Cryptorchidism refers to an abnormal condition in which the testes have not descended into the scrotum within 2 months after birth in infants, either bilaterally or unilaterally. Cryptorchidism is divided into true cryptorchidism and false cryptorchidism. False cryptorchidism refers to the situation where the testes are not reached in the scrotal membrane, but the testes can be felt above the scrotum or in the inguinal region; true cryptorchidism not only cannot be felt in the scrotum, but also cannot be felt in the upper scrotum or inguinal region, its position is too high, often located in the abdominal cavity. Whether it is true or false cryptorchidism, or bilateral or unilateral cryptorchidism, they are all called cryptorchidism.
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Cryptorchidism
- Table of Contents
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1. What are the causes of cryptorchidism
2. What complications can cryptorchidism lead to
3. What are the typical symptoms of cryptorchidism
4. How to prevent cryptorchidism
5. What tests need to be done for cryptorchidism
6. Diet taboos for cryptorchid patients
7. Conventional methods of Western medicine for the treatment of cryptorchidism
1. What are the causes of cryptorchidism
Cryptorchidism is caused by abnormal descent of the testes and is a congenital disease. The occurrence of cryptorchidism is related to hormone levels, testicular pedicle, and short spermatic cord. Cryptorchidism mostly occurs unilaterally, with an incidence rate of 10% to 25% for bilateral cryptorchidism. Cryptorchidism often occurs with inguinal hernia. Cryptorchidism that remains in the abdominal cavity or inguinal region, due to the higher temperature than the scrotum, the testes are in this environment for a long time, leading to poor testicular development and degeneration of the seminiferous tubules, thus causing spermatic dysfunction. Cryptorchidism can also become testicular tumors during the youth and middle age, so cryptorchidism should be treated early, and the testes should be retracted into the scrotum to avoid complications. Since the mechanism of normal descent of the testes during fetal development is not clear, there are also many theories about the etiology of cryptorchidism, and the causes and mechanisms of the body are as follows.
One, endocrine theory
Some scholars believe that cryptorchidism may be due to a functional imbalance of the hypothalamus-pituitary-gonadal axis before puberty, insufficient secretion of luteinizing hormone (LH)-interstitial cell (leydies cell) axis, leading to a decrease in plasma testosterone. Because the descent of the testes is closely related to the level of testosterone, some scholars have also measured the normal testosterone level in cryptorchid patients, proposing that the main factor is a deficiency of 5α-reductase, which causes a disturbance in the production of dihydrotestosterone, or insufficient androgen receptors in target organs or receptor gene mutations, etc., which hinder the binding of testosterone to target cell receptor proteins
Certain disorders of pituitary gonadotropins and androgens, such as Kallmann syndrome (LH-RH deficiency), incomplete pituitary development due to anencephaly, etc., are often accompanied by cryptorchidism, indicating that there is a certain relationship between pituitary gonadotropins and androgens and the descent of the testes. Recently, some people have found anti-gonadotropin cell antibodies in the blood of cryptorchid patients, suggesting that cryptorchidism may be an autoimmune disease of the patient's pituitary
Two, anatomical factors
1, Absence of the testicular pedicle: during the descent of the testes, the testicular pedicle has a pulling effect, the terminal branches of the pedicle mainly attach to the bottom of the scrotum, and the testes descend into the scrotum with the traction of the pedicle
2, Unclosed processus vaginalis
3, Abnormal development of the inguinal region: small internal ring or mechanical obstruction at the scrotal orifice
4, Short testicular vessels or sperm ducts
Three, developmental defect of the testes themselves
Some cases have inherent defects in the testicle itself, such as atrophy of the testicle after torsion in utero, only retaining the spermatic cord and residual end of the vas deferens, separation of the testicle and epididymis, and congenital absence of the epididymis, etc., which affect the descent of the testicle.
2. What complications can cryptorchidism cause easily?
Cryptorchidism is a common congenital disease. Some babies are born without one of their testicles, and if not treated actively, complications may occur as follows.
