Undescended Testis (Cryptorchidism) β Neonatal to Adult
UK primary care algorithm Β· RCGP SCA preparation Β· Based on NICE, EAU Paediatric Guidelines, BAUS
Progress0 / 9
The full reasoning pathway β undescended testis needs timely referral for orchidopexy to protect fertility and reduce cancer risk; acute absence may be torsion. Counsel and safety-net.StartDecisionInvestigateActionReferStop / Admit
PresentationUndescended testis
Age, uni/bilateral, palpable vs impalpable, retractile vs true UDT. Examine in warm relaxed setting; distinguish retractile testis.
Confirmed undescended at review β refer for orchidopexy (ideally by ~12β18 months).
Retractile testis
Monitor
Brings down and stays; usually no surgery; monitor (can ascend).
Ascending / acquired
Refer
Previously descended, now undescended β surgical referral.
Step 6 Β· ReferEscalation
Emergency acute torsion / bilateral impalpable neonate. Paediatric surgery / urology for orchidopexy; advise lifelong testicular self-examination (higher cancer risk).
Step 8 Β· counselling & family advice
Step 8 Β· Counselling & family adviceSet expectations and long-term plan
Explain timing β spontaneous descent is unlikely after ~6 months, so confirmed UDT warrants orchidopexy by ~12β18 months to optimise fertility and aid testicular examination. Counsel on the slightly higher testicular-cancer risk and teach lifelong testicular self-examination (even after surgery). Reassure for retractile testes; arrange surgical review for acquired/ascending testis.
Step 9 Β· review & safety-net
Step 9 Β· Review & safety-netDon't lose the timely referral
Re-examine retractile testes at routine reviews β they can ascend and become acquired UDT needing surgery. Emergency for an acute painful empty scrotum (torsion) or urgent for bilateral impalpable testes in a neonate (?DSD/endocrine). Ensure the orchidopexy referral is actioned and not lost to follow-up; reinforce self-examination from puberty.
β οΈ Timely orchidopexy matters: an undescended testis carries higher risks of subfertility and testicular cancer, so refer promptly β and counsel lifelong self-examination even after correction.
Safety
Step 1 β Screen for Emergencies & Can't-Miss Associations
Most undescended testes (UDT) are not emergencies, but certain presentations require urgent action β particularly in neonates and when associated with DSD or torsion.
Bilateral UDT in neonate Non-palpable bilaterally + hypospadias β Same-day paediatrics Disorder of Sexual Development (DSD) β sex chromosome analysis urgent
Non-palpable bilateral UDT Both testes absent β Urgent paediatrics Anorchia, DSD, congenital adrenal hyperplasia in 46XX infant
Acute pain β UDT site Sudden pain in inguinal canal / abdomen where testis lies β 999 Emergency Torsion of undescended testis (higher risk than scrotal testis)
Mass in inguinal canal Palpable firm mass in older boy/adult with history of UDT β 2WW Urology Testicular malignancy (3β5Γ higher risk in UDT)
Late presentation adult Man >18y with known untreated UDT + new symptoms β 2WW Urology Malignancy risk elevated, orchidectomy often recommended
Bilateral non-palpable UDT with genital ambiguity in a neonate must be treated as a DSD until proven otherwise β this includes the possibility of congenital adrenal hyperplasia (CAH) in a 46XX female, which carries life-threatening salt-wasting crisis risk. The EAU/ESPU guidelines state that all bilateral impalpable testes with genital anomaly require urgent endocrine and genetic assessment. Undescended testes carry a 3β5Γ elevated risk of testicular cancer (NICE, 2023) β men with late-treated or untreated UDT must have lifelong cancer surveillance.
Distinguish true UDT from retractile testis (physiological) β key decision that determines need for intervention.
