About 3% of newborns and 0.5% of older boys have a testis missing from their scrotums, and in 20% of them it is missing on both sides. An incompletely descended testis lies along the track of descent of the testis, the common sites for it are in a child's inguinal canal, or inside his abdomen. A maldescended testis may lie in his suprainguinal pouch, just superior to his external ring deep to the membranous part of his superficial fascia, in his perineum, or on the medial aspect of his thigh. The distinction between incomplete descent and maldescent may be difficult. A testis which is absent from the scrotum will make hormones but not sperms. So if neither of his testes are in his scrotum, he will have his normal secondary sex characteristics, including potency, but he will be infertile. The less complete the descent, the greater his chance of infertility. If a testis is absent on one side only, he will probably be fertile, but his misplaced testis is more easily injured, and is about 30 times more likely to become malignant. Even so, because malignant testicular tumours are so rare anyway, this is a small risk.
Spermatogenesis is normal in an incompletely descended testis and in a maldescended one, until the age of 6. This is also the age at which nearly all ''retractile testes' (see below) will have settled normally into the scrotum. So wait until the age of six before you advise orchidopexy. If neither of his testes are in his scrotum by this time, orchidopexy may make him fertile. If one of them is, he will probably be fertile anyway, and it is uncertain if the small risk of malignancy will be altered, so orchidopexy has little point. Its main effect is psychological. Maldescended testes are usually good ones, which can be brought down more readily. Unfortunately, the evidence for orchidopexy improving fertility is still inconclusive.
UNDESCENDED TESTES If neither testis is present in a newborn's scrotum, the possibilities are: (1) Retractile testes (very common). (2) A genuine undescended or maldescended testis. (3) An intersex (rare). He may look male, but really be a female with the adrenogenital syndrome.
If the testes of a boy under 2 years retract into his groin to lie at his external ring or even a little within it, especially when he is cold, but can be manipulated downwards (retractile testes), consider him normal. By puberty they will probably be permanently in his scrotum. Follow him at least to the age of 16. If at any stage his testes cannot be manipulated into the correct position in his scrotum (unusual), see below.
If neither of his testes can be manipulated into his scrotum, refer him for orchidopexy at the age of 6 or as soon after as possible.
If only one of them is missing, orchidopexy is much less important.
If he has a hernia and an undescended testis on the same side, orchidopexy should be done at the same time as herniorrhaphy; it will be much more difficult later.
ORCHIDOPEXY [s7]FOR UNDESCENDED TESTIS INDICATIONS. Testes which are not in place in the scrotum by the age of 6, and cannot be brought down to their normal position. If possible refer him. If you really cannot refer him and are experienced, consider proceeding as follows. The important part of the operation is getting enough cord length, the method of fixation is less important.
ANAESTHESIA. (1) General anaesthesia (10.1). (2) Ketamine (8.1).
METHOD. Aim to mobilize his spermatic cord to obtain more length, and then to fix his testes in their normal places. Deal with incomplete descent and maldescent in the same way.
To mobilize his spermatic cord, make a 5 cm incision from just lateral to his mid inguinal point to the root of his scrotum. Open his inguinal canal from his external to his internal ring. Find his spermatic cord containing his spermatic vessels and vas. Use sharp dissection to mobilize his cord and testis from all surrounding structures, including his dartos muscle. If he has a hernia remove the sac. Avoid any trauma which may cause bleeding.
If you now have enough length of cord to bring his testis down into his scrotum, stop here.
If not, incise his external oblique and transversus muscles lateral to his inguinal ring and open his peritoneal cavity. Dissect his cord from the peritoneum covering it for about 5 cm. This is not easy, so don't attempt it unless you have had some experience.
To fix his testis in his scrotum, insert your finger into his scrotal sac to open it up. Then place his testis in his scrotum. Insert a non-absorbable suture from his skin into his testis, and then out again, as a mattress suture. Tie this over small pieces of gauze. Or open the midline septum of his scrotum, and push his testis to the other side. Narrow the hole in the septum round his cord, with multifilament. Close his skin wound with monofilament.
If you fail to bring down his testis fully, a two- stage procedure will be necessary. Fix his testis as far as you have been able to bring it with a mattress suture as described above. If he has bilateral incompletely descended testes do nothing on the other side. Refer him for a second operation on this side, or for an operation on the other side.
If his testes are maldescended, manage them as for incomplete descent.
CAUTION ! (1) Be sure to discuss with his parents what you can achieve by operation on an incompletely descended testis. (2) Take great care not to damage the blood supply of his testis. (3) At the end explain the outcome of the operation.
Fig. 23-34 ANAESTHESIA FOR CIRCUMCISION for patients over 15. Under 15 use ketamine (A 8.1). A, and B, with the patient's prepuce forward, infiltrate a ring of anaesthetic solution [f10]without [f11]adrenalin at site of section. C, pull back his prepuce. To do this you may have to infiltrate a little more solution and make a dorsal slit in it. D, and E, infiltrate another ring of solution, at the site of section, just behind his glans. Pull his prepuce forwards again, and all is ready for circumcision to start.