Pediatric Cryptorchidism

　　First, etiology

　　The mechanism of testicular descent has not been elucidated, and the etiology of cryptorchidism is not very clear. It is currently believed to be related to the following factors:

　　1. Endocrine disorders Clinical studies have shown that the imbalance of the hypothalamus-pituitary-testicular axis leads to a lower level of testosterone in cryptorchid patients than in normal individuals. The descent process of the testicle is closely related to the level of testosterone. Testosterone-dihydrotestosterone binds to receptor proteins on the surface of the spermatic cord and scrotum, promoting the descent of the testicle.

　　2. Insufficient mesonephric inhibitory substance (MIS) In the early stage of embryogenesis, the fetus has both mesonephric and mesonephric ducts. As the primitive male genital glands develop into testicles, the stromal cells in the testicles secrete testosterone, and the Sertoli cells secrete mesonephric inhibitory substance (MIS) to inhibit the development of the mesonephric duct. If MIS is insufficient, the mesonephric duct may remain or not degenerate at all, causing an obstacle to the descent of the testicle.

　　3. Anatomical obstruction Cryptorchidism often terminates at the pubic tubercle or above the scrotum, and the residual abnormal ligament, fascia covering the inguinal orifice, can all prevent the descent of the testicle.

　　Second, pathogenesis

　　The testicles of cryptorchidism often have varying degrees of underdevelopment, the volume is significantly smaller than that of the healthy side, the texture is soft, and there may also be maldevelopment of the epididymis and vas deferens, with an incidence rate of 36% to 79%. The main pathological feature of cryptorchidism is the developmental disorder of germ cells, followed by a decrease in the number of stromal cells. The average diameter of the seminiferous tubules in cryptorchidism is smaller than that of the normal ones, and the collagen tissue around the seminiferous tubules is hyperplastic. The pathological changes of cryptorchidism become more obvious with age, and many studies believe that the tissue pathological changes of the testicles after 2 years of age are difficult to recover, so surgery should be completed before 2 years of age. In adults with cryptorchidism, the seminiferous tubules degenerate, and almost no normal sperm can be seen. The degree of pathological changes is also related to the position of the cryptorchidism; the higher the position, the more serious the pathological damage; the closer to the scrotum, the less severe the pathological damage.

　　1. Decreased fertility or infertility The pathogenesis of cryptorchidism is mainly the developmental disorder of germ cells, which affects fertility. Generally speaking, the fertility of patients with bilateral cryptorchidism is significantly reduced, but if the position of the cryptorchidism is low, it is possible to retain some fertility. The fertility of unilateral cryptorchidism is not significantly affected if the testicle and epididymis on the opposite side have normal development.

　　2. The processus vaginalis of cryptorchidism is basically not closed, and if an intestinal hernia occurs, it forms an indirect hernia, which can lead to incarceration, and the processus vaginalis should be ligated simultaneously during surgery.

　　3. Testicular injury due to the fact that the testicles are located within the inguinal canal or near the pubic tubercle, is relatively superficial and easy to be directly damaged by external forces.

　　4. Torsion of cryptorchidism The probability of torsion in undescended testicles is 20 to 50 times higher than that in scrotal testicles. Cryptorchidism torsion usually manifests as a painful mass in the inguinal region, resembling an incarcerated inguinal hernia, but without obvious gastrointestinal symptoms. The symptoms and signs of the right abdominal cryptorchidism torsion are quite similar to those of acute appendicitis. Therefore, in pediatric acute abdominal conditions, attention should be paid to the examination of testicles in the scrotum.

　　5. Malignancy of cryptorchidism The incidence of malignancy in cryptorchidism is 18 to 40 times higher than that in normal testicles. The incidence of malignancy in high-positioned cryptorchidism, especially abdominal cryptorchidism, is 6 times higher than that in low-positioned cryptorchidism. The incidence of malignancy after testicular fixation before 6 years of age is much lower than that after surgery after 7 years of age. The age of onset of malignancy in cryptorchidism is mostly after 30 years old.