True UDT (cryptorchidism)
Cannot be manipulated into scrotum by examination. Remains in ectopic position. Requires surgical treatment by age 12β18 months
Retractile testis
Can be milked into scrotum manually. Returns spontaneously when relaxed. Cremasteric hyperactivity. Watchful waiting β most resolve by puberty. Review annually
Ascending testis
Previously scrotal testis ascends with growth. Seen age 4β10y. Requires treatment as per UDT. Distinguish from retractile on examination
Ectopic testis
Testis has deviated from normal descent path: femoral pouch, perineal, base of penis. Usually palpable. Surgical treatment required
Atrophic / anorchic
Absent testis on USS / surgery. Vanishing testis (intrauterine torsion). Prosthesis and hormonal monitoring offered
NHS Newborn screening
Checked at newborn physical examination (NIPE) and 6β8 week check. Refer if UDT confirmed at 3 months (allows time for spontaneous descent)
The retractile vs true UDT distinction prevents unnecessary surgery. Up to 80% of UDT present at birth descend spontaneously in the first 3 months β most are retractile. Spontaneous descent after 6 months is rare; therefore intervention is recommended by 12β18 months (BAUS/ESPU 2024). Ascending testes are increasingly recognised β previously in the scrotum at NIPE but ascending during childhood β and carry the same long-term risks as true UDT. Annual review of retractile testes is mandatory as 30β40% ascend during childhood (La Scala et al.).
Diagnose
Step 3 β Classification by Position & Palpability
Position determines surgical approach and prognosis for fertility and cancer risk.
Palpable UDT (80%)
Can be felt in inguinal canal or superficial inguinal pouch. More common. Orchidopexy success rate >95%. Positions: high scrotal, inguinal, superficial inguinal pouch
Non-palpable UDT (20%)
Cannot be felt on examination. May be: intra-abdominal (50%), intracanalicular (30%), atrophic/absent (20%). Requires laparoscopy for diagnosis and treatment
Between internal and external rings. Most common position. Open orchidopexy standard treatment
Superficial inguinal pouch (Denis Browne pouch)
Below external ring, lateral to scrotum. Often mistaken for scrotal. Orchidopexy straightforward
Bilateral
Present in 10% of UDT. Higher association with DSD, hormonal deficiency. Requires karyotype + endocrine assessment
Classification guides surgical planning: non-palpable UDT requires diagnostic laparoscopy rather than open inguinal exploration, as intra-abdominal testes need different surgical approach. Malignancy risk correlates with position β intra-abdominal testes have the highest cancer risk (8β10Γ normal). Knowing the position also informs prognosis for fertility: the higher the position, the greater the germ cell damage and the lower the eventual sperm count (Lee & Coughlin, 2001). Early orchidopexy (before 12β18 months) significantly improves fertility outcomes and reduces cancer risk.
Diagnose
Step 4 β Targeted Examination
Examine in warm room, warm hands, child relaxed (ideally supine then cross-legged). The cremasteric reflex is hypersensitive in young children β warmth reduces false elevation.
Scrotum inspection
Poorly developed / hypoplastic hemiscrotum on affected side β confirms UDT. Bilateral hypoplasia β bilateral UDT or DSD
Inguinal canal palpation
Milk from internal ring downwards. Feel for soft ovoid structure. Palpable testis β can be brought towards scrotum? True UDT vs retractile
Mobility test
Can testis be guided to midscrotum without tension? Yes β retractile (no surgery). No β true UDT (refer). Does it remain after release? Retractile will spring back
Cough impulse, reducible swelling β associated patent processus vaginalis present in >90% UDT β will be repaired at same operation
Pubertal staging
Tanner staging in older boys. Bilateral UDT with delayed puberty β hypogonadism (Klinefelter's, Kallmann's)
Adult presentation
Examine standing. Hard/irregular mass in inguinal region β malignancy until proven otherwise β 2WW
The examination is the most important diagnostic tool in UDT β imaging rarely adds to a careful clinical exam for palpable testes. The mobility test is key: a testis that can be placed in the scrotum and REMAINS there after release is retractile; one that springs back or cannot reach the scrotum is a true UDT. Contralateral compensatory hypertrophy is a reliable surrogate for absent/atrophic testis (Eaton et al., sensitivity 71%, specificity 95%) β reducing the need for imaging to confirm absence. In older men, any firm irregular inguinal mass with a history of UDT is malignancy until proven otherwise.
Diagnose
Step 5 β Investigations
Investigations are selective β most UDT diagnosed clinically. Over-investigation delays referral.