1. Decreased fertility or infertility
The main pathological change of cryptorchidism is the disorder of germ cell development, which can lead to a decrease in fertility or infertility. Patients with bilateral cryptorchidism have a significant decrease in fertility. If the position of the testicle is high, due to severe pathological damage, severe disorder of germ cell development can lead to infertility. However, if the position of the cryptorchidism is low, after appropriate treatment, it is expected to retain some fertility.
2. Congenital inguinal hernia
About 65% of cryptorchidism patients have congenital inguinal hernia. This is caused by the failure of the processus vaginalis to close between the peritoneal cavity and the tunica vaginalis of the testicle, with the intestinal loop descending into the scrotum through the processus vaginalis. Almost all cryptorchidism patients have an unclosed processus vaginalis between the peritoneal cavity and the processus vaginalis, and when the orifice of the processus vaginalis is narrow, it does not form a hernia. Some children may have a large hernia within a few months after birth, which can compress the spermatic vessels, further atrophy the cryptorchidism, and some may develop incarcerated and strangulated hernia, which all require early surgical treatment. In general, surgery is performed after the child grows up and is treated together with the cryptorchidism.
3. Torsion of cryptorchidism
Wallenstein's statistics show that among 150 patients with testicular torsion, 90 (60%) are cryptorchidism patients. The opportunity for undescended testicles to twist is 21 to 53 times higher than that of testicles in the scrotum. The cause and mechanism of the disease are unknown and may be related to abnormal attachment of the testicular pedicle or retractor muscle.
4. Injury of cryptorchidism
Since cryptorchidism often locates in the inguinal canal or near the pubic tubercle, its location is relatively superficial and fixed, making it easy to be traumatized by external violence. As age increases, the range of activity of cryptorchidism patients increases, and the opportunity for trauma also increases. After injury, the testicle is prone to fibrosis, which accelerates its atrophy.
5. Malignant change of cryptorchidism
The opportunity for testicular tumors in cryptorchidism patients is 20 to 40 times higher than that in normal testicles. High cryptorchidism, especially intraperitoneal cryptorchidism, has an incidence of malignancy about 4 to 6 times higher than that of low cryptorchidism. The incidence of testicular tumors in intraperitoneal cryptorchidism is 22.7%, and Campbell's statistics show that the incidence of malignancy is as high as 48.5%, while cryptorchidism at the inguinal or external ring is only 6.8%. According to clinical observations, surgery after the age of 10 cannot prevent the occurrence of tumors, surgery before the age of 10 can significantly reduce the occurrence of tumors, and surgery before the age of 3 can avoid the occurrence of tumors. It is generally believed that orchidopexy surgery cannot prevent the occurrence of malignant changes, even if surgery is performed early, it will not reverse this tendency of malignancy. However, testicles that have descended into the scrotum are easily found early if they undergo malignant changes. The age of onset of malignant changes in cryptorchidism is often after 30 years old. The causes of onset are not only related to the inherent factors of the testicle, but also related to local temperature, hemodynamic disorders, and endocrine dysfunction.
3. What are the typical symptoms of cryptorchidism?
Cryptorchidism patients mainly manifest as the loss of fertility, the occurrence of malignant tumors, hernia, and testicular torsion, and their specific clinical manifestations are described as follows.
1. Infertility
Cryptorchidism can cause damage to germ cells, and early surgical treatment to fix the testicle in the scrotum can reduce the risk of reduced fertility. The earliest postpartum histological abnormality of cryptorchidism can be observed in the first month after birth, which is the dysplasia of stromal cells. After puberty, unilateral cryptorchidism should be removed, as it is prone to malignant change and torsion in the future, and most of the testicles have lost fertility.
2. Malignant transformation
Children with undescended testicles at birth have a risk of testicular malignant tumors. The incidence of germ cell tumors in men with cryptorchidism is about 40 times higher than that of normal people. The location of undescended testicles affects the relative risk of testicular tumors, the higher the location, the greater the risk of malignant change. Half of the intra-abdominal testicles will undergo malignant change. The most common type of testicular tumor caused by cryptorchidism is seminoma. The incidence of in situ carcinoma in patients with cryptorchidism is 1.7%.