　　Firstly, cryptorchidism can occur in either unilateral or bilateral forms

Single-sided cryptorchidism is more common. In patients with unilateral cryptorchidism, the incidence on the right side is slightly higher than on the left. However, even in cases of bilateral cryptorchidism, there is still a sufficient amount of androgens produced, which can maintain the development of male secondary sexual characteristics and rarely affects sexual behavior after adulthood. Patients with cryptorchidism without complications generally have no自觉 symptoms, mainly manifested as flattened scrotum on the affected side, asymmetric between the left and right scrotum in unilateral cases, and empty and sunken scrotum in bilateral cryptorchidism. If concurrent inguinal hernia occurs, a mass on the affected side may appear after activity, accompanied by discomfort and distension, and in severe cases, may present with episodic abdominal pain, vomiting, fever. If cryptorchidism occurs torsion, if the cryptorchidism is located at the inguinal canal or external ring, then the main manifestation is a local painful mass, without normal testicles in the affected scrotum, gastrointestinal symptoms are mild. If the cryptorchidism is located in the abdomen, the pain is located in the lower abdomen near the internal ring after torsion. The symptoms and signs of the right abdominal cryptorchidism torsion are quite similar to those of acute appendicitis, the main difference being that the tenderness of the abdominal cryptorchidism torsion is lower, closer to the internal ring. In addition, if there are no testicles in the affected scrotum, it should be highly suspected that there is an abdominal testicular torsion. According to the location of the testicles, cryptorchidism is clinically divided into:

　　1. High-positioned cryptorchidism, referring to the testicles located within the abdomen or near the inguinal internal ring, accounting for 14% to 15% of cryptorchidism.

　　2. Low-positioned cryptorchidism, referring to the testicles located at the inguinal canal or external ring.

　　Secondly, cryptorchidism can also be divided into 4 categories

　　1. Abdominal testicles, the testicles are located above the internal ring.

　　2. Inguinal canal testicles, the testicles are located between the internal and external rings.

　　3. Ectopic testicles, the testicles are deviated.

　　4. Retractable testicles, the testicles can be pushed or pulled into the scrotum, and then they shrink back to the inguinal region after releasing.

　　The risk of testicular malignancy within the abdomen is 6 times higher than in other locations. The older the child is at the time of testicular fixation, the higher the risk of malignancy. Therefore, early testicular fixation is recommended, which also facilitates examination.

　　Routine examinations are generally normal, and chromosomal tests may be necessary for differentiation when needed. The risk of testicular malignancy within the abdomen is 6 times higher than in other locations. The older the child is at the time of testicular fixation, the higher the risk of malignancy. Therefore, early testicular fixation is recommended, which also facilitates examination. Routine ultrasound, CT, and MRI examinations can be performed, which are used for the diagnosis of undetectable testicles, and laparoscopy can be used for unilateral cases.

　　1. Folk Remedy 1

　　Boil 500g of rooster for consumption. It is rich in androgens and has the effect of increasing tissue immune function, promoting the alleviation of symptoms of cryptorchidism.

　　2. Folk Remedy 2

　　Boil 200g of animal testicles for consumption. It is rich in androgens and is very suitable for patients with this disease, which is often caused by a lack of androgens.

　　3. Folk Remedy 3

　　Boil 250g of lamb with radish for consumption. It has a certain drying property and has a significant nutritional effect on the kidneys, suitable for patients with this disease, and has a good effect of warming and tonifying the kidney yang.

　　Cryptorchidism treatment must be completed before the age of 2. Cryptorchidism found in the neonatal period can be observed regularly. If the testicle has not descended into the scrotum by 6 months, the chance of spontaneous descent is very small, and hormone or surgical treatment should be considered. The purpose of treatment is to improve fertility, change physical defects, avoid psychological and spiritual trauma in children, and reduce the tendency of testicular malignancy.
　　1. Hormone Treatment
　　Hormone treatment can be tried for low cryptorchidism, and it can also be used cautiously in children who have undergone testicular descent fixation surgery. Treatment is mostly suitable for children under 1 year old, and it can start after 6 months.
　　2. Surgical Treatment
　　Once the diagnosis of cryptorchidism is confirmed, the child can undergo surgery after 6 months. For those who are ineffective with hormone treatment and have exceeded 1 year of age, surgery should be performed as soon as possible, and the latest should not exceed 2 years. The main surgical methods include open surgery and laparoscopic surgery. Laparoscopic surgery has a significant advantage in the diagnosis and treatment of high cryptorchidism. Other surgical methods include testicular autotransplantation, and if there is a poor development or atrophy of the testicles, an orchiectomy should be performed. If it is not possible to lower the testicle to the scrotum in one operation, a staged operation is required.