In this lecture, we’re going
to review, very briefly,
testicular problems in children.
So let’s start with undescended testes.
This is probably the most
common problem we’ll encounter.
It’s also called cryptorchidism.
This is when a testis is not
palpable in a baby’s scrotum.
It’s fairly common.
Ten percent of the time, the impalpability
of the testes is bilateral.
In other words, both testes
have failed to descend.
It’s important when you see this in a child
to distinguish an undescended testis
from a testicle that is still
just high up in the canal
because those usually will
descend on their own.
So really feel all the way up
to the beginning of the canal
to try and feel that testis.
Also occasionally retractile testes,
for example if the child was cold,
are high up and could be missed.
Those can be generally
milked down into the sac.
This is very common, like I said,
and happens between 2 and 5% to
the time in full term babies.
It’s even more common in premature
infants with fairly one-third of infants
who are premature suffering
from an undescended testicle.
If the patient has bilateral
undescended testes or hypospadias,
consider a disorder of
There are many such disorders.
Generally, we’ll get an ultrasound,
both to look for gonads
and to exclude uterus
in a phenotypical male.
So these are all many different
genes that can cause this.
One example would be an
SRY mutation variant.
So in patients where we
have undescended testes,
we may obtain labs as well especially
if there is unclear sexual development.
We often get electrolytes and
if we’re concerned about
congenital adrenal hyperplasia.
You can hear about more of that
in one of our endocrine lectures.
In patients where there is
we may get LH and FSH to see if there
is central lack of development
or we may also check for a
We may also get karyotyping if we’re
unclear as to which gender this baby is.
However, most of undescended
testes are unilateral
and most descend on their own
within the first 6 months of age
in phenotypically and
genetically normal males.
If this testis has not descended, we
may need to move on to an orchiopexy.
In an orchiopexy, the
viable testicle is
manipulated into the scrotum
and sutured in place.
The non-viable testicle, which can
happen sometimes, would be removed
and often times later, a prosthesis may
be placed for cosmetic appearance.
HCG can be injected intramuscularly
and that may help with the descent
of testicles into the scrotum in
a small percentage of patients.
This is not commonly done,
but it is sometimes done.
So why do we do orchiopexy?
Well one of it is simply
is more efficient in the
outside of the body.
But also, an undescended testis
is at risk for neoplasm.
This tends to happen
In patients where there is a delay or
they simply don’t get around
to doing an orchiopexy,
these infants are at increased
risk once they had puberty
of developing testicular cancer.
Additionally, we like to bring
them down after one year
and not with too much more delay because
this may affect decreased fertility.
If the patient is not repaired,
they may also be at increased risk
for testicular torsion and a hernia.
Again, non-viable testes are
typically just removed.
So let’s move now to three common
causes of a painful testicle
in a child who has essentially
So this person has come in and they
are now having testicular pain.
What could cause it?
One emergency is testicular torsion.
Testicular torsion is a surgical emergency.
It’s caused by a twisting of the
testicle on itself inside the scrotum.
This results in interruption
of blood supply,
results in acute necrosis and
potentially loss of the testicle.
It is exquisitely painful.
The hydatid torsion, also known as a torsed
appendix testis is painful but is benign.
This is treated with NSAIDs.
This is a torsion of just
the appendix of the testis
and may appear quite appropriately as a
little blue dot on the scrotal wall.
Last is epididymitis.
Epididymitis may cause pain in the
testis, but this is an infection.
In younger children, it
can be caused by viruses
or bacteriuria type
organisms such as E. coli.
In adolescents, this is more likely to be
caused by sexually transmitted diseases
like gonorrhea and chlamydia.
So if we look at the age when these
three things typically happen,
epididymitis is actually more
common very early in childhood
and that’s from E.
coli like organisms
and then later on you may
get as a result of being
infected with a sexually
Hydatid torsion or a
torsed appendix testis
tends to happen around
10 years of age or so
and testicular torsion is usually
seen in adolescent males.
So let’s look at testicular
So there is a twisted epididymitis
and the testis becomes black and
this is testicular torsion.
Here, you can see a patient
with testicular torsion.
A few things are key.
One, they will be in exquisite pain.
Two, it will start off as red and this
one is perhaps starting to turn blue
and if left alone, will turn black which
means it is now dead and necrosed.
The patient’s testicle
will have a high lie.
You can see this here.
The testis is elevated and it’s
often in a lateral position.
It’s swung laterally.
Also, if you were to take
the time to do this,
there would be an absent
Remember, a cremasteric reflex is noted
when you stroke the inner side of the thigh
preferably with a cold object
and testicle will rise up.
Because the cremaster muscle in
this patient has become entrapped,
there is no cremasteric reflex.
For patients with testicular
torsion, this is an emergency.
The first thing we should
do is provide morphine
and then very quickly
call the urologist.
Often times, you can prevent
a surgery, however,
if you first try to
manually reduce it.
The way this is reduced is by
turning the testis outward.
We say “open the book”.
So you approach the testis and you turn it
as if you were opening the cover of a book
and this should relieve the torsion
and allow blood to flow again.
Please provide morphine when
you’re doing this procedure.
Alternatively, if that’s
not going to do the trick
or you’re unable to reduce the
torsion, you need to call the surgeons.
They will come racing in from
home to fix the problem.
So that’s my summary of these three
things that cause testicular pain.
Thanks for your time.