Scrotal USS Selective
Useful to confirm position of palpable UDT and rule out concurrent pathology. NOT reliable for intra-abdominal testes (sensitivity 45%). Do not delay referral for USS
MRI scrotum/abdomen Specialist
For non-palpable UDT β better than USS for abdominal location. Requested by urology/paediatric surgery, not primary care
Rise in testosterone confirms functional testicular tissue. For bilateral non-palpable β specialist investigation
Tumour markers Adult/teen
AFP, Ξ²-hCG, LDH if adult/adolescent with suspected malignancy in UDT position. Order before referral
NOT needed (routine)
CT/MRI not indicated in primary care. Bone age, gonadotrophins only if delayed puberty/DSD suspected. Do not request USS and wait β refer directly
BAUS and ESPU guidelines explicitly state that USS should not be used to confirm or exclude intra-abdominal UDT β its sensitivity is only 45% for this location (Tasian et al., 2011). Diagnostic laparoscopy is gold standard for non-palpable UDT. Requesting USS for non-palpable UDT in primary care can falsely reassure and delay appropriate surgical exploration. For bilateral UDT in neonates, the AMH (anti-MΓΌllerian hormone) test is the most sensitive marker for testicular tissue presence and guides DSD workup β but this is ordered by the specialist, not primary care. The GP's role is to refer promptly and appropriately.
Refer
Step 6 β Referral Criteria and Timing
Same-day paediatrics
Bilateral UDT + hypospadias in neonate (possible DSD/CAH). Acute pain in UDT position (torsion)
Urgent paediatrics (within days)
Bilateral non-palpable UDT at any age. Bilateral UDT with ambiguous genitalia. Suspected DSD
Routine paediatric surgery / urology
UDT confirmed at 3-month GP check (allows spontaneous descent window). Refer by age 3β4 months for operation by 12β18 months. Ascending testis β refer when identified
2WW Urology (adult/teen)
Adult with untreated UDT + new mass / symptoms. AFP or Ξ²HCG raised. Any solid inguinal mass with UDT history
Routine urology (adult)
Adult with known UDT requesting orchidopexy or orchidectomy counselling. Fertility concerns post-UDT
Annual review (GP)
Retractile testis: review annually until puberty. Document testicular position at each appointment. Refer if ascends or cannot be placed in scrotum
Timing of referral is critical β orchidopexy before 12β18 months significantly improves fertility outcomes and may reduce cancer risk (Pettersson et al. NEJM 2007 showed late orchidopexy after 13y still carries elevated cancer risk). NICE quality standard QS176 specifies referral for boys with UDT should occur by 3 months. The NHS Newborn Physical Examination Programme mandates documentation at NIPE and 6-week check. GPs are responsible for identifying ascending testes on routine child health reviews β failure to refer delays treatment beyond the optimal window.
Treat
Step 7 β Treatment Pathways
Primary care role is watchful waiting for retractile testis and prompt referral for true UDT. Definitive treatment is surgical.
Retractile testis (GP-managed)
Watchful waiting No surgery
Annual examination until puberty. Reassure parents. Most resolve spontaneously. Refer if ascends
True UDT β palpable
Orchidopexy Age 12β18m
Open inguinal orchidopexy. Concurrent hernia repair (PPV present in >90%). Day-case surgery. Refer by 3β4 months
Non-palpable UDT
Laparoscopy Β± orchidopexy Staged
Diagnostic laparoscopy β orchidopexy if viable. Staged Fowler-Stephens if high intra-abdominal. Prosthesis if absent
Hormonal RxhCG or GnRH analogues β NOT recommended as primary treatment (ESPU/BAUS 2024). Descent rates <20%, inferior to surgery. May be used in specific DSD contexts by specialist only
Adult UDTOrchidopexy vs orchidectomy β Decision shared with patient. Orchidopexy allows surveillance; orchidectomy removes cancer risk. Both options valid. Specialist decision after USS/MRI
Post-op careWound care, analgesia (paracetamol + ibuprofen). Return to school 1β2 weeks. Avoid contact sports 4 weeks. GP review at 6 weeks
Orchidopexy before 12β18 months is the current evidence-based recommendation (ESPU/EAU 2024, BAUS 2023). Earlier surgery correlates with better germ cell preservation β histological studies show progressive germ cell loss with increasing age in UDT. Hormonal therapy (hCG/GnRH) is no longer recommended as primary treatment due to poor efficacy (<20% descent) and potential adverse effects on germ cells (apoptosis observed in animal models). For adult men with untreated UDT, the decision between orchidopexy (allows continued surveillance) and orchidectomy (eliminates cancer risk) is complex and must be individualised β BAUS guidelines recommend referral for specialist counselling.