3. Hernia
90% of undescended testicle patients have an open processus vaginalis. The processus vaginalis usually closes after the testicle descends and within the first month after birth, and an open processus vaginalis is associated with a higher risk of epididymal abnormalities. The clinical significance of an open processus vaginalis is that it can affect the hormone treatment effect of cryptorchidism.
4. Testicular torsion
Cryptorchidism may have abnormal attachment of the testicular pedicle, retractor muscle, or tunica vaginalis, which is prone to testicular torsion. Although undescended testicles rarely occur torsion, torsion should be considered in cases of abdominal pain or inguinal pain accompanied by empty scrotum on the same side.
4. How to prevent cryptorchidism
Cryptorchidism is a congenital condition with no testicles in the scrotum, and it can cause many complications and has the risk of malignant changes. Therefore, it is necessary to take positive preventive measures. Experts say that the prevention of cryptorchidism should start early.
1. Cryptorchidism should be prevented early, starting from embryonic formation, pregnant women should strengthen nutrition, pay attention to drug contraindications, and avoid affecting fetal development. Once cryptorchidism is found, it should be treated early, especially considering surgical treatment, and the age for surgical treatment is generally 3 to 5 years.
2. Parents of boys should carefully check their son's scrotum to discover the problem of cryptorchidism early, and the prevention of cryptorchidism should start early. Generally, testicles of peanut size can be felt on both sides of the scrotum, with a tangible feeling. If the scrotum is empty and the testicles cannot be felt, or if there is only one, go to the hospital for treatment immediately.
Currently, it is considered that cryptorchidism surgery can be performed after 2 years of age, and the latest time should not exceed 10 years old, otherwise it may affect the function of sperm. In short, prevention of cryptorchidism should start early, and the harm caused by cryptorchidism to men's physical and mental health should be avoided.
5. What laboratory tests need to be done for cryptorchidism
The examination of cryptorchidism includes ultrasound, CT, MRI, laparoscopy, and hormone tests, and the specific methods of examination are described as follows.
1. Mainly for testicles that cannot be felt, ultrasound can be used as a routine preoperative examination to determine the existence and location of the testicles.
2. CT, MRI do not have an advantage over ultrasound in diagnosing cryptorchidism. Dorsal artery and vein angiography and spermatic vein angiography are not recommended for use. There is no significance in performing radioactive examinations on undescended testicles, as in most cases, the choice of surgery, the method of surgery, and the improvement of cryptorchidism function do not depend on imaging results.
3. Laparoscopy is the current 'gold standard' for cryptorchidism diagnosis, and treatment can be performed during localization.
4. Bilateral or unilateral cryptorchidism accompanied by small penis, hypospadias, etc., requires human chorionic gonadotropin (HCG) stimulation test, androgen, follicle-stimulating hormone (FSH), luteinizing hormone (LH), human müllerian inhibitory substance/anti-müllerian hormone (MIS/AMH) determination, karyotype, genetic gene determination, and other examinations.
6. Dietary taboos for cryptorchidism patients
Cryptorchidism can be treated with surgical methods, and attention should be paid to adjustment after treatment. The adjustment methods after cryptorchidism surgery are described as follows.
1. Catheter placement
Laparoscopic surgery for cryptorchidism is usually not necessary to place a catheter in the bladder through the urethra before surgery, but it will be changed to be inserted after anesthesia and removed after surgery. For larger surgeries or inpatient surgeries, a catheter is usually placed before surgery to avoid bladder injury during surgery and to avoid the phenomenon of postoperative pain when patients need to urinate immediately after getting up, causing wound pain. It can be seen that the placement of the catheter is mainly to help postoperative patients reduce postoperative discomfort. Therefore, as long as the patient feels good after surgery and can get up to use the toilet, they can request the doctor to remove the catheter.
