, or concern about atrophy after attempted orchidopexy |