Lifestyle
Step 8 β Education, Counselling & Long-Term Support
Parental education Explain difference between retractile and true UDT. Reassure about retractile testis. Explain why surgery is needed for true UDT by 18 months
Cancer surveillance (lifelong) Men with history of UDT have elevated lifetime cancer risk. Teach monthly testicular self-examination at puberty. Report any new lumps promptly β do not wait
Fertility counselling Bilateral UDT: inform about potential subfertility risk. Semen analysis in adulthood if fertility is a concern. Early referral to fertility services if abnormal
Psychological support Adolescent boys: address body image concerns about underdeveloped scrotum / testicular prosthesis. Refer CAMHS if significant distress
Sports & activity After orchidopexy: avoid contact sports and cycling for 4 weeks. No restrictions thereafter. Protective cup for contact sport encouraged
School / nursery notification Brief absence post-surgery (1β2 weeks). Provide fit note for parents/carers. No PE for stated period β provide letter
Follow-up instructions Retractile testis: bring child annually until 12β13y. Any change in position β book GP appointment. Confirm testis in scrotum at annual check
Hormone health Bilateral UDT / anorchia: refer paediatric endocrinology for puberty monitoring. Testosterone replacement may be needed. Klinefelter's β fertility counselling
Parental anxiety about UDT is high β clear explanation of the retractile/true UDT distinction prevents unnecessary worry and inappropriate pressure on GPs to refer all retractile cases. Lifelong cancer surveillance is essential: even after successful orchidopexy, the cancer risk remains elevated (~2Γ normal) compared to the general population. Fertility counselling is a key component of care β bilateral UDT orchidopexy has variable fertility outcomes; early discussion enables men to make informed family-planning decisions. Psychological impact of genital surgery and altered appearance in adolescence is well-documented and should not be overlooked in consultations.
Confirm testicular growth at puberty onset. Refer endocrinology if no pubertal development by 14y (bilateral UDT)
Adult surveillance (lifelong)
Advise all patients with history of UDT β annual testicular self-examination. 2WW referral for any new lump. Continue even if orchidopexy performed in childhood
Safety-net 999
Acute severe inguinal/abdominal pain after surgery or in known UDT β torsion. Any post-op wound dehiscence or bleeding
Safety-net same-day GP
Post-op fever, wound infection, scrotal haematoma. Inability to find testis at 6-week check
Fertility review (adult)
Offer semen analysis at age 20β25 for men with bilateral UDT history or if fertility concern raised. Refer andrology if abnormal
Malignancy safety net
Any hard, irregular, painless scrotal/inguinal mass β 2WW urology regardless of UDT history and whether orchidopexy was performed
Long-term surveillance after UDT is the GP's ongoing responsibility even if surgery was performed in childhood. NICE NG12 and BAUS guidelines note that orchidopexy reduces but does not eliminate cancer risk β the contralateral normally-descended testis also has slightly elevated risk in men with unilateral UDT. The NIPE programme requires GP awareness of follow-up; failure to identify ascending testis at child health reviews is a recognised clinical governance issue. Informing young men of their elevated cancer risk and teaching TSE empowers early detection β testicular cancer is the most common cancer in men aged 15β35 in the UK.
Educational use only. Pathway based on: ESPU/EAU Guidelines on Paediatric Urology β Undescended Testes (2024); BAUS Cryptorchidism Guidelines (2023); NICE QS176 Undescended Testes in Boys (2022); NICE NG12 Suspected Cancer (2023); NHS Newborn Physical Examination (NIPE) Programme Standards (2021). Always adapt to individual patient context and local pathways.