2. Nutritional intake
After cryptorchidism surgery, more water should be taken to supplement the fluid loss during surgery. Usually, after the surgery, patients can resume eating. Initially, warm water can be drunk first, and if there is no discomfort, you can start with liquid food, and normal diet can be resumed the next day. Since wound healing requires the use of protein, high-protein foods should be consumed to accelerate wound healing, and spicy foods should be avoided to prevent stomach acid secretion and gastrointestinal discomfort.
3. Pay attention to daily life
Maintain a comfortable lifestyle and engage in slight exercise, which is helpful for body recovery, and normal routine can be resumed two weeks after surgery. In the initial stage of surgery (within two weeks), horseback riding, cycling, and prolonged sitting should be avoided to prevent pelvic congestion and postoperative discomfort. Secondly, special attention should be paid to avoiding lifting objects weighing more than five kilograms or activities that increase abdominal burden. After eight weeks, gradually increase the amount of exercise according to personal physical condition and constitution, which can reduce the discomfort caused by temporary reduction in pelvic support in the future.
7. Conventional methods of Western medicine for treating cryptorchidism
Cryptorchidism, whether unilateral or bilateral, has degenerative changes in pathology and becomes more severe with age. The ideal age for preserving fertility is 12 to 24 months after birth. The spontaneous descent of the testicle can be completed within 3 months after birth. The decisive treatment for undescended testicles should be completed between 6 to 12 months after birth, which is the best time for orchidopexy.
1. Hormonal therapy
The etiology of cryptorchidism, especially bilateral cryptorchidism, may be related to endocrinology, therefore endocrine treatment can be given after the age of 1. The endocrine hormones currently used are as follows.
1. Human chorionic gonadotropin (HCG):The purpose of treatment is to improve the function of interstitial cells (leydig’s cells) and supporting cells (Sertoli cells), promote testicular development, increase testosterone secretion, and promote testicular descent. The effective rate is about 14% to 50%, with a dose of 1000-1500U, injected intramuscularly every other day, followed by a follow-up after 1 month. The total dose should be more than 10,000U, and 20,000U does not increase the efficacy, but may have adverse reactions that promote testicular atrophy.
2. Luteinizing Hormone-Releasing Hormone (LH-RH):The effective rate is 30% to 40%, with a dose of 1.2mg/d. 200μg per nostril, 3 times/d, through nasal atomization inhalation, 4 weeks as a course, followed by a follow-up after 3 months.
3. LH-RH HCG:When both are used together, they can improve the efficacy, with a dose of LH-RH 1.2mg/d, divided into 3 times for nasal atomization inhalation, and continued for 4 weeks, followed by HCG 1000-1500U, once a week, for a total of 3 weeks.
2. Surgical treatment
Orchiopexy is the main method of treating cryptorchidism. If the initial diagnosis is more than 6 months or hormone treatment is ineffective, surgical treatment can be performed after the age of 1. The orchidopexy with an oblique incision in the inguinal region has been widely used in China. For cryptorchidism with short testicular vessels, it can be divided into two stages of surgery to fully ensure the blood supply of the testicles, but there is also a possibility of second operation injury to the testicular vessels. For high cryptorchidism with long vas deferens, the Fowler-Stephens technique can be applied. Recently, an improved method of this technique, Fowler-Stephens staged surgery, has been recommended, which is that the initial surgery only cuts off the vascular pedicle of the high position of the vas deferens, does not perform orchidopexy, and the second stage is to fix the testicle in the scrotum after the collateral circulation is established, which reduces the chance of testicular atrophy.
3. Treatment for undetected testicles
For the testicles that have not been palpated in physical examinations, imaging and hormone stimulation tests, the treatment method should be abdominal inguinal exploration as the first choice. If there is an inguinal hernia sac but no testicles, further laparoscopic or laparotomy should be performed. If there is no hernia sac on the same side and no testicles, it can be diagnosed as absent testicles, and there is no need for further exploration. If the laparoscope finds vascular cord-like substances at the internal ring, it indicates that there may be residual nodules of testicles in the abdominal cavity